Metachronous type III and type II acute aortic dissections in puerperium.

The case of a 30-year-old non-Marfan woman who developed a type III acute aortic dissection 5 days after delivery, followed within 16 h by an independent type II dissection, is reported. Preoperative CT scan imaging and TEE suggested metachronous type II and type III dissection. This was confirmed at surgery, where limited dissection of the aortic root without communication with the isthmic area via the aortic arch was evidenced. The patient underwent repair of the aortic root and adjacent ascending aorta and was medically treated for her type III dissection. This is the first report of metachronous acute aortic dissections in puerperium.

Aortic valve surgery in octogenarians: predictive factors for operative and long-term results.

OBJECTIVE: To assess factors influencing operative and long-term outcome in octogenarians undergoing aortic valve surgery (AVR). METHODS: Records of 220 consecutive octogenarians having AVR between 1992 and 2004 were reviewed, and follow-up obtained (99% complete). Of the group (mean age: 82.8 years; 174 females), 142 patients (65%) were in New York Heart Association (NYHA) class III-IV, 22 (10%) had previous myocardial infarction, 11 (5%) had previous coronary artery bypass grafting (CABG), and 8 (4%) had percutaneous aortic valvuloplasty. There were 44 urgent procedures (20%), and additional CABG was performed in 58 patients (26%). RESULTS: Operative mortality was 13% (9% for AVR, 24% for AVR+CABG). Among the 29 patients who died, 14 (48%) were operated on urgently (32% mortality for urgent procedures). Causes of hospital death were respiratory insufficiency or infection in 16 patients (16/29=55%), myocardial infarction in 8 (28%), stroke in 2 (7%), sepsis in 2 (7%), and renal failure in 1 (3%). Significant postoperative complications were atrial fibrillation in 48 patients (22%), respiratory insufficiency in 46 (21%), permanent atrio-ventricular bloc in 12 (5%), myocardial infarction in 10 (5%), hemodialysis in 4 (2%), and stroke in 4 (2%). Mean hospital and intensive care unit (ICU) stays were 17.6+/-5.2 and 6.9+/-3.4 days, respectively. Multivariate predictors (p<0.05) of hospital death were urgent procedure, associated CABG, NYHA class IV, and percutaneous aortic valvuloplasty. Age, associated CABG, and urgent procedure were predictors of prolonged ICU stay. Mean follow-up was 58.2 months and actuarial 5-year survival was 73.2+/-6.9%. Age, preoperative myocardial infarction, urgent procedure, and duration of ICU stay were independent predictors of late death. Among 130 patients alive at follow-up, 91% were angina free and 81% in class I-II. CONCLUSIONS: AVR in octogenarians can be performed with acceptable mortality, although significant morbidity. These results stress the importance of early operation on elderly patients with aortic valve disease, avoiding urgent procedures. Associated coronary artery disease is a harbinger of poor operative outcome. Long-term survival and functional recovery are excellent.

Amputation in diabetic patients.

In diabetes-related amputations, the risk of nonhealing or infection of a wound and the need for revision are increased. Medical treatment before amputation should optimize general and local conditions including the regression of edema, the control of infection, and the optimization of glucoregulation. A major argument for foot-sparing surgery is the poor functional recovery after major limb amputation. Diabetic patients are frail, with an increased postoperative morbidity and mortality after major amputation. Factors detrimental to functional outcome are advanced age, end-stage renal disease, dementia, and above-knee amputation. A multidisciplinary approach is required to optimize the results of diabetes-related amputations. The authors discuss medical and technical aspects that may reduce the failure of minor or major diabetes-related amputations.

Evidence for association between the HLA-DQA locus and abdominal aortic aneurysms in the Belgian population: a case control study.

