Prognostic and predictive value of ultrasound-based estimated ankle brachial pressure index at early follow-up after endovascular revascularization of chronic limb-threatening ischaemia: a prospective, single-centre, service evaluation.

Background: Ankle brachial pressure index can be estimated (eABPI) using cuffless ankle Doppler ultrasound. We evaluated the prognostic value of eABPI measured during pre- and post-procedural ultrasound exams to predict the clinical outcome after endovascular revascularisations. Methods: In this prospective, single-centre, service evaluation, consecutive patients with symptomatic peripheral artery disease undergoing lower limb endovascular revascularisations between July, 26 2018 and January, 13 2022 at Surrey and Sussex Healthcare NHS Trust (Redhill, UK) were analysed. eABPI was determined using the higher acceleration index measured with angle-corrected duplex ultrasound in ankle arteries before and ≤1 month post-procedure. Clinical outcomes (mortality, major amputations, amputation-free survival [AFS], clinically driven target lesion revascularization [cdTLR], major adverse limb events [MALE; cdTLR and major amputation], wound healing) were assessed over 1 year. Findings: Of 246 patients treated, for 219 patients (median 75 [IQR 66-83] years) pre- and post-procedural eABPI (0.50 [0.33-0.59] and 0.90 [0.69-1.0], p < 0.0001) were available, respectively. In n = 199 patients with chronic limb-threatening ischaemia (CLTI) Kaplan-Meier survival analyses showed that higher post-procedural, but not pre-procedural, eABPI was associated with favourable AFS, MALE, cdTLR, and wound healing. This was confirmed in Cox regression analysis and remained significant with adjustment for pre-procedural eABPI, age, sex, co-morbidities, treated levels, wound score, and foot infection. Whereas all clinical outcomes, except for survival, were significantly better at ≥0.7 vs <0.7, wound healing (unadjusted: HR 1.7 (95% CI 1.2-2.6), adjusted: HR 2.1 (95% CI 1.3-3.1), cdTLR, and MALE (unadjusted: HR 0.41 (95% CI 0.18-0.93), adjusted: HR 0.28 (95% CI 0.11-0.74) were significantly improved at ≥0.9 vs <0.9. Interpretation: Post-procedural eABPI can provide valid, clinically important prognostic and predictive information. Our data indicate that revascularisations should target values of at least 0.9 to achieve optimal outcomes. Future studies need to confirm generalisability and cost-effectiveness in a wider context. Funding: European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation.

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review.

PURPOSE: The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). MATERIALS AND METHODS: A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? RESULTS: The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. CONCLUSIONS: The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study.

We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.

Patient Reported Outcome Measures Used to Assess Quality of Life in Aortic Dissection: a Systematic Scoping Review using COSMIN Methodology.

OBJECTIVE: To systematically identify all patient reported outcome measures (PROMs) (quality of life [QOL] instruments or other instrument/methodology) that have been used to date in aortic dissection (AD) and to explore how well these instruments evaluate QOL according to the Consensus based Standards for the selection of health Measurement Instruments (COSMIN) methodology or guideline. DATA SOURCES: Embase, MEDLINE, PsycINFO, CINAHL, and Cochrane Library were search on 1st July 2022. REVIEW METHODS: This scoping review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) and the COSMIN guidelines for performing systematic reviews of validated PROMs. Studies that reported on any aspect or domain of QOL using a PROM or other instrument or methodology on AD were included. Data synthesis, including psychometric property analysis and risk of bias assessment were performed according to COSMIN guidelines. RESULTS: Forty-five studies, published between 1994 and 2021 reporting on 5 874 patients (mean age 63 years, 70.6% male), were included. A total of 39 PROMs were used, and three studies used semi-structured interviews. The majority (69%) of studies were in patients with type A aortic dissection (TAAD). The most common PROM used was the SF-36 (51%). Six studies evaluated one or more psychometric properties of a PROM. Only one of these studies was specifically designed as a validation study. No study reported on content validity. Internal consistency was the most evaluated psychometric property. No study evaluated all the psychometric properties according to COSMIN methodology. The methodological quality used to assess these PROMs was judged to be adequate or very good. CONCLUSION: This review highlights the heterogeneity of PROMs or methods used to determine QOL in AD patients. The lack of research regarding a comprehensive evaluation of the psychometric properties of a PROM used in AD highlights the need for the development and validation of a dissection specific PROM. [PROSPERO registration no. CRD42022310477].

Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS: This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION: The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER: NCT03886675.

Trends in Hospital Admissions, Operative Approaches, and Mortality Related to Abdominal Aortic Aneurysms in England Between 1998 and 2020.

OBJECTIVE: To assess trends in abdominal aortic aneurysm (AAA) hospital admissions, interventions, and aneurysm related mortality in England, and to examine the impact of endovascular repair on mortality for the years 1998 - 2020. METHODS: Hospital admission and operative approach (endovascular aortic aneurysm repair, or open surgical repair [OSR]) using Hospital Episodes Statistics (HES), and aneurysm related mortality data from the Office for National Statistics for England standardised to the 2013 European Standard Population, were analysed using linear regression and Joinpoint regression analyses. Aneurysm related mortality was compared between the pre-endovascular era (1998 - 2010) and the endovascular era (2011 - 2019). RESULTS: A declining trend in hospital admission incidence was observed, mainly due to a decline in ruptured admissions from 34.6 per 100 000 (95% confidence interval [CI] 33.5 - 35.6) to 13.5 per 100 000 (95% CI 12.9 - 14.2; ßi = -1.04, r2 = .97, p < .001). Operative interventions have been declining over the last 23 years mainly due to the statistically significant decline in open procedures (41.2 per 100 000 in 2000 [95% CI 40 - 42.3] to 9.6 per 100 000 [95% CI 9.1 - 10.1]; ßi = -1.92, r2 = .95; p < .001). There was an increasing trend toward endovascular procedures (5.8 per 100 000 [95% CI 5.3 - 6.2] in 2006 to 16.9 per 100 000 [95% CI 16.2 - 17.5] in 2020; ßi = .82, r2 = .30, p = .040). Reductions in aneurysm related mortality due to AAAs were observed for males and females, irrespective of age and rupture status. CONCLUSION: A significant decrease in hospital admissions for AAAs was observed over the last 23 years in England, paralleled by a shift toward endovascular repair and a decline in OSR. Declines in aneurysm related mortality were observed overall, and in the endovascular era irrespective of age, sex, and rupture status.

Quantifying the burden of survivorship associated with infrarenal abdominal aortic aneurysms.

OBJECTIVES: Survivorship encompasses the physical, psychological, social, functional, and economic experience of a living with a chronic condition for both the patient and their caregiver. It is made up of nine distinct domains and remains understudied in nononcological pathologies, including infrarenal abdominal aortic aneurysmal disease (AAA). This review aims to quantify the extent to which existing AAA literature addresses the burden of survivorship. METHODS: The MEDLINE, EMBASE, and PsychINFO databases were searched from 1989 through September 2022. Randomized controlled trials, observational studies, and case series were included. Eligible studies had to detail outcomes related to survivorship in patients with AAA. Owing to the heterogeneity between studies and outcomes, no meta-analysis was conducted. Study quality was assessed with specific risk of bias tools. RESULTS: A total of 158 studies were included. Of these, only five (treatment complications, physical functioning, comorbidities, caregivers, and mental health) of the nine domains of survivorship have been studied previously. The available evidence is of variable quality; most studies display a moderate to high risk of bias, are of an observational study design, are based within a limited number of countries, and consist of an insufficient follow-up period. The most frequent complication after EVAR was endoleak. EVAR is associated with poorer long-term outcomes compared with open surgical repair in most studies retrieved. EVAR showed better outcomes in regard to physical functioning in the short term, but this advantage was lost in the long term. The most common comorbidity studied was obesity. No significant differences were found between open surgical repair and EVAR in terms of impact on caregivers. Depression is associated with various comorbidities and increased the risk of a nonhospital discharge. CONCLUSIONS: This review highlights the absence of robust evidence regarding survivorship in AAA. As a result, contemporary treatment guidelines rely on historic quality-of-life data that are narrow in scope and nonrepresentative of contemporary clinical practice. As such, there is an urgent need to reevaluate the aims and methodology associated with traditional quality-of-life research moving forward.

The diagnostic and triage accuracy of digital and online symptom checker tools: a systematic review.

