Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. METHODS: In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause. RESULTS: In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. CONCLUSIONS: Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).

Impacts, Tolerance, Adaptation, and Mitigation of Heat Stress on Wheat under Changing Climates.

Heat stress (HS) is one of the major abiotic stresses affecting the production and quality of wheat. Rising temperatures are particularly threatening to wheat production. A detailed overview of morpho-physio-biochemical responses of wheat to HS is critical to identify various tolerance mechanisms and their use in identifying strategies to safeguard wheat production under changing climates. The development of thermotolerant wheat cultivars using conventional or molecular breeding and transgenic approaches is promising. Over the last decade, different omics approaches have revolutionized the way plant breeders and biotechnologists investigate underlying stress tolerance mechanisms and cellular homeostasis. Therefore, developing genomics, transcriptomics, proteomics, and metabolomics data sets and a deeper understanding of HS tolerance mechanisms of different wheat cultivars are needed. The most reliable method to improve plant resilience to HS must include agronomic management strategies, such as the adoption of climate-smart cultivation practices and use of osmoprotectants and cultured soil microbes. However, looking at the complex nature of HS, the adoption of a holistic approach integrating outcomes of breeding, physiological, agronomical, and biotechnological options is required. Our review aims to provide insights concerning morpho-physiological and molecular impacts, tolerance mechanisms, and adaptation strategies of HS in wheat. This review will help scientific communities in the identification, development, and promotion of thermotolerant wheat cultivars and management strategies to minimize negative impacts of HS.

Isolation and characterization of drought and ABA responsive promoter of a transcription factor encoding gene from rice.

Water deficit is a significant impediment to enhancing rice yield. Genetic engineering tools have enabled agriculture researchers to develop drought-tolerant cultivars of rice. A common strategy to achieve this involves expressing drought-tolerant genes driven by constitutive promoters such as CaMV35S. However, the use of constitutive promoters is often limited by the adverse effects it has on the growth and development of the plant. Additionally, it has been observed that monocot-derived promoters are more successful in driving gene expression in monocots than in dicots. Substitution of constitutive promoters with stress-inducible promoters is the currently used strategy to overcome this limitation. In the present study, a 1514 bp AP2/ERF promoter that drives the expression of a transcription factor was cloned and characterized from drought-tolerant Indian rice genotype N22. The AP2/ERF promoter was fused to the GUS gene (uidA) and transformed in Arabidopsis and rice plants. Histochemical GUS staining of transgenic Arabidopsis plants showed AP2/ERF promoter activity in roots, stems, and leaves. Water deficit stress and ABA upregulate promoter activity in transformed Arabidopsis and rice. Quantitative PCR for uidA expression confirmed induced GUS activity in Arabidopsis and rice. This study showed that water deficit inducible Os-AP2/ERF-N22 promoter can be used to overcome the limitations of constitutive promoters. Transformants overexpressing Os-AP2/ERF-N22 showed higher relative water content, membrane stability index, total chlorophyll content, chlorophyll stability index, wax content, osmotic potential, stomatal conductance, transpiration rate, photosynthetic rate and radical scavenging activity. Drought tolerant (N22) showed higher expression of Os-AP2/ERF-N22 than the susceptible (MTU1010) cultivar. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-022-01246-9.

Evaluating the potential of circulating hTERT levels in glioma: can plasma levels serve as an independent prognostic marker?

Glioma is an aggressive primary Neuro-epithelial tumor with dismal prognosis, since there is a lack of molecular work-up during routine radiological monitoring of the disease. Currently, a number of potential molecular prognostic and predictive biomarkers are being characterized in line with structured diagnosis defined in World Health Organization guidelines 2016. Human-telomerase reverse-transcriptase (hTERT), a marker of proliferation and maintenance of genomic integrity has thus been investigated for its clinical relevance as an independent prognosticator in glioma. Expression of the protein in tumor tissue and in plasma of 72 diffuse glioma patients (astrocytoma) grade II-IV was determined and compared with relevant controls using immunofluorescence-immunohistochemistry and enzyme-linked immuno-sorbent assay. Appropriate statistical tests were applied to establish a correlation between on-site tumor and circulating levels of the marker and its independence of covariates. Expression of the marker in glioma tissues was significantly different from controls (p < 0.0001) and could discriminate within grades with ≥80% sensitivity. The tissue and plasma levels were positively associated with grades (r = 0.8845, p < 0.0001) and (r = 0.2834, p = 0.0158) respectively, while an inverse correlation with overall survival (r = -0.6558, p < 0.0001) and (r = -0.3941, p = 0.0006) respectively, was recorded. Plasma hTERT was significantly correlated with corresponding intra-tumor expression of hTERT (r = 0.2794, p = 0.0175). Multivariate Cox-regression identified plasma hTERT (p < 0.0005) as a prognostic factor; not associated with age, site or extent of resection (p > 0.05). This is the first experimental evidence for association of higher plasma levels of hTERT with overall survival in both low and high grade glioma.

