Sex disparities in popliteal artery aneurysms.

OBJECTIVE: Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS: POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS: Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS: Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Filarial extract of Litomosoides sigmodontis induces a type 2 immune response and attenuates plaque development in hyperlipidemic ApoE-knockout mice.

A type 1 immune response is involved in atherosclerosis progression, whereas the role of a type 2 polarization, especially with regard to an enhanced T helper (Th)2 cell differentiation, is still unclear. Helminths trigger type 2 immune responses, protecting the host from inflammatory disorders. We investigated whether an increased type 2 polarization by administration of Litomosoides sigmodontis adult worm extract (LsAg) affects atherosclerosis in apolipoprotein E-deficient (ApoE-/-) mice. Injections of 50 µg LsAg, i.p. into ApoE-/- mice induced a type 2 immune response shown by increased frequencies of peritoneal eosinophils and alternatively activated macrophages. To analyze the effect of LsAg on atherosclerosis initiation, ApoE-/- mice received a high-fat diet for 12 wk and weekly injections of 50 µg LsAg from wk 5 to 12. Therapeutic effects on advanced atherosclerosis were analyzed in mice that were fed a high-fat diet for 12 wk followed by 12 wk of normal chow and weekly LsAg injections. Both preventive and therapeutic LsAg application significantly decreased plaque size. Therapeutic treatment even caused regression of plaque size and macrophage density in the aortic root and reduced Th1-specific gene expression and intraplaque inflammation. In addition, plaque size after therapeutic treatment was inversely correlated with plaque-infiltrated alternatively activated macrophages. In vitro, LsAg treatment of HUVECs reduced intracellular levels of phosphorylated NF-κB-p65, IκB-α, and JNK1/2. In bifurcation flow-through slides, THP-1 cell adhesion to a HUVEC monolayer was decreased by LsAg in regions of nonuniform shear stress. Applying inhibitors of the respective kinases suggests JNK1/2 inhibition is involved in the suppressed cell adhesion. A switch to an enhanced type 2 immune response by LsAg exerts antiatherogenic effects on murine plaque development, indicating a protective role of a hampered type 1 polarization. In vitro, LsAg affects endothelial signaling pathways, among which JNK1/2 inhibition seems to be involved in the suppression of monocytic cell adhesion under proatherogenic shear stress.-Constanze, K., Tauchi, M., Furtmair, R., Urschel, K., Raaz-Schrauder, D., Neumann, A.-L., Frohberger, S. J., Hoerauf, A., Regus, S., Lang, W., Sagban, T. A., Stumpfe, F. M., Achenbach, S., Hübner, M. P., Dietel, B. Filarial extract of Litomosoides sigmodontis induces a type 2 immune response and attenuates plaque development in hyperlipidemic ApoE-knockout mice.

Reconstruction for renal artery aneurysms using the tailoring technique.

OBJECTIVE: Renal artery (RA) aneurysm (RAA) is a rare and complex disease. Treatment options for a RAA include endovascular surgery and open surgery with ex vivo repair or in situ reconstruction. This study evaluated the long-term outcome after vascular reconstruction of RAAs using the tailoring technique. Tailoring or aneurysmorrhaphy means a partial resection of the aneurysm with direct suture of the remaining arterial wall. METHODS: A single-center retrospective study was conducted between January 1990 and December 2015. The tailoring technique was used to surgically repair 88 RAAs in 80 patients (52 women) with a mean age of 52.9 years. Patients' demographic data, vascular therapy, and renal function during follow-up were retrospectively evaluated. RESULTS: The localization of the RAA was at the right kidney in 58 patients. The mean size of the aneurysm was 21.4 ± 9.7 mm (range, 8-67 mm). Hypertension was diagnosed in 56 patients, and 23 were asymptomatic. One RAA was ruptured. The overall morbidity rate was 16.3%, including bleeding (n = 4), RA stenosis (n = 3), RA occlusion (n = 4), RA dissection (n = 1), and myocardial infarction (n = 1). One patient died of myocardial infarction for a 30-day mortality rate of 1.3%. The 30-day primary patency rate was 90.0%. The 30-day secondary patency rate was 95.0%. Follow-up data were obtained from 71 patients who underwent tailoring in 78 RAAs. The mean follow-up period was 60.7 months (range 2-229 months). In 76.4% of patients with RAA and hypertension, RAA reconstruction contributed to the cure or improvement of hypertension. The long-term patency after RAA reconstruction was demonstrated in a Kaplan-Meier curve, with cumulative patency rates of 98.7%, 97.4%, 94.8%, and 92.3% after 18, 24, 36, and 48 months, respectively. Estimated survival rates were 98.8%, 97.5%, and 96.3% after 12, 48, and 60 months, with an estimated mean time of 216.5 ± 7.2 months. CONCLUSIONS: The tailoring technique is a safe and effective procedure with good long-term outcomes. RAA reconstruction contributed to the cure or improvement of renovascular hypertension.

Results of Renal Transplantation on Alloplastic Arterial Grafts.