Digital and online symptom checkers are an increasingly adopted class of health technologies that enable patients to input their symptoms and biodata to produce a set of likely diagnoses and associated triage advice. However, concerns regarding the accuracy and safety of these symptom checkers have been raised. This systematic review evaluates the accuracy of symptom checkers in providing diagnoses and appropriate triage advice. MEDLINE and Web of Science were searched for studies that used either real or simulated patients to evaluate online or digital symptom checkers. The primary outcomes were the diagnostic and triage accuracy of the symptom checkers. The QUADAS-2 tool was used to assess study quality. Of the 177 studies retrieved, 10 studies met the inclusion criteria. Researchers evaluated the accuracy of symptom checkers using a variety of medical conditions, including ophthalmological conditions, inflammatory arthritides and HIV. A total of 50% of the studies recruited real patients, while the remainder used simulated cases. The diagnostic accuracy of the primary diagnosis was low across included studies (range: 19-37.9%) and varied between individual symptom checkers, despite consistent symptom data input. Triage accuracy (range: 48.8-90.1%) was typically higher than diagnostic accuracy. Overall, the diagnostic and triage accuracy of symptom checkers are variable and of low accuracy. Given the increasing push towards adopting this class of technologies across numerous health systems, this study demonstrates that reliance upon symptom checkers could pose significant patient safety hazards. Large-scale primary studies, based upon real-world data, are warranted to demonstrate the adequate performance of these technologies in a manner that is non-inferior to current best practices. Moreover, an urgent assessment of how these systems are regulated and implemented is required.

Trends in Thoracic Aortic Aneurysm Hospital Admissions, Interventions, and Mortality in England between 1998 and 2020: An Observational Study.

OBJECTIVE: To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of endovascular repair on mortality for the years 1998 to 2020. METHODS: Hospital admission and operative approach (thoracic endovascular aortic repair, [TEVAR] or open surgical repair) using Hospital Episodes Statistics, and ARM data from the Office for National Statistics for England standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998 - 2008) and the endovascular era (2009 - 2019). RESULTS: A rising trend in hospital admission incidence has been observed, mainly due non-ruptured admissions (4.11 per 100 000 in 1998; 95% confidence interval (CI) 3.71 - 4.50 to 12.61 per 100 000 in 2020; 95% CI 12.00 - 13.21 in 2020; r2 = .98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100 000; 95% CI 1.91 - 2.41 in 2020 vs. 0.26 per 100 000; 95% CI 0.16 - 0.36 in 2006; r2 = .90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females aged > 80 years with ruptured disease (15.26 deaths per 100 000 vs. 9.50 deaths per 100 000; p < .001). CONCLUSION: A significant increase in hospital admissions for non-ruptured TAA has been observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM, irrespective of sex and age. The significant reductions in age standardised death rates from ruptured and non-ruptured TAA in the endovascular era, particularly for females aged > 80 years with ruptured disease, affirm the positive impact of an endovascular approach to TAA.

The Haemodynamic and Pathophysiological Mechanisms of Calcific Aortic Valve Disease.

The aortic valve (AoV) is the outflow valve for the left heart [...].

Misinformation About the Human Gut Microbiome in YouTube Videos: Cross-sectional Study.

BACKGROUND: Social media platforms such as YouTube are integral tools for disseminating information about health and wellness to the public. However, anecdotal reports have cited that the human gut microbiome has been a particular focus of dubious, misleading, and, on occasion, harmful media content. Despite these claims, there have been no published studies investigating this phenomenon within popular social media platforms. OBJECTIVE: The aim of this study is to (1) evaluate the accuracy and reliability of the content in YouTube videos related to the human gut microbiome and (2) investigate the correlation between content engagement metrics and video quality, as defined by validated criteria. METHODS: In this cross-sectional study, videos about the human gut microbiome were searched for on the United Kingdom version of YouTube on September 20, 2021. The 600 most-viewed videos were extracted and screened for relevance. The contents and characteristics of the videos were extracted and independently rated using the DISCERN quality criteria by 2 researchers. RESULTS: Overall, 319 videos accounting for 62,354,628 views were included. Of the 319 videos, 73.4% (n=234) were produced in North America and 78.7% (n=251) were uploaded between 2019 and 2021. A total of 41.1% (131/319) of videos were produced by nonprofit organizations. Of the videos, 16.3% (52/319) included an advertisement for a product or promoted a health-related intervention for financial purposes. Videos by nonmedical education creators had the highest total and preferred viewership. Daily viewership was the highest for videos by internet media sources. The average DISCERN and Health on the Net Foundation Code of Conduct scores were 49.5 (SE 0.68) out of 80 and 5.05 (SE 2.52) out of 8, respectively. DISCERN scores for videos by medical professionals (mean 53.2, SE 0.17) were significantly higher than for videos by independent content creators (mean 39.1, SE 5.58; P<.001). Videos including promotional materials had significantly lower DISCERN scores than videos without any advertisements or product promotion (P<.001). There was no correlation between DISCERN scores and total viewership, daily viewership, or preferred viewership (number of likes). CONCLUSIONS: The overall quality and reliability of information about the human gut microbiome on YouTube is generally poor. Moreover, there was no correlation between the quality of a video and the level of public engagement. The significant disconnect between reliable sources of information and the public suggests that there is an immediate need for cross-sector initiatives to safeguard vulnerable viewers from the potentially harmful effects of misinformation.