Superior Lower Extremity Vein Graft Bypass Patency among Married Patients with Peripheral Artery Disease.

BACKGROUND: Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. METHODS: Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. RESULTS: Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3 ± 10.8 years vs. 62.2 ± 10.6 years; P = 0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P = 0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82 ± 0.57 mm vs. 2.52 ± 0.65 mm; P = 0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P = 0.05); other predictive covariates included preoperative antiplatelet therapy (HR = 0.27; 95% confidence limits [0.10, 0.74]; P = 0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93-7.04]; P = 0.07). CONCLUSIONS: Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.

Gender-specific Differences in Great Saphenous Vein Conduit. A Link to Lower Extremity Bypass Outcomes Disparities?

BACKGROUND: Inferior lower extremity bypass (LEB) outcomes have been reported among women with peripheral arterial disease (PAD), but the mechanisms responsible for this disparity are unknown. Great saphenous vein (GSV) is considered the conduit of choice for LEB; GSV diameter is associated with graft patency and therefore is often used as a criterion for suitability for use as bypass conduit. We hypothesized that gender-based differences in GSV may contribute to LEB outcomes disparities. To explore this hypothesis, we performed a gender-based analysis of GSV anatomic characteristics among patients with PAD who were studied with duplex ultrasound vein mapping during evaluation for LEB. METHODS: Consecutive patients undergoing ultrasound vein mapping for planned LEB were analyzed. Minimum above- and below-knee GSV diameters were obtained in addition to demographic, procedural, and clinical data. Associations between gender and GSV diameter were evaluated using multivariate mixed models adjusting for anatomic location and within-patient correlation. RESULTS: One hundred five patients were analyzed. Mean patient age was 65 ± 11 years, 25% were women, and 78% were white. Mixed model estimates of minimum GSV diameters were 3.14 ± 0.09 mm above knee and 2.74 ± 0.09 below knee for men versus 3.23 ± 0.14 above-knee and 2.49 ± 0.14 below knee for women. A gender-based interaction between anatomic location and GSV diameter was identified, with women having a greater difference between above- and below-knee GSV diameters (or taper; mean difference of 0.73 ± 0.12 vs. 0.41 ± 0.17 mm; P = 0.017). CONCLUSIONS: GSV taper (difference between above- and below-knee diameters) is greater in women and may contribute to inferior patency after LEB with vein conduit, particularly for below-knee target vessels. Further research is necessary to evaluate specific hemodynamic effects of graft taper and links with other clinical endpoints. In addition to minimum diameter, vein graft taper may warrant consideration when planning LEB.

Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions.

BACKGROUND: Endovascular intervention is considered the first-line treatment for chronic mesenteric ischemia (CMI) when feasible. Two-vessel revascularization is most definitive when celiac (CA) and superior mesenteric arteries (SMA) are diseased, but single-vessel intervention may be performed in patients with 2-vessel disease due to anatomic/technical factors. We evaluated anatomic predictors of clinical outcomes associated with endovascular treatment of CMI among patients with occlusive SMA lesions. METHODS: Patients with CMI treated with endovascular revascularization over 10 years were identified. Patients with SMA occlusions were selected for analysis. Between-group comparisons based on inclusion of an SMA revascularization were evaluated using t-test and chi-squared test. Freedom from symptomatic recurrence or repeat intervention was analyzed using proportional hazards regression. RESULTS: Fifty-four patients with CMI were analyzed. Sixteen (29.6%) patients had CA-only intervention, and 38 (70.4%) patients had SMA revascularization with or without CA intervention. No significant differences in demographics or comorbidity were identified between groups. In the CA-only intervention group, 8 of the 16 (50%) patients developed symptomatic recurrence compared with 8 of the 31 (21.1%) patients whose intervention included the SMA. Patients treated without SMA intervention also had decreased freedom from both symptomatic recurrence (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.2-8.6, P = 0.016) and repeat intervention (HR 5.5, 95% CI 1.8-16.3, P = 0.001). CONCLUSIONS: Among patients with CMI and occlusive SMA lesions, SMA revascularization appears to be the key determinant for symptomatic outcomes and repeat intervention. Patient counseling should include potential future need for surgical revascularization if endovascular SMA treatment cannot be accomplished.