BACKGROUND: The aim of this retrospective study was to report results of a consecutive series of kidney transplant patients in whom the renal artery was implanted on a prosthetic vascular graft (PVG). METHODS: Between January 2011 and December 2014, 208 deceased donor renal transplantations (68 female, 140 male, mean age 52, SD 16 years) were performed. Medical charts and outpatient clinical records of patients who had undergone renal artery implantation on a PVG were reviewed. Extensive literature research added to our 4 patients further 170 published cases during 1989 and 2015 and was compared with regular transplanted patients. Data on patient characteristics, prior vascular procedures, postoperative and long-term outcome were collected. RESULTS: Patients with transplant renal artery anastomosis on a PVG were 4 years older than the control group. Function of the graft was similar in these patients compared to regular renal transplant patients. Resistance indices assessed in our clinic over the entire follow-up period showed also no significant difference between the 2 groups. Thirty-day mortality was 6% (none in our group), which occurred mostly in combination when renal transplantation and PVG replacement was performed simultaneously. CONCLUSION: Grafting of the renal artery to a PVG is feasible and yields good results, despite the technical difficulties involved.

Elevated risk of thrombophilia in agenesis of the vena cava as a factor for deep vein thrombosis.

BACKGROUND: Congenital absence of the inferior vena cava (AIVC) is a rare malformation which may be associated with an increased risk for deep vein thrombosis (DVT). However, the role of thrombophilia in AIVC and DVT is unknown. METHODS: Between 1982 and 2013 41 patients (12 female, 29 male, mean age 28 S.D. 11 years) were detected at the University of Düsseldorf, Germany, with AIVC. Based on medical history, clinical examination, imaging and coagulation studies, we performed on this collective a risk characterisation. Extensive literature research added further 123 published cases during 1993 and 2013. AIVC-patients were compared with iliocaval DVT-patients without AIVC (n = 168) treated during the same period in our clinic (90 female, 78 male, mean age 38 S.D. 17 years). RESULTS: In contrast to classical DVT younger men were more often affected. Factor-V-Leiden-mutation, 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphism and hyperhomocysteinemia individually are associated with an increased risk of DVT in patients with AIVC. Aplasia/hypoplasia of the right or left kidney is also associated with IVCA. CONCLUSIONS: AIVC should be considered in young patients who present with DVT involving the vena cava. Analysis of publications with AIVC and our patients yielded a typical spectrum of AIVC-associated DVT characteristics: AIVC occurs in young male adults, is revealed by proximal DVT, not necessarily accused by precipitating factors like immobilisation, and is mostly located bilateral. Hereditary coagulation abnormalities seem to be more often a contributing factor for DVT in AIVC.

Subclavian carotid transposition: immediate and long-term outcomes of 126 surgical reconstructions.

BACKGROUND: Subclavian carotid transposition (SCT) is a safe, effective, and durable treatment in atherosclerotic disease of the proximal subclavian artery. We report about our experience in SCT in a retrospective study with a long-term outcome in 126 cases and discuss our results with the current literature. METHODS: From January 1995 to December 2013, we treated 126 patients (51 men, 75 women; mean age, 60.9 years; range, 25-80 years) for proximal subclavian atherosclerotic lesions. Preoperative angiography revealed 58 stenoses (46.0%) and 68 occlusions (54.0%). We performed 126 SCTs. The following parameters were documented through a retrospective chart review: demographic data, occlusion site, preoperative symptoms, cardiovascular risk profile, coexisting cerebrovascular disease, and postoperative outcome. Continuous variables are summarized as mean. Categoric variables are expressed as frequency and percentage. Survival and patency rates were estimated using Kaplan-Meier analysis. RESULTS: Four immediate occlusions and 1 hemodynamic relevant stenosis (4.0%) occurred postoperatively. Thrombectomy was successful in 2 and a carotid axillary bypass was performed in 3 cases. Three strokes occurred, one during concomitant carotid endarterectomy. The 30-day mortality was 0%. Follow-up data were obtained on 106 of 126 patients (84.0%). The mean follow-up period was 53.8 months (range, 3-159 months). Twenty-three (18.3%) late deaths occurred. Estimated survival was 121.48 ± 6.86 months (range, 3-112 months). Ninety-five percent reported continuous resolution of symptoms. Primary patency rate was 96.0% and secondary patency rate was 100% at 30 days. The long-term patency rate was 96.3% at a mean follow-up of 53.8 months. CONCLUSIONS: SCT is safe, effective, and durable in the long term. SCT is a standard procedure for occlusion and stenosis. Vessel occlusions, ineffective angioplasty, and preparation for thoracic stent grafting make SCT an important procedure in the surgeon's repertoire.

Vascular challenges in renal transplantation.