Coverage of the Coeliac Artery During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the clinical impact of coeliac artery (CA) coverage during thoracic endovascular aortic repair (TEVAR). METHODS: This systematic review and meta-analysis was conducted according to the PRISMA guidelines. Electronic databases were searched from 1989 to 2020 for studies reporting visceral ischaemia, spinal cord ischaemia (SCI), 30 day/in hospital mortality, endoleaks, re-intervention, and caudal stent graft migration following CA coverage in patients undergoing TEVAR. Meta-analysis was conducted using random effects modelling. The quality of the evidence was graded using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Fifteen observational studies with 236 patients (108 male, age range 61.3 - 79 years) were included. The pooled visceral ischaemia rate was 13% with significant heterogeneity between studies (95% confidence intervals [CI] 4 - 24; I2 = 72%, p < .001). The SCI rate was 5% (95% CI 2 - 9; I2 = 0%); the 30 day/in hospital mortality was 4% (95% CI 1 - 7; I2 = 0%); the overall endoleak rate was 21% (95% CI 13 - 29; I2 = 35%) with a 5% (95% CI 0 - 13; I2 = 38%) rate of type Ib and 2% (95% CI 0 - 8; I2 = 43%) rate of type II endoleak from retrograde CA flow. The re-intervention rate was 13% (95% CI 6 - 22; I2 = 54%); the caudal stent graft migration rate was 3% (95% CI 0 - 9, I2 = 0%). The certainty of the body of evidence was judged to be very low for all outcomes. CONCLUSION: CA coverage during TEVAR is associated with high rates of visceral ischaemia, spinal cord ischaemia, 30 day/in hospital mortality, endoleaks, and re-intervention. Although the literature is of poor quality and questions remain over effects estimates, there is evidence that CA coverage should be avoided if at all possible, during TEVAR. REGISTRATION: PROSPERO registration number 244084.

Ankle Doppler for Cuffless Ankle Brachial Index Estimation and Peripheral Artery Disease Diagnosis Independent of Diabetes.

Ankle brachial pressure index (ABPI) is the first-line test to diagnose peripheral artery disease (PAD). Its adoption in clinical practice is poor and its validity, particularly in diabetes, is limited. We hypothesised that ABPI can be accurately and precisely estimated based on cuffless Doppler waveforms. Retrospective analysis of standard ABPI and handheld Doppler waveform characteristics (n = 200). Prospective analysis of angle-corrected Doppler acceleration index (AccI, n = 148) and standard ABPI with testing of performance to diagnose PAD as assessed with imaging reference standards in consecutive patients. The highest AccI from handheld Doppler at ankle arteries was significantly logarithmically associated with the highest standard ABPI (E[y] = 0.32 ln [1.71 ∗ x + 1], p < 0.001, R2 = 0.68, n = 100 limbs). Estimated ABPI (eABPI) based on AccI closely resembled ABPI (r = 0.81, p < 0.001, average deviation −0.01 ± 0.13 [SD], n = 100 limbs). AccI from angle-corrected Doppler in patients without overt media sclerosis (ABPI ≤ 1.1) improved ABPI prediction (E[y] = 0.297 ∗ ln[0.039 ∗ x + 1], R2 = 0.92, p = 0.006, average deviation 0.00 ± 0.08, n = 100). In a population (n = 148 limbs) including diabetes (56%), chronic limb-threatening ischaemia (51%) and media sclerosis (32%), receiver operating characteristics analysis of (angle-corrected) eABPI performed significantly better than standard ABPI to diagnose PAD defined by ultrasound (ROC AUC = 0.99 ± 0.01, p < 0.001; sensitivity: 97%, specificity: 96%) at the ≤0.9 cut-off. This was confirmed with CT angiography (ROC AUC = 0.98, p < 0.001, sensitivity: 97%, specificity: 100%) and was independent of the presence of diabetes (p = 0.608). ABPI can be estimated based on ankle Doppler AccI without compression, and eABPI performs better than standard ABPI to diagnose PAD independent of diabetes. eABPI has the potential to be included as a standard component of lower extremity ultrasound.

