Solitary iliac branch endoprosthesis placement for iliac artery aneurysms.

BACKGROUND: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Individual Differences in Heparin Sensitivity and Their Effect on Heparin Anticoagulation During Arterial Vascular Surgery.

OBJECTIVES: To investigate whether a fixed heparin dose results in adequate heparinisation levels and consequent inhibition of haemostatic activation in all patients. METHODS: This prospective clinical pilot study included 24 patients undergoing arterial vascular surgery. Individual heparin responsiveness was assessed using the Heparin Dose Response (HDR) test, while the activated clotting time (ACT) and heparin concentration were measured to monitor the peri-procedural degree of anticoagulation. Finally, peri-operative haemostasis was evaluated with rotational thromboelastometry (ROTEM). RESULTS: Eight patients were identified with reduced heparin sensitivity (RS group) and 16 patients with normal heparin sensitivity (NS group). Compared with the NS group, the RS group showed less prolonged ACTs after heparinisation with heparin concentrations below the calculated target heparin concentration. ROTEM revealed shorter clot formation times in the intrinsically activated coagulation test (INTEM) 3 min (114 ± 48 s vs. 210 ± 128 s) and 30 min after the initial heparin bolus (103 ± 48 s vs. 173 ± 81 s) in the RS group compared with the NS group. In the RS group, one patient developed a major thromboembolic complication. CONCLUSIONS: This study shows that a third of the study population had reduced heparin sensitivity, which was associated with lower levels of heparinisation, and lower inhibition levels of clot initiation and clot formation. Identifying patients with reduced heparin sensitivity by monitoring the anticoagulant effect of heparin could decrease the risk of thrombotic complications after arterial vascular surgery.

Predictors of Failure of Closure in Percutaneous EVAR Using the Prostar XL Percutaneous Vascular Surgery Device.

OBJECTIVE: To identify predictors of failure in percutaneous endovascular aneurysm repair (P-EVAR) using the Prostar XL Percutaneous Vascular Surgery Device (Abbot Vascular, Santa Clara, CA, USA) and the need for conversion to conventional femoral cutdown (O-EVAR). METHODS: Consecutive patients who underwent P-EVAR with the Prostar XL device between January 2009 and April 2012 were included in this series. Patients with a circular calcified common femoral artery (CFA) oncomputed tomography angiography were operated using O-EVAR and were therefore excluded. To identify predictors of success of closure in P-EVAR, artery characteristics, sheath size used, and comorbidities were analyzed in a univariate logistic regression model. RESULTS: Percutaneous access was achieved in 154 femoral access sites with conversion to O-EVAR was needed in10 (6.5%). Significant predictors of conversion included sheath size (continuous, relative risk [RR] 1.50, p < .03)and the ratio between sheath size and CFA diameter >0.75 (RR 8.93, p < .01). Variables such as calcification quantity scores, CFA diameter, body mass index, and comorbidities were not significant. CONCLUSION: The data demonstrate that sheath size, in particular, combined with CFA diameter predicts failure of closure in P-EVAR using the Prostar XL device. This ratio can be utilized to help in decision making with regard to the EVAR approach. A ratio of >0.75 would favor a primary open groin approach.

Case report: direct revascularization in acute mesenteric ischemia by an endovascular approach.

BACKGROUND: Acute mesenteric ischemia is a relatively rare but life-threatening clinical condition. Outcome depends on early diagnosis and prompt intervention. CASE PRESENTATION: A 85-year-old man and a 75-year-old woman developed acute mesenteric ischemia due to cardiac embolism. The first patient received an insufficient dose of anticoagulants for atrial fibrillation and the second patient dicontinued her anticoagulantia to avoid bleeding during a routine colonoscopy. Both patients presented with severe abdominal pain and computed tomography showed thrombus in de superior mesenteric artery. Successfulrevascularization with good clinical outcome was achieved by means of an endovascular first approach. CONCLUSION: This case report shows that an endovascular approach - in contrast to open surgery - not only enables to revascularize main trunk lesions but can also facilitate revascularization of side branches. Endovascular treatment used to be limited to a selected group of patients without signs of bowel necrosis, but there is a tendency to initiate endovascular revascularization in all patients because it is associated with a reduced mortality, a reduced laparotomy rate and reduction in the resected length of bowel.