Association between childhood allergic disease, psychological comorbidity, and injury requiring medical attention.

BACKGROUND: Children with allergic disease have multiple risk factors for accidental injuries. OBJECTIVE: To determine the prevalence of injuries requiring medical treatment in US children with allergic disease. METHODS: The authors analyzed data from the 2007 to 2008 National Survey of Children's Health, including a nationally representative sample of 27,556 children 0 to 5 years old. RESULTS: The prevalence (95% confidence interval [CI]) of at least 1 allergic disease was 29.4% (28.0-30.8); 6.6% (5.8-7.4) were diagnosed with asthma, 15.0% (14.0-16.0) with eczema, 11.6% (10.6-12.6) with hay fever, and 6.1% (5.4-6.9) with food allergy. Children with allergic disorders had higher odds of at least 1 comorbid psychiatric and behavioral disorder (PBD; survey logistic regression; odds ratio 2.93, 95% CI 2.13-4.03), including attention-deficit/hyperactivity disorder (4.75, 2.89-7.80), depression (6.03, 1.29-28.27), anxiety (5.54, 2.70-11.37), conduct/oppositional defiant disorder (2.97, 1.88-4.70), and learning delay (2.49, 1.70-3.66), but not autism/Asperger disorder (1.89, 0.98-3.64). The prevalence of injury in the past year requiring medical attention was 10.5% (95% CI 9.5-11.4). The association between allergic disease and injury requiring medical attention was mediated in part by a PBD (Sobel test 0.0021, 95% CI 0.0014-0.0029, P < .0001; bootstrapping approach, indirect effects, odds ratio 1.005, 95% CI 1.003-1.007; Baron-Kenny ß(yx,m) = 0.04, P < .0001, R(2) = 0.002). However, children with at least 1 allergic disorder (1.74, 1.23-2.46), including eczema (1.59, 1.01-2.50), asthma (1.91, 1.10-3.31), hay fever (2.05, 1.24-3.39), and food allergies (2.00, 1.10-3.67), had higher odds of sustaining injuries even after controlling for comorbid PBDs and medical disorders. CONCLUSION: The results suggest that the association between allergic disease and injury is multifactorial, including being secondary to PBD.

Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine.

BACKGROUND: Spinal tuberculosis is the most common form of skeletal tuberculosis. Various approaches have been described for surgical management of spinal tuberculosis, but many entail wide exposures with attendant morbidity; whether minimally invasive surgical (MIS) approaches are suitable is unknown. QUESTIONS/PURPOSES: We evaluated (1) neurologic results, (2) radiographic results, and (3) complications in patients with thoracic and lumbar spinal tuberculosis treated with two MIS approaches. METHODS: We retrospectively evaluated 22 patients with thoracic and lumbar tuberculosis managed surgically from October 2008 to February 2011 using MIS methods; one patient was lost to followup, leaving 21 patients with a minimum followup of 15 months (mean, 30 months; range, 15-59 months) for analysis. MIS approaches were used for patients with disease below D6 and minimum pedicle diameters of 4.5 mm to permit percutaneous screw placement. The MIS approach was divided into two groups depending on the extent of destruction of the vertebral body: a posterior-only group (n = 9), where posterior transpedicular decompression sufficed, and the hybrid group (n = 12), requiring anterior débridement and ventral-column reconstruction by conventional or mini-open thoracotomy. All but two patients with more than two contiguous bodies involvement underwent MIS posterior fixation by percutaneous transpedicular screws. Plain radiographs were evaluated for deformity correction and correction maintenance. Neurologic recovery and complications were ascertained by chart review. RESULTS: All patients with neurologic deficits recovered completely with no motor deficits at followup; 13% improved by three grades, 53% by two grades, and 33% by one grade. Mean correction was 2.5° (thoracic) and 8° (lumbar) in the posterior-only group and 4.2° in the hybrid group. Some correction loss occurred with healing (2° and 1.6° in the posterior-only and hybrid groups, respectively), but in none of those who had fixation did this progress to more than preoperative status. Two of 22 patients (9%) had complications. One had a malposition of L5 screw causing painful radiculopathy without motor deficit and required repositioning. The other had an intraoperative dural tear repaired by onlay fascial patch and cerebrospinal fluid diversion. There were no approach-related complications, neurologic deterioration, or implant fatigue at last followup. CONCLUSIONS: We found evidence of neurologic recovery, avoidance of deformity progression, and few complications with these MIS approaches. Comparative trials are called for between open and MIS approaches for patients with spinal tuberculosis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Multi-modal medical image fusion using improved dual-channel PCNN.