Technical Note: Left Subclavian Artery Scallop Endografts to Facilitate a Proximal Landing Zone and Upper Extremity Access for Branched Endovascular Aortic Repair of Type II Thoracoabdominal Aortic Aneurysms.

PURPOSE: To describe the dual purpose of left subclavian artery (LSA) scallop endografts to create the proximal landing zone (PLZ) and facilitate antegrade left-sided upper extremity access for branched endovascular aortic repair (BEVAR) of Type II thoracoabdominal aneurysms (TAAA) with a short PLZ. TECHNIQUE: Three patients with an inadequate (< 20 mm) PLZ underwent a 2-stage repair of Type II TAAA. Following femoral cut-down, a custom-made LSA scallop endograft was deployed into zone 2 to create the PLZ and maintain perfusion to the LSA. In a second procedure 36-96 days after insertion of the scalloped thoracic stent-graft, a branched abdominal stent-graft was subsequently deployed to dock into the proximal scallop endograft as the second stage. Via a left axillary conduit, a 12Fr sheath was used to cannulate the LSA scallop to facilitate selective catheterisation of antegrade branch cuffs and renovisceral target vessels, and insertion and deployment of bridging stents. The LSA scallop was also used to selectively catheterise and stent the perfusion branches via left-sided brachial puncture that were left open in each of the three cases 8-14 days after the second procedure to minimise the risk of spinal cord ischaemia. There were no neurological or endoleak complications. CONCLUSION: LSA scallop endografts are a feasible and useful adjunct to create the PLZ and to provide antegrade access for visceral stenting of branches and target vessels through the LSA scallop in branched endovascular repair of Type II TAAA with short PLZ.

Four-year results of the Bolton relay proximal scallop endograft in the management of thoracic and thoracoabdominal aortic pathology with unfavorable proximal landing zone.

BACKGROUND: Thoracic endovascular aortic repair with a scallop design (scallop-TEVAR) is a useful treatment strategy to extend the proximal landing zone (PLZ), while maintaining perfusion to one or more of the supra-aortic trunks (SATs) when treating aortic pathology with an unfavorable PLZ. The durability of this approach with the Bolton Relay scallop endograft (Terumo Aortic, Sunrise, Fla) has not been established. METHODS: A retrospective review of prospectively collected data on consecutive patients that received scallop-TEVAR in zones 0 to 2 at a tertiary aortic unit was undertaken. The main outcome was durability, characterized by survival estimates, freedom from reintervention to the thoracic aorta and PLZ, migration and aneurysm sac regression. RESULTS: Between 2009 and 2019, 38 patients (71% male; median age, 70 years) underwent scallop-TEVAR for thoracic aortic pathology (n = 28, 74%) or as a part of thoracoabdominal aneurysm repair (n = 10 [26%]). The use of scallop-TEVAR significantly extended the PLZ (median, 5 mm preoperative PLZ vs 26 mm extended PLZ; P = .0001). A total of 41 SATs were perfused with a scallop, including the left subclavian artery (n = 25), left common carotid artery (n = 6), neo/innominate artery (n = 4), left subclavian artery, and vertebral artery (n = 1), innominate artery, and left common carotid artery (n = 2) in conjunction with 15 extra-anatomical bypasses. The PLZ was at Ishimaru zone 0 and 1 in 6 cases (16%), respectively, and zone 2 in 26 cases (68%). Technical success was 98%. The 30-day mortality was 5% (2/38; 1 death from myocardial infarction and 1 from multiorgan failure). A minor stroke occurred in three patients (8%) and temporary spinal cord ischemia in two patients (5%). The median follow-up was 4.5 years (range, 0-10.53 years) during which two patients (5%) developed type Ia endoleak and required intervention to the PLZ (one from device-related migration and one from disease progression). All-cause and aorta-related survival were 72% and 85% and freedom from thoracic and PLZ reintervention was 92% and 97%, respectively. There were no cases of early or late thoracic aortic rupture, retrograde type A aortic dissection or SAT occlusion. CONCLUSIONS: Scallop-TEVAR offers a less invasive treatment option to extend the seal zone in selected patients with an unfavorable PLZ, allowing for a durable repair in terms of overall survival and reintervention. Periprocedural stroke remains a principle concern.