Age-related decline in the synthesis of glycosaminoglycans by cultured human fibroblasts (WI-38).

A gradual decline in the synthesis of glycosaminoglycans, as evidenced by reduced rates of incorporation of [35S]-sulfate and [14C]-glucosamine into total cellular and extracellular glycosaminoglycans, occurred during the last 4 to 5 passages (1 : 2 splits) of WI-38 cultures before phase out. While labelling of cellular glycosaminoglycans by both radioactive precursors was reduced to about the same extent, a relatively greater decline in [35S]-sulfate than in [14C]-glucosamine incorporation into extracellular glycosaminoglycans was observed during the last passages. These changes in glycosaminoglycan metabolism are interpreted as an expression of cellular aging and a function of glycosaminoglycans in growth regulation (and possibly in the process of cellular senescence) is discussed.

Age-related changes in the distribution pattern of glycosaminoglycans synthesized by cultured human diploid fibroblasts (WI-38).

A gradual decline in the synthesis of glycosaminoglycans, as evidenced by reduced rates of incorporation of [35S] sulfate and [14C] glucosamine into cellular and medium glycosaminoglycans, was observed during the last (about 5) population doublings before phase-out. The decline was accompanied by a change in the distribution pattern of individual glycosaminoglycans with a relative decrease in the incorporation rate of [14C] glucosamine into cellular and medium hyaluronic acid. The incorporation rate of [14D] glucosamine and [35S] sulfate into cellular and medium heparan sulfate continually increased during the last population doublings ("senescence"). The possibility of a coupling between cell growth and hyaluronic acid synthesis or an involvement of hyaluronic acid in the adhesion of cells (among one another or/and to the substratum), and the functional significance of heparan sulfate as a growth inhibitor were discussed.

Effect of short- or long-term treatment with exogenous glycosaminoglycans on growth and glycosaminoglycan synthesis of human fibroblasts (WI-38) in culture.

Short-term (several days) or long-term (several weeks and months) treatment of cultured human diploid fibroblasts (WI-38; phase II) with heparin at 20--500 micrograms/ml inhibited cell proliferation and stimulated glycosaminoglycan synthesis (as measured by the incorporation rates of [35S] sulfate and [14C] glucosamine into cellular and medium glycosaminoglycans). Characterization of the individual glycosaminoglycan types revealed an increased portion of incorporated radioactivity in the heparan sulfate and hyaluronic acid fractions of heparin-treated cells. Treatment with chondroitin-4-sulfate, chondroitin-6-sulfate, dermatan sulfate of hyaluronic acid at concentrations up to 500 micrograms/ml exhibited no or slightly inhibitory (especially in the case of hyaluronic acid) effects on growth and glycosaminoglycan synthesis. The average cellular protein and RNA content of short- or long-term heparin (100 micrograms/ml)-treated cells was elevated by about 70--80%. "Senescent" (phase III) WI-38 cells exhibited a relative increase of [35S] sulfate and [14C] glucosamine incorporation into cell-bound and medium heparan sulfate. Possible mechanisms for the action of heparin (for example, interaction with specific cell-surface sites) and a potential role of heparan sulfate in the regulation of cell growth are discussed.

Mutagenic activity in the stomach and small intestine of rats after oral administration of nitrosated beef extract.

The products formed by the reaction of beef extract with nitrite were assayed in the Salmonella/microsome mutagenicity test. In strain TA1538, TA98 and TA100 a direct-acting mutagenic response was observed. The presence of liver-microsome preparation resulted in decreased mutagenicity. To study the absorption, distribution and excretion of mutagenic substances in nitrosated beef extract, the test material was given perorally to rats. Investigations of the stomach, bile fluid, urine, small intestine and blood samples were carried out, and mutagenicity was found in the contents of stomach and small intestine. It is supposed that unlike beef extract itself, its nitroso product is not excreted in the bile but passes directly from the stomach and small intestine.