BACKGROUND: Chronic inflammation and autoimmunity likely contribute to the pathogenesis of abdominal aortic aneurysms (AAAs). The aim of this study was to investigate the role of autoimmunity in the etiology of AAAs using a genetic association study approach with HLA polymorphisms. METHODS: HLA-DQA1, -DQB1, -DRB1 and -DRB3-5 alleles were determined in 387 AAA cases (180 Belgian and 207 Canadian) and 426 controls (269 Belgian and 157 Canadian) by a PCR and single-strand oligonucleotide probe hybridization assay. RESULTS: We observed a potential association with the HLA-DQA1 locus among Belgian males (empirical p = 0.027, asymptotic p = 0.071). Specifically, there was a significant difference in the HLA-DQA1*0102 allele frequencies between AAA cases (67/322 alleles, 20.8%) and controls (44/356 alleles, 12.4%) in Belgian males (empirical p = 0.019, asymptotic p = 0.003). In haplotype analyses, marginally significant association was found between AAA and haplotype HLA-DQA1-DRB1 (p = 0.049 with global score statistics and p = 0.002 with haplotype-specific score statistics). CONCLUSION: This study showed potential evidence that the HLA-DQA1 locus harbors a genetic risk factor for AAAs suggesting that autoimmunity plays a role in the pathogenesis of AAAs.

HLA-DQA is associated with abdominal aortic aneurysms in the Belgian population.

Chronic inflammation and autoimmunity likely contribute to the pathogenesis of abdominal aortic aneurysms (AAAs). The aim of this study was to investigate the role of autoimmunity in the etiology of AAAs using a genetic association study approach with human leukocyte antigen (HLA) polymorphisms (HLA-DQA1, -DQB1, -DRB1 and -DRB3-5 alleles) in 387 AAA cases and 426 controls. We observed an association with the HLA-DQA1 locus among Belgian males, and found a significant difference in the HLA-DQA1*0102 allele frequencies between AAA cases and controls. In conclusion, this study showed potential evidence that the HLA-DQA1 locus harbors a genetic risk factor for AAAs suggesting that autoimmunity plays a role in the pathogenesis of AAAs.

Genome scan for familial abdominal aortic aneurysm using sex and family history as covariates suggests genetic heterogeneity and identifies linkage to chromosome 19q13.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a relatively common disease, with 1% to 2% of the population harboring aneurysms. Genetic risk factors are likely to contribute to the development of AAAs, although no such risk factors have been identified. METHODS AND RESULTS: We performed a whole-genome scan of AAA using affected-relative-pair (ARP) linkage analysis that includes covariates to allow for genetic heterogeneity. We found strong evidence of linkage (logarithm of odds [LOD] score=4.64) to a region near marker D19S433 at 51.88 centimorgans (cM) on chromosome 19 with 36 families (75 ARPs) when including sex and the number of affected first-degree relatives of the proband (N(aff)) as covariates. We then genotyped 83 additional families for the same markers and typed additional markers for all families and obtained a LOD score of 4.75 (P=0.00014) with sex, N(aff), and their interaction as covariates near marker D19S416 (58.69 cM). We also identified a region on chromosome 4 with a LOD score of 3.73 (P=0.0012) near marker D4S1644 using the same covariate model as for chromosome 19. CONCLUSIONS: Our results provide evidence for genetic heterogeneity and the presence of susceptibility loci for AAA on chromosomes 19q13 and 4q31.

Effects of BM-573, a thromboxane A2 modulator on systemic hemodynamics perturbations induced by U-46619 in the pig.

The aim of our study was to evaluate the effects of thromboxane A2 (TXA2) agonist, U-46619, on systemic circulatory parameters in the pigs before and after administration of a novel TXA2 receptor antagonist and synthase inhibitor (BM-573). Twelve anesthetized pigs were randomly assigned in two groups: in Ago group (n=6), the animals received six consecutive injections of U-46619 at 30 min interval, while in Anta group (n=6) they received an increasing dosage regimen of BM-573 10 min before each U-46619 injection. The effects of each dose of BM-573 on ex vivo platelet aggregation induced by arachidonic acid, collagen or ADP were also evaluated. Vascular properties such as characteristic impedance, peripheral resistance, compliance, arterial elastance were estimated using a windkessel model. Intravenous injections of 0.500 mg/ml of BM-573 and higher doses resulted in a complete inhibition of platelet aggregation induced by arachidonic acid. In the same conditions, BM-573 completely blocked the increase of arterial elastance, and stabilized both mean aortic blood pressure and mean systemic blood flow. In conclusion, BM-573 could therefore be a promising therapeutic approach in pathophysiological states where TXA2 plays a main role in the increase of vascular resistance like in pathologies such as systemic hypertension.

