Outcome and technical evolution of type 2 endoleak embolization with ethylene-vinyl-alcohol copolymer.

PURPOSE: This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR). METHODS: A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events. RESULTS: The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded. CONCLUSION: The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

Chimney stent graft for left subclavian artery preservation during thoracic endograft placement.

OBJECTIVE: Carotid to subclavian artery bypass (CSB) has been the standard for revascularizing the left subclavian artery during coverage by thoracic endovascular aortic repair (TEVAR). The purpose of this study is to determine if a chimney stent graft (CSG) offers similar outcomes as an alternative to open bypass. METHODS: A retrospective review of a single vascular surgery registry between February 2011 and September 2017 was performed of all left subclavian revascularization during elective TEVAR. Arch reconstructions involving more than just the left subclavian artery were excluded. Indications, demographics, procedural details, and outcomes were analyzed using standard statistical analysis. RESULTS: Eighty-one patients with a mean age of 68 years (range, 32-87 years) had left subclavian revascularization (64 [79%] CSB vs 17 [21%] CSG) during TEVAR. Median follow-up for CSG was 8 months (range, 0-52 months) and for CSB was 14.5 months (range, 3-72). Demographics between the groups were similar except for more males in both groups (43 [67%] in CSB vs 10 [59%] in CSG; P = .28). The CSB group had significantly more aneurysms than dissections compared with CSG (45 [70%] vs 6 [35%]; P = .008). There were no perioperative occlusions or ischemic issues for either group in the perioperative period. Postoperative hematoma rates trended higher in the CSB (7.11% vs 1.6%; P = .53) with three (4.6%) of the CSB requiring evacuation of hematoma. Left hemispheric strokes were 6% in the CSB with none occurring in the CSG group. Perioperatively, the CSB group had one recurrent laryngeal nerve and one graft infection. Length of stay was similar in both groups (CSB, 8.4 days vs CSG, 9.1 days). Perioperative mortality was not statistically significant between both groups with two deaths (3%) in the CSB and none in the CSG group. No gutter leaks were identified on follow-up computed tomography scan during long-term follow-up. Patency rates were similar with only one occlusion in the CSB group at 23 months. CONCLUSIONS: Left common carotid to subclavian artery bypass has been the standard for revascularization of the left subclavian artery during coverage by TEVAR. Chimney stent grafting to perfuse the left arm appears to offer equivalent results as a minimally invasive alternative.

Plasma membrane Ca2+-ATPase 4 in murine epididymis: secretion of splice variants in the luminal fluid and a role in sperm maturation.

Plasma membrane Ca(2+)-ATPase isoform 4 (PMCA4) is the primary Ca(2+) efflux pump in murine sperm, where it regulates motility. In Pmca4 null sperm, motility loss results in infertility. We have shown that murine sperm PMCA4b interacts with Ca(2+)/CaM-dependent serine kinase (CASK) in regulating Ca(2+) homeostasis and motility. However, recent work indicated that the bovine PMCA4a splice variant (missing in testis) is epididymally expressed, along with 4b, and may be transferred to sperm. Here we show, via conventional and in situ RT-PCR, that both the splice variants of Pmca4 mRNA are expressed in murine testis and throughout the epididymis. Immunofluorescence localized PMCA4a to the apical membrane of the epididymal epithelium, and Western analysis not only confirmed its presence but showed for the first time that PMCA4a and PMCA4b are secreted in the epididymal luminal fluid (ELF), from which epididymosomes containing PMCA4a were isolated. Flow cytometry indicated the presence of PMCA4a on mature caudal sperm where it was increased ~5-fold compared to caput sperm (detected by Western blotting) and ~2-fold after incubation in ELF, revealing in vitro uptake and implicating PMCA4a in epididymal sperm maturation. Coimmunoprecipitation using pan-PMCA4 antibodies, revealed that both variants associate with CASK, suggesting their presence in a complex. Because they have different kinetic properties for Ca(2+) transport and different abilities to bind to CASK, our study suggests a mechanism for combining the functional attributes of both PMCA4 variants, leading to heightened efficiency of the pump in the maintenance of Ca(2+) homeostasis, which is crucial for normal motility and male fertility.