Investigations on the detection of mutagenic activity of beef extract in rats after oral administration.

After oral administration of beef extract the body fluids of Aroclor-treated and untreated rats were investigated for mutagenicity using the Salmonella/microsome test. In the stomach contents, the bile and the urine of the animals, mutagenic activity was discovered after S-9 activation. Although the mutagenic substances must have been transported by the blood stream to the excreting organs no increased mutagen-induced his+ revertants were observed in venous blood. Direct-acting mutagens were not detected in the tested body fluids, either in the Aroclor-treated rats or in the untreated ones.

The use of balloon-tipped pulmonary artery catheters in children undergoing cardiac surgery.

Percutaneous pulmonary artery (PA) catheterization via the internal jugular vein was studied in 58 children undergoing cardiac surgery. Central venous cannulation, which succeeded in all children, was associated with a 10% incidence of inadvertent carotid artery puncture without untoward effects. Successful placement of the PA catheter was achieved in 47 (92%) of the 51 children in whom it was anatomically possible to enter the pulmonary artery at the time of the catheterization. Four (8%) catheter tip cultures were positive. The PA catheter yielded important information in diagnosing low cardiac output, severe pulmonary hypertension or residual cardiac defects in 27 (47%) children. Twenty (35%) children had critical therapeutic interventions because of the PA catheter information. The high yield of important data and the low incidence of major complications seem to justify the use of percutaneously inserted PA catheters in children with an increased operative risk.

Testing of sunset yellow and orange II for genotoxicity in different laboratory animal species.

The azo dyes Sunset Yellow and Orange II were gavaged to rodent species to check bile, urine, and fecal extracts for possible mutagenic activity in the Ames test or in bone marrow cells for clastogenicity using cytogenetic test systems. After oral application the dyes showed a negative response in bile, excrements, and bone marrow. When an exogenous metabolic activation was performed, increased revertant numbers using Salmonella strain TA100 were obtained only in fecal extracts of Sunset Yellow-treated animals. It is concluded that no genotoxic harm is to be expected from the ingestion of Sunset-Yellow or Orange II.

Processing of tetanus and botulinum A neurotoxins in isolated chromaffin cells.

Tetanus and botulinum A neurotoxins were introduced into the cytosol of chromaffin cells by means of an electric field in which the plasma membrane is forced to form pores of approximately 1 micron at the sites facing the electrodes. As demonstrated by electron microscopy, both [125I] and gold-labelled tetanus toxin (TeTx) diffuse through these transient openings. Dichain-TeTx, with its light chain linked to the heavy chain by means of a disulfide bond, causes the block of exocytosis to develop more slowly than does the purified light chain. The disulfide bonds, which in both toxins hold the subunits together, were cleaved by the intrinsic thioredoxin-reductase system. Single chain TeTx, in which the heavy and light chains are interconnected by an additional peptide bond, was far less effective than dichain-TeTx at blocking exocytosis, which indicates that proteolysis is the rate-limiting step. The toxins were degraded further to low-molecular weight fragments which, together with intact toxins and subunits, were released by the cells. The intracellular half-life of [125I] dichain-TeTx was approximately three days. The number of light-chain molecules required to maintain exocytosis block in a single cell, as calculated by two different methods, was less than 10. The long duration of tetanus poisoning may result from the persistence of intracellular toxin due to scarcity of free cytosolic proteases. This may also hold for the slow recovery from botulism.

Influence of sulphite on the release of glycolytic metabolites in the perfused rat liver.

Sulphite interacts reversibly and irreversibly in vitro with many compounds of biological relevance. A possible inhibitory action of sulphite on hepatic lactate dehydrogenase activity was studied using the perfused rat liver to determine glycolytic metabolites released by the liver during sulphite infusion. A sulphite-dependent reversible inhibition of lactate release but no increase in pyruvate production indicated that lactate dehydrogenase was inhibited by sulphite concentrations in the millimolar range. This effect was diminished by addition of pyruvate to the perfusion medium. It appears very unlikely that, under physiological conditions, sulphite levels in the portal blood or the liver of the rat would reach concentrations that inhibit lactate dehydrogenase activity.