This paper proposes a medical image fusion method in the non-subsampled shearlet transform (NSST) domain to combine a gray-scale image with the respective pseudo-color image obtained through different imaging modalities. The proposed method applies a novel improved dual-channel pulse-coupled neural network (IDPCNN) model to fuse the high-pass sub-images, whereas the Prewitt operator is combined with maximum regional energy (MRE) to construct the fused low-pass sub-image. First, the gray-scale image and luminance of the pseudo-color image are decomposed using NSST to find the respective sub-images. Second, the low-pass sub-images are fused by the Prewitt operator and MRE-based rule. Third, the proposed IDPCNN is utilized to get the fused high-pass sub-images from the respective high-pass sub-images. Fourth, the luminance of the fused image is obtained by applying inverse NSST on the fused sub-images, which is combined with the chrominance components of the pseudo-color image to construct the fused image. A total of 28 diverse medical image pairs, 11 existing methods, and nine objective metrics are used in the experiment. Qualitative and quantitative fusion results show that the proposed method is competitive with and even outpaces some of the existing medical fusion approaches. It is also shown that the proposed method efficiently combines two gray-scale images.

Novel extra-anatomic intra-abdominal reconstruction for treatment of paravisceral aortic infection.

Adequate treatment of native or prosthetic aortic infection requires extensive surgical debridement and establishing flow to the extremities using extra-anatomic or in situ reconstruction, each with its inherent limitations. Infection of the paravisceral aortic segment precludes an axillofemoral bypass as the sole treatment because of inability to provide visceral perfusion. In situ autograft or allograft reconstructions could be limited by conduit availability or significantly prolonged operative time, or both. Placement of an antibiotic-soaked prosthetic in a field with gross purulence carries a high risk of reinfection. We describe a technique for extra-anatomic, intra-abdominal reconstruction using an antibiotic-soaked prosthetic graft to avoid the infected paravisceral aortic bed and achieve antegrade lower extremity and visceral vessel perfusion.

Intimal sarcoma in an inflammatory aneurysm after endovascular aneurysm repair.

Long-term outcomes after endovascular aneurysm repair (EVAR) for inflammatory aneurysms are unknown. We present a young patient with new-onset back pain and failure to thrive 6 years after EVAR for an inflammatory abdominal aortic aneurysm (AAA). Endograft explanation was performed with a presumed diagnosis of infection. Pathology revealed intimal sarcoma in the excluded aneurysm sac with liver metastasis. This report presents a detailed review of literature regarding potential association of prosthetic implantation and carcinogenesis.

Can a signature molecular-profile define disparate survival in BRAF-positive Gliosarcoma and identify novel targets for therapeutic intervention?