Distribution of F-18 fluorodeoxyglucose (F-18 FDG) in abdominal aortic aneurysm: high accumulation in macrophages seen on PET imaging and immunohistology.

A 68-year-old man was hospitalized for unstable angina and underwent emergency coronary artery bypass surgery. During the operation, a pulsatile large abdominal aortic aneurysm (AAA) was discovered. To define the optimal treatment of the abdominal aneurysm, after bypass surgery, CT scans and positron emission tomography (PET) were performed, as we routinely do. PET imaging combined with immunohistologic examination showed a region of increased F-18 FDG uptake corresponding to an inflammatory infiltrate in the aortic wall in contrast to the thrombus in the aneurysm (devoid of inflammatory cells). The luminal area showed midlevel F-18 FDG uptake corresponding to circulating mediators.

TIMP-2 and PAI-1 mRNA levels are lower in aneurysmal as compared to athero-occlusive abdominal aortas.

OBJECTIVE: Significant alterations of the vascular wall occurs in abdominal aortic aneurysm (AAA) and atherosclerotic occlusive disease (AOD) that ultimately may lead to either vascular rupture or obstruction. These modifications have been ascribed to one or a group of proteases, their inhibitors or to the matrix macromolecules involved in the repair process without considering the extent of the observed variations. METHODS: The mRNA steady-state level of a large spectrum of proteolytic enzymes (matrix metalloproteinases: MMP-1, -2, -3, -8, -9, -11, -12, -13, -14; urokinase plasminogen activator: u-PA), their physiological inhibitors (tissue inhibitors of MMPs: TIMP-1, -2, -3; plasminogen activator inhibitor: PAI-1) and that of structural matrix proteins (collagens type I and III, decorin, elastin, fibrillins 1 and 2) was determined by RT-PCR made quantitative by using a synthetic RNA as internal standard in each reaction mixture. The profile of expression was evaluated in AAA (n=7) and AOD (n=5) and compared to non-diseased abdominal (CAA, n=7) and thoracic aorta (CTA, n=5). RESULTS: The MMPs -8, -9, -12 and -13 mostly associated with inflammatory cells were not or barely detected in CAA and CTA while they were largely and similarly expressed in AAA and AOD. Expression of protease inhibitors or structural proteins were only slightly increased in both pathological conditions with the exception of elastin which was reduced. The main significant difference between AAA and AOD was a lower expression of TIMP-2 and PAI-1 in the aneurysmal lesions. CONCLUSIONS: The remodeling of the aortic wall in AAA and AOD involves gene activation of a large and similar spectrum of proteolytic enzymes while the expression of two physiological inhibitors, TIMP-2 and PAI-1, is significantly lower in AAA compared to AOD. The repair process in the aneurysmal disease seems similar to that of the occlusive disease.

Contribution of PET scanning to the evaluation of abdominal aortic aneurysm.

The size of abdominal aortic aneurysms (AAA) is the most usual predictor of the risk for rupture. Because chronic metalloproteinases production and activation by inflammatory cells causes degradation of elastin and collagen in the aneurysmal wall, the detection of an increased metabolic process preceding fissuration and rupture could be a more sensitive predictor of rupture risk. We investigated the metabolic activity of the aneurysmal wall by whole-body positron emission tomography (PET) in 26 patients with a documented AAA (mean diameter 63 mm, extremes 45 mm and 78 mm). A positive (18)F-fluorodeoxyglucose ((18)F-FDG) uptake at the level of the AAA was observed in 38% of the cases (10 of 26 patients). Nine of these 10 patients required emergent or urgent aneurysmectomy for ruptured (n = 1), leaking (n = 1), rapidly expanding (n = 2), or painful (n = 5) aneurysms; the negative (18)F-FDG uptake patients had a more benign course. This preliminary study suggests a possible correlation between (18)F-FDG uptake by the aneurysm wall and the triggering of processes leading to rupture. The (18)F-FDG uptake in the aneurysm wall may correspond to the accumulation of inflammatory cells responsible for the production and activation of degrading enzymes. PET scan seems useful in high-risk patients. Positive PET imaging in these cases would help us to decide to proceed with surgery, despite factors favoring a surveillance strategy.