Appearance of sulphite and S-sulphonates in the plasma of rats after intraduodenal sulphite application.

Before intraduodenal administration of sodium sulphite solutions to anaesthetized rats, the portal vein and the vena cava were cannulated for blood sampling. Examination of the plasma showed that S-sulphonates were present in both pre- and post-hepatic blood, whereas free sulphite was detectable in the portal blood only. It can be concluded that sulphite is absorbed and quickly metabolized, either by oxidation or by the formation of S-sulphonates.

Attempts to induce cytogenetic effects with sulphite in sulphite oxidase-deficient Chinese hamsters and mice.

Chinese hamsters and mice were made sulphite-oxidase deficient by the feeding of a low-molybdenum diet with sodium tungstate as a drinking-water supplement. Hepatic sulphite-oxidase activity was checked spectrophotometrically. Under normal conditions, sulphite-oxidase activity is high in the mouse and low in the Chinese hamster. Sulphite (SO3--) was given in a single or double oral dose in aqueous solution or dissolved in fruit juice or by repeated subcutaneous injections up to the maximum tolerated doses. Possible cytogenetic effects were studied in bone-marrow cells using three test systems--the sister chromatid exchange, chromosome aberration and micronucleus tests. No induction of cytogenetic effects was observed with any of the three tests in either species, indicating that no damage at the chromosomal level was induced by sulphite in these animals, even when sulphite-oxidase activity was reduced to a very low level.

Outcome and complications in patients treated with continuous ambulatory peritoneal dialysis (CAPD) at a single centre during 11 years.

OBJECTIVE: To evaluate outcome and complications in patients treated with CAPD at our centre a retrospective study was performed. METHODS: Relevant data from all 123 consecutive patients on the CAPD program from 1982 to 1994 were reviewed. RESULTS: Patient survival after 1, 2, 3 years was 89, 78, 69 and 50% respectively. The probability of having a functioning catheter after 1, 2, 3 and 5 years was 90, 77 and 68%, respectively. We observed 179 technical complications (42 intra-abdominal pressure, 137 catheter-related). Peritonitis (220 episodes, 62% gram-positive) occurred with a mean incidence of 1 episode in 13 treatment months and was the main reason (26 cases, 68% gram-positive) for catheter removal. (Mixed) Gram-negative peritonitis was associated with a higher mortality, and relatively more often resulted in termination of CAPD treatment when compared to gram-positive peritonitis. Introduction in 1988 of a new fluid exchange system (Twin Bag) and alcohol disinfection of hands was accompanied by a decreased incidence of peritonitis and exit-site infections, but to date patient, technique and catheter survival have not improved. CONCLUSION: Although therapeutic measures have resulted in a reduced incidence of peritonitis and exit-site infections, infectious and technical complications remain a serious threat to patient and technique survival in CAPD treatment.

Myocardial imaging using thallium 201 scintigraphy after dipyridamole infusion: a case history.

Coronary artery disease frequently occurs in combination with peripheral vascular disorders and is an important cause of morbidity and mortality during or after peripheral vascular surgery. However, the detection of coronary artery disease in patients with peripheral vascular disease may be complicated, since most of these patients are unable to perform conventional exercise testing. The authors report a sixty-two-year-old man with an infrarenally located aneurysm of the abdominal aorta who underwent thallium 201 scintigraphy combined with dipyridamole infusion as an alternative exercise test. The subsequent thallium 201 images showed perfusion defects indicative of severe coronary artery disease. Coronary angiography showed an occluded right coronary artery and a significant proximal stenosis in the left anterior descending coronary artery. The patient underwent successful aortocoronary bypass surgery, and two months later, the aortic aneurysm was operated on without complications. As a result, dipyridamole thallium 201 scintigraphy should be considered as a valuable diagnostic test to detect coronary artery disease in patients with peripheral vascular disorders.

["Endarterectomy revisited": long-term results of aorto-iliac disobliteration with the "arterial disobliteration device" (plaque cracker). A 7-year follow-up study]. / "Endarterectomy revisited": Langzeitergebnisse nach aorto-iliakaler Desobliteration mit der "Arterial Disobliteration Device" (Plaque-cracker). Eine 7-Jahres-Nachkontrolle.