Purpose: Gliosarcoma (GS) has a low incidence but is aggressively invasive, with poor-survival. Even though GS is recognized as a different subgroup from glioblastoma (GB), there is no molecular panel available to define its clinical outcome. The objective was to identify the molecular imprint of GS in terms of expression of human telomerase reverse transcriptase (hTERT), high mobility group A1 (HMGA-1), kinesin superfamily protein-14 (KIF-14), epidermal growth factor receptor (EGFR) markers with reference to disparate prognosis and identify plausible targets for intervention. Materials and Methods: We retrieved 9-GS samples from a cohort of 57-GB patients during a 36 months study period and compared them with 10 molecularly typed GB-samples and 15 controls. Conventional-immunohistochemistry (IHC) was used for histopathology of GS and immunofluorescence-IHC was performed for quantification of identified marker-panel. Statistical tools for non-parametric data were used for inferring results. Results: GS was confirmed by reticulin-staining and positivity for glial fibrillary acidic protein, Vimentin, smooth muscle actin. Immune-reactivity for BRAF-V600Ewas present in both glial and sarcomatous cells and negative expression of isocitrate dehydrogenase, ATRX, TP53.Comparison between GS, GB, and control tissues showed that the expression of markers reached significance (P < 0.0001), without the influence of confounders. Significant correlation of EGFR was found with hTERT (r = 0.77), HMGA-1 (r = 0.72), KIF-14 (r = 0.82) suggesting that their combined analysis can define prognosis. To establish the diagnostic accuracy (threshold ≥80% specificity), AUC for EGFR was 0.78 (>3.95), KIF-14 0.97 (>7.45), hTERT 0.63 (>23.86), and HMGA-1 0.53 (>15.45). Conclusion: This is the first evidence-based investigation presenting differential expression of proliferation and stemness markers hTERT, HMGA-1, KIF-14 in-correlation with EGFR, indicating a plausible-association between survival and disease-progression in individual GS-cases. It can serve as a model for further studies in this glioma-subgroup and the designing of a target panel for personalized treatment.

Insight of PBZ mediated drought amelioration in crop plants.

Water scarcity is a significant environmental limitation to plant productivity as drought-induced crop output losses are likely to outnumber losses from all other factors. In this context, triazole compounds have recently been discovered to act as plant growth regulators and multi-stress protectants such as heat, chilling, drought, waterlogging, heavy metals, etc. Paclobutrazol (PBZ) [(2RS, 3RS)-1-(4-chlorophenyl)- 4, 4-dimethyl-2-(1H-1, 2, 4-trizol-1-yl)-pentan-3-ol)] disrupts the isoprenoid pathway by blocking ent-kaurene synthesis, affecting gibberellic acid (GA) and abscisic acid (ABA) hormone levels. PBZ affects the level of ethylene and cytokinin by interfering with their biosynthesis pathways. Through a variety of physiological responses, PBZ improves plant survival under drought. Some of the documented responses include a decrease in transpiration rate (due to reduced leaf area), higher diffusive resistance, relieving reduction in water potential, greater relative water content, less water use, and increased antioxidant activity. We examined and discussed current findings as well as the prospective application of PBZ in regulating crop growth and ameliorating abiotic stresses in this review. Furthermore, the influence of PBZ on numerous biochemical, physiological, and molecular processes is thoroughly investigated, resulting in increased crop yield.

On-farm hydro and nutri-priming increases yield of rainfed pearl millet through physio-biochemical adjustments and anti-oxidative defense mechanism.

Seed priming technique has a marvelous potential in enhancing seed germination and crop establishment under limited soil moisture conditions, which ultimately increases yield. Therefore, we investigated the effects of seed priming on physiology, growth, yield and antioxidant defense system of pearl millet (Pennisetum glaucum L.) under rain-fed condition. The experiments were conducted under laboratory as well as field conditions comprising three treatments i.e., non-primed seeds (control, T0), priming with tap water (hydropriming) (T1) and priming with 2% KNO3 2% for 6 hours at 25°C followed by shade drying (T2). The results showed that chlorophyll content (10.37-14.15%) and relative water content (RWC) (12.70-13.01%) increased whereas proline (-19.44 to -25%) and soluble sugar (-15.51 to -29.13%) contents decreased on account of seed priming in pearl millet under field conditions. The seed priming significantly improved the plant height, final plant stand and grain weight which resulted in increased yield. Enhanced activities of superoxide dismutase (SOD) (5.89 to 8.10 unit/g/seed/min), catalase (CAT) (22.54 to 39.67 µmol/min/g/seed) and ascorbate peroxidase (APX) (8.92 to 22.10 µmol/cm/min/g) and concomitant decrease in H2O2 and malondialdehyde (MDA) content suggests their role in imparting oxidative tolerance at initial stages of growth in primed seed. The lab studies suggest that the improved yield might be attributes to increased seed germination and seedling vigor. It is recommended that the hydropriming (tap water) or KNO3 (2%) priming of seeds for 6 hours under ambient conditions is effective to enhance growth and yield of pearl millet under rainfed conditions.

Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava.

OBJECTIVES: To identify factors affecting long-term outcome after open surgical reconstructions (OSR) and hybrid reconstructions (HR) for chronic venous obstructions. METHODS: Retrospective review of clinical data of 60 patients with 64 OSR or HR for chronic obstruction of iliofemoral (IF) veins or inferior vena cava (IVC) between January 1985 and September 2009. Primary end points were patency and clinical outcome. RESULTS: Sixty patients (26 men, mean age 43 years, range 16-81) underwent 64 procedures. Ninety-four percent had leg swelling, 90% had venous claudication, and 31% had active or healed ulcers (CEAP classes: C3 = 30, C4 = 12, C5 = 8, C6 = 12). Fifty-two OSRs included 29 femorofemoral (Palma vein: 25, polytetrafluoroethylene [PTFE]: 4), 17 femoroiliac-inferior vena cava (IVC) (vein: 3, PTFE: 14) and six complex bypasses. Twelve patients had HR, which included endophlebectomy, patch angioplasty, and stenting. Early graft occlusion occurred after 17% of OSR and 33% HR. Discharge patency was 96% after OSR, 92% after HR. No mortality or pulmonary embolism occurred. Five-year primary and secondary patency was 42% (95% confidence interval [CI] 29%-55%) and 59% (CI 43%-72%), respectively. For Palma vein grafts it was 70% and 78%, for femoroiliac and ilio-infrahepatic IVC bypasses it was 63% and 86%, and for femoro-infrahepatic IVC bypasses it was 31% and 57%, respectively. Complex OSRs and hybrid procedures had 28% and 30% 2-year secondary patency, respectively. The only factor that significantly affected graft patency in multivariate analysis was May-Thurner syndrome with associated chronic venous thrombosis. For HR, stenting into the common femoral vein patch vs iliac stents only significantly increased patency. At last follow-up, 60% of the patients had no venous claudication and no or minimal swelling. All ulcers with patent grafts healed but 50% of these recurred. CONCLUSIONS: Both OSR and HR are viable options if endovascular procedures fail or are not feasible. Palma vein bypass and femoroiliac or iliocaval PTFE bypasses have excellent outcomes with good symptomatic relief.

Contemporary management of giant renal and visceral arteriovenous fistulae.

PURPOSE: To evaluate our experience with treatment of giant arteriovenous fistulae (AVFs) involving the renal and visceral vasculature and assess outcomes. METHODS: Clinical data from 12 consecutive patients (10 women; median age 58 years, range 37-79) undergoing intervention for 14 giant renal/visceral AVFs over a 15-year period (1994-2008) were retrospectively reviewed. Only patients with extra-parenchymal, wide arteriovenous communications were included. Thirteen were located in the renal artery and one in the splenic artery. The etiology was most likely post-traumatic/iatrogenic in 6 patients, idiopathic in 4 (1 bilateral), congenital in 1 (bilateral), and one was associated with fibromuscular dysplasia. In 4 cases, the lesion was asymptomatic. RESULTS: Two large renal AVFs were treated with open surgery: one elective AV fistula repair early in our experience and the other an emergent nephrectomy for rupture. Twelve AV fistulae were closed successfully using endovascular techniques performed solely through the feeding vessel without cannulating the draining vein. All symptomatic patients, except one with continued dyspnea from cardiac causes, had complete symptomatic relief. There was no mortality. Morbidity included 2 access site hematomas that were managed conservatively. Loss of renal parenchyma ranged from 5% to 30%, but median serum creatinine levels remained stable. CONCLUSION: Endovascular treatment of giant renal/visceral AVFs is challenging but feasible and safe, with good organ preservation. Endovascular techniques have replaced open surgical repair as a first-line treatment for these challenging lesions.