Effects of increased afterload on left ventricular performance and mechanical efficiency are not baroreflex-mediated.

OBJECTIVE: To assess baroreflex intervention during increase in left ventricular afterload, we compared the effects of aortic banding on the intact cardiovascular system and under hexamethonium infusion. METHODS: Six open-chest pigs, instrumented for measurement of aortic pressure and flow, left ventricular pressure and volume, were studied under pentobarbital-sufentanil anesthesia. Vascular arterial properties were estimated with a four-element windkessel model. Left ventricular contractility was assessed by the slope of end-systolic pressure-volume relationship. RESULTS: The effects of aortic banding on mechanical aortic properties were unaffected by autonomic nervous system inhibition. However, increase in peripheral arterial vascular resistance and in heart rate were prevented by hexamethonium. Aortic banding increased left ventricular contractility and stroke work. Left ventricular-arterial coupling remained unchanged, but mechanical efficiency was impaired. These ventricular changes were independent of baroreflex integrity. CONCLUSIONS: Our results demonstrate that an augmentation in afterload has a composite effect on left ventricular function. Left ventricular performance is increased, as demonstrated by increase in contractility and stroke work, but mechanical efficiency is decreased. These changes are observed independently of baroreflex integrity. Such mechanisms of autoregulation, independent of the autonomic nervous system, are of paramount importance in heart transplant patients.

[Hematuria caused by nutcracker syndrome: peroperative confirmation of its presence]. / Hématurie causée par un "nutcracker syndrome" ou "syndrome du casse-noisettes": confirmation peropératoire de sa réalité.

Nutcracker syndrome should be considered in the case of left ureteric haematuria based on computed tomography with vascular reconstruction of the hilar region of the kidney. The best confirmation is obtained by studying the pressure gradient between the left renal vein and the inferior vena cava during cavography. Various modalities of surgical treatment have been proposed by a few authors, but have been criticised by some authors who question the clinical reality of this syndrome and the efficacy of treatment. The decision to operate may be difficult and other investigations may be useful to confirm the diagnosis. We report the case of a patient in whom the diagnosis of nutcracker syndrome was confirmed intraoperatively by the immediate appearance of massive, reversible haematuria induced by clamping of the renal vein during vein dissection and augmentation plasty. In the light of this original case, we believe that a preoperative percutaneous haematuria provocation test by temporary obstruction of the left renal vein during venography could allow a more formal diagnosis of nutcracker syndrome when this syndrome is highly suspected.

Genome-wide association study identifies a sequence variant within the DAB2IP gene conferring susceptibility to abdominal aortic aneurysm.

We performed a genome-wide association study on 1,292 individuals with abdominal aortic aneurysms (AAAs) and 30,503 controls from Iceland and The Netherlands, with a follow-up of top markers in up to 3,267 individuals with AAAs and 7,451 controls. The A allele of rs7025486 on 9q33 was found to associate with AAA, with an odds ratio (OR) of 1.21 and P = 4.6 x 10(-10). In tests for association with other vascular diseases, we found that rs7025486[A] is associated with early onset myocardial infarction (OR = 1.18, P = 3.1 x 10(-5)), peripheral arterial disease (OR = 1.14, P = 3.9 x 10(-5)) and pulmonary embolism (OR = 1.20, P = 0.00030), but not with intracranial aneurysm or ischemic stroke. No association was observed between rs7025486[A] and common risk factors for arterial and venous diseases-that is, smoking, lipid levels, obesity, type 2 diabetes and hypertension. Rs7025486 is located within DAB2IP, which encodes an inhibitor of cell growth and survival.

Association of abdominal aortic aneurysm, horseshoe kidneys, and left-sided inferior vena cava: report of two cases.

Surgery for abdominal aortic aneurysm may be challenging when rare renal or venous anomalies are present. This article reports two similar cases of aortic abdominal aneurysm associated with horseshoe kidney and left-sided inferior vena cava treated with a transperitoneal approach. Preoperative knowledge of the anatomic situation enabled appropriate aneurysm repair. Operative strategy is discussed. This report describes an uncommon venous vascular malformation complex and stresses the importance of computed tomography imaging not only in assessing the characteristics of the aneurysmal disease but also in detecting variations in pertinent vascular or parenchymal anatomy.