In 1973 LeVeen et al. described a new technique for extensive, retroperitoneal disobliteration of the aorto-bifemoral tract using the arterial disobliteration device (ADD). In Europe this technique was first described in 1981 by Widdershoven and Willekens. Later on more publications from Spain, Poland, Belgium and the Netherlands appeared. At the Groot Ziekengasthuis in 's-Hertogenbosch (the Netherlands) the new procedure was introduced in 1984. Until 1991, 158 patients were operated. The results were analysed. The average follow-up time was 44 months (range 3-84). In 44.5% of these patients intermittent claudication was the reason for operation. In 40.5% of the cases there was untreatable ischemic rest pain and in 15% there was also ischemic gangrene of one or both legs. Aorto-bi-iliac disobliteration was performed in 55 patients, aorto-bi-femoral disobliteration in 31 patients and unilateral disobliteration in another 48 patients. In 24 patients we performed an unilateral aorto-femoral with a contralateral aorto-iliac desobstruction. Both the operation technique and the results are described. Five patients died in the early postoperative period and in 16 patients early reintervention i.e. within 6 hours after the initial operation was necessary for hemorrhage or acute vascular occlusion. During the follow-up 15 patients died. Recurrent occlusion was seen six times while in two patients restenosis developed. In conclusion; in selected patients with aorto-femoral occlusive disease the ADD-procedure can replace the up to now usual procedures.

[One hundred years of the Association of Surgeons in the Netherlands. IV. Thoracic surgery]. / Honderd jaar Nederlandse Vereniging voor Heelkunde. IV. Thoraxchirurgie.

In the Netherlands, two disciplines are involved, in thoracic surgery. Firstly, general surgeons, since thoracic surgery initially consisted of surgical treatment for pulmonary tuberculosis, bronchiectasis and empyema. Once tuberculostatics became available, surgical treatment of pulmonary tuberculosis became less important and lung/thoracic operations were carried out primarily for lung cancer. Secondly, cardio-pulmonary surgeons (now known as 'cardiothoracic surgeons') also play a role in thoracic surgery. This discipline is also allowed to carry out heart surgery. Surgery for stage-I and -II lung cancer is the mainstay of the practice of general thoracic surgeons. Surgery after induction chemotherapy for stage-III tumours is under investigation to find out whether this will improve treatment results. Video-assisted thoracic surgery (VATS) is a most interesting development, and has led to the revival of volume-reduction surgery for lung emphysema. Education is of paramount importance in ensuring the quality of surgery. In the near future there will be a need for qualified thoracic surgeons in the Netherlands and organisational and financial measures should be taken to prevent a shortage.

[Spiral computed tomographic angiography as a substitute for intra-arterial angiography of aorta and its branches]. / Spiraaltomografische angiografie als vervanger van intra-arteriële angiografie van aorta en zijtakken.

Until recently, intra-arterial angiography was the diagnostic method of first choice when pathology of the aorta or its branches was suspected. A disadvantage of this technique is that only the lumen of spaces with blood flow can be visualised and that the soft tissue surroundings remain (partly) invisible. Spiral computer tomographic angiography (CTA) has some major advantages compared with conventional angiography. The technique is less invasive and faster. Also, the soft tissue is imaged by CTA. In addition, computer reconstructions allow viewing from all directions without the limitations of overprojection. Spiral CTA is a suitable technique for imaging the thoracic part of the aorta: in case of dissection if transoesophageal echography is not available, in case of an aneurysm to determine the diameter and in case of rupture as a highly sensitive but not very specific examination technique. For imaging of the abdominal part of the aorta, spiral CTA may be considered. In case of an aneurysm or a possible rupture of this part of the aorta it is then possible to visualize the operation area and to choose the optimal approach. For the exclusion of stenoses in mesenteric arteries or in renal arteries, spiral CTA offers the advantage of non-invasivity. The technique is less suitable for demonstration of these stenoses and does not allow immediate intervention.