BACKGROUND: The increasing demand for transplantable organs, especially kidneys, has led to expanded criteria for renal transplant donors. As a result of the expanded criteria, more organs with vascular anomalies and/or pathologies are available for transplant. This retrospective study evaluated the impact of vascular repair on the outcome in kidney transplantation in a single center over a 15-year period. MATERIAL AND METHODS: Between January 1997 and May 2012, 1134 deceased donor renal transplantations were performed in the Department for Vascular and Endovascular Surgery of the University of Düsseldorf, Germany. RESULTS: A vascular reconstruction of some type was necessary to repair renal vessels or to prepare the recipient site for transplantation in 374 of 1134 (33.0%) renal transplantations. The iliac artery in 12.3% (139/1134) of cases and the renal artery in 10.1% (115/1134) of cases showed severe atherosclerosis and a thrombo-endarterectomy was required. Organ loss occurred in 13 cases (1.1%) due to vascular failure. The 5-year graft survival for kidneys with reconstructed renal arteries was 84.3% in deceased donor renal transplantations (86.1% without arterial reconstruction). CONCLUSIONS: The demand for renal transplants has led to more marginal-quality organs and older donors and/or recipients waiting for a second or third transplantation. Thus, the expertise of a vascular surgeon is extremely helpful in a transplantation center because it allows for marginal organ transplantation with acceptable 5-year graft survival rates.

Isolated dissection of the superior mesenteric artery treated using open emergency surgery.

BACKGROUND: Isolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts. METHODS: Two cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided. RESULTS: Both patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities. CONCLUSION: Open surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.

Long-term graft outcome after renal arterial reconstruction during living related kidney transplantation.

BACKGROUND/OBJECTIVES: The aim of this retrospective study was to evaluate the repair of vascular variations/pathologies in living donor kidney transplantations in a single centre over a 15-year period. METHODS: Between 01/1997 and 05/2012, 338 living donor renal transplantations were performed in the Department for Endovascular and Vascular Surgery, University of Düsseldorf, Germany. Twenty-four of them showed disorders, like multiple renal arteries (MRA), atherosclerotic stenosis or fibromuscular dysplasia (FMD) needing vascular repair before transplantation. RESULTS: Mean age of donors was 51 ± 11.2, in recipient's 44 ± 13.9 years. In seven transplantations, renal artery (RA) repair was performed because of MRA. Atherosclerotic stenosis of the RA was apparent in 12 cases needing a repair with disobliteration. FMD was the reason in five transplantations for vascular repair. Complications like renal vessel thrombosis, lymphocele, heamorrhage, distal urinary leakage and ureteral obstruction was not significantly associated with RA reconstruction. Comparison of renal function in kidneys with reconstructed RA compared with kidneys without vascular repair showed no significant difference in primary function and serum creatinine up to the first year after transplantation. Mean follow-up was 75.6 ± 48.1 months. The 5-year graft survival rate for kidneys with RA repair was 88.5 vs. 93.4 % without reconstruction. CONCLUSIONS: We could show that RA pathologies, suitable repaired, are not a contraindication for transplantation with acceptable 5-year-graft-survival rates.

[Atherosclerosis--progression by nonspecific activation of the immune system]. / Atherosklerose--Progression durch unspezifische Aktivierung des Immunsystems.

Atherogenesis is a disease of middle-sized and large-caliber blood vessels that can be divided into three major phases. The initial lesions of early atherosclerosis are characterized by the adhesion and subendothelial emigration of blood-borne monocytes, which differentiate into macrophages and provide the morphologic basis for the formation of foam cells and fatty streak lesions. These lesions are found in most children and teenagers in industrialized nations. The next key event in atherogenesis is the proliferation of smooth muscle cells within the intima and media, resulting in the gradual compromise of the vessel lumen. Myofibroblastic cells also contribute to lesion growth through the production of excessive amounts of extracellular matrix. Such lesions are clinically silent unless progression to the next phase continues: the lesions degenerate, forming a mostly necrotic "lipid core" consisting of extracellular lipid, cholesterol crystals, inflammatory cells and necrotic debris. A fibrous cap is formed which prevents the interaction of blood cells, particularly of platelets with the highly proaggregatory material found in the lipid core. However, continuous inflammatory activity and/or heightened mechanical stress (i.e., in hypertension) tends to weaken the fibrous caps. Eventually, plaque rupture ensues, platelets aggregate, and the lesions become clinically manifest in such dramatic events as myocardial infarction, stroke, or mesenteric ischemia. Research into lesion formation and progression is limited by the fact that lesions develop in silence over many decades and that animal models only incompletely model the situation in humans. Most currently debated concepts accept the "response to injury" hypothesis formulated by the late Russell Ross and the multi-factorial nature of atherogenesis. The discussion today circles around the relative contributions of low density lipoproteins (oxidized or enzymatically modified LDL?), the immune response (adaptive or innate?), infectious agents (CMV, Chlamydia pneumoniae?), and/or hereditary factors, to name only a few of the most widely debated concepts. Irrespective of the outcome of this pathomechanistic discussion, the knowledge of established risk factors (hypercholesterolemia, hypertension, diabetes, smoking, etc.) and protective interventions (lifestyle changes, physical exercise, "healthy" diets, effective dietary and pharmacologic control of hyperglycemia, blood pressure or hyperlipidemia) has helped to define atherosclerosis as a "new entity" that has little to do with the archaic concept of a "degenerative" vessel disease. The new concept takes us into the responsibility--puts us in charge of our own and our patients' cardiovascular risk--whether we like it or not. The smoking obese doctor no longer fits into the modern medical landscape.