Output from VIP cells of the mammalian central clock regulates daily physiological rhythms.

The suprachiasmatic nucleus (SCN) circadian clock is critical for optimising daily cycles in mammalian physiology and behaviour. The roles of the various SCN cell types in communicating timing information to downstream physiological systems remain incompletely understood, however. In particular, while vasoactive intestinal polypeptide (VIP) signalling is essential for SCN function and whole animal circadian rhythmicity, the specific contributions of VIP cell output to physiological control remains uncertain. Here we reveal a key role for SCN VIP cells in central clock output. Using multielectrode recording and optogenetic manipulations, we show that VIP neurons provide coordinated daily waves of GABAergic input to target cells across the paraventricular hypothalamus and ventral thalamus, supressing their activity during the mid to late day. Using chemogenetic manipulation, we further demonstrate specific roles for this circuitry in the daily control of heart rate and corticosterone secretion, collectively establishing SCN VIP cells as influential regulators of physiological timing.

Changes in neuronal activity across the mouse ventromedial nucleus of the hypothalamus in response to low glucose: Evaluation using an extracellular multi-electrode array approach.

The hypothalamic ventromedial nucleus (VMN) is involved in maintaining systemic glucose homeostasis. Neurophysiological studies in rodent brain slices have identified populations of VMN glucose-sensing neurones: glucose-excited (GE) neurones, cells which increased their firing rate in response to increases in glucose concentration, and glucose-inhibited (GI) neurones, which show a reduced firing frequency in response to increasing glucose concentrations. To date, most slice electrophysiological studies characterising VMN glucose-sensing neurones in rodents have utilised the patch clamp technique. Multi-electrode arrays (MEAs) are a state-of-the-art electrophysiological tool enabling the electrical activity of many cells to be recorded across multiple electrode sites (channels) simultaneously. We used a perforated MEA (pMEA) system to evaluate electrical activity changes across the dorsal-ventral extent of the mouse VMN region in response to alterations in glucose concentration. Because intrinsic (ie, direct postsynaptic sensing) and extrinsic (ie, presynaptically modulated) glucosensation were not discriminated, we use the terminology 'GE/presynaptically excited by an increase (PER)' and 'GI/presynaptically excited by a decrease (PED)' in the present study to describe responsiveness to changes in extracellular glucose across the mouse VMN. We observed that 15%-60% of channels were GE/PER, whereas 2%-7% were GI/PED channels. Within the dorsomedial portion of the VMN (DM-VMN), significantly more channels were GE/PER compared to the ventrolateral portion of the VMN (VL-VMN). However, GE/PER channels within the VL-VMN showed a significantly higher basal firing rate in 2.5 mmol l-1 glucose than DM-VMN GE/PER channels. No significant difference in the distribution of GI/PED channels was observed between the VMN subregions. The results of the present study demonstrate the utility of the pMEA approach for evaluating glucose responsivity across the mouse VMN. pMEA studies could be used to refine our understanding of other neuroendocrine systems by examining population level changes in electrical activity across brain nuclei, thus providing key functional neuroanatomical information to complement and inform the design of single-cell neurophysiological studies.

CNS Targets of Adipokines.

Our understanding of adipose tissue as an endocrine organ has been transformed over the last 20 years. During this time, a number of adipocyte-derived factors or adipokines have been identified. This article will review evidence for how adipokines acting via the central nervous system (CNS) regulate normal physiology and disease pathology. The reported CNS-mediated effects of adipokines are varied and include the regulation of energy homeostasis, autonomic nervous system activity, the reproductive axis, neurodevelopment, cardiovascular function, and cognition. Due to the wealth of information available and the diversity of their known functions, the archetypal adipokines leptin and adiponectin will be focused on extensively. Other adipokines with established CNS actions will also be discussed. Due to the difficulties associated with studying CNS function on a molecular level in humans, the majority of our knowledge, and as such the studies described in this paper, comes from work in experimental animal models; however, where possible the relevant data from human studies are also highlighted. © 2017 American Physiological Society. Compr Physiol 7:1359-1406, 2017.