The same sequence variant on 9p21 associates with myocardial infarction, abdominal aortic aneurysm and intracranial aneurysm.

Recently, two common sequence variants on 9p21, tagged by rs10757278-G and rs10811661-T, were reported to be associated with coronary artery disease (CAD) and type 2 diabetes (T2D), respectively. We proceeded to further investigate the contributions of these variants to arterial diseases and T2D. Here we report that rs10757278-G is associated with, in addition to CAD, abdominal aortic aneurysm (AAA; odds ratio (OR) = 1.31, P = 1.2 x 10(-12)) and intracranial aneurysm (OR = 1.29, P = 2.5 x 10(-6)), but not with T2D. This variant is the first to be described that affects the risk of AAA and intracranial aneurysm in many populations. The association of rs10811661-T to T2D replicates in our samples, but the variant does not associate with any of the five arterial diseases examined. These findings extend our insight into the role of the sequence variant tagged by rs10757278-G and show that it is not confined to atherosclerotic diseases.

Comparison of inflammatory responses after off-pump and on-pump coronary surgery using surface modifying additives circuit.

BACKGROUND: Cardiac surgery is followed by various degrees of inflammation, which have harmful consequences. Because of the central role of extracorporeal circulation (EC), off-pump coronary bypass surgery is deemed preferable. Do different modalities of EC challenge this view? METHODS: Four groups of similar patients underwent coronary surgery: (group 1) on-pump, EC with closed surface modifying additives (SMA) circuit and no pump suckers (n = 20); (group 2) on-pump, EC with open SMA circuit and pump suckers (n = 20); (group 3) off-pump (beating heart) and heparin 3 mg/kg (n = 20); (group 4) off-pump (beating heart) and heparin 1 mg/kg (n = 20). Interleukins (IL)-6, IL-8, IL-10, myeloperoxidase, elastase, and terminal complex of the complement (TCC) were analyzed at various times: at induction (time I); after heparin (time II); after complete revascularization (time III); after protamine (time IV); and 24 hours later (time V). RESULTS: The TCC was significantly higher in groups 1 and 2 at time III. The pattern of IL-6 was the same for the four groups. No significant difference in myeloperoxydase content was noted; however, elastase was significantly higher in the two EC (on-pump) groups. CONCLUSIONS: Except for the complement system and elastase, on-pump surgery with SMA-coated circuits did not elicit any greater inflammatory response than off-pump surgery.

Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results.

AIMS: To assess risk factors for early and late outcome after concurrent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). METHODS AND RESULTS: Records of all 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 were reviewed, and follow-up obtained (100% complete). In the group (mean age 67 years; 74% males), 62% had triple-vessel disease, 57% unstable angina, 31% left main coronary stenosis, 19% congestive heart failure, and 35% either a history of vascular procedures or existing vasculopathies. Preoperative assessment revealed transient ischaemic attack in 16%, stroke in 7%, and bilateral carotid disease in 20%. There were 7% emergent and 19% urgent operations, and ascending aorta was described as atheromatous or calcified in 21%. Hospital death occurred in 19 patients, myocardial infarction in seven, and permanent stroke in 12. Significant multivariable predictors of hospital death were aortic calcifications, coexisting vasculopathy, and emergent procedure. Significant predictors of postoperative stroke were calcified or dilated aorta, and of prolonged hospital stay were advanced age, unstable angina, and coexisting vascular disease. For hospital survivors, 10-year actuarial late event-free rates were: death, 50%; myocardial infarction, 84%; stroke, 93%; percutaneous angioplasty, 95%; redo CABG, 98%; and all morbidity and mortality, 48%. Significant multivariable predictors of late deaths were coexisting vasculopathy, age, renal insufficiency, previous cardiac surgery, tobacco abuse, calcified or atheromatous aorta, and duration of intensive care unit stay. CONCLUSION: Concurrent CEA and CABG can be performed with acceptable operative mortality and morbidity, and good long-term freedom from coronary and neurologic events. Atheromatous aortic disease is a harbinger of poor operative and long-term outcome.

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm.

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).