Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella.

PURPOSE: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms. MATERIALS AND METHODS: The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed. RESULTS: Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak. CONCLUSION: EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms. CLINICAL IMPACT: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Endovascular Stent Graft Repair for True and Post-Traumatic False Aneurysms of the Subclavian Artery.

OBJECTIVE: Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs. METHODS: The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed. RESULTS: Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak. CONCLUSIONS: Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

Therapeutic management of isolated internal iliac artery aneurysms.

OBJECTIVE: Isolated internal iliac artery aneurysms (IIIAAs) are rare, life-threatening entities for which the optimal treatment strategy has not been established. This study aimed to evaluate the outcomes of open and endovascular treatment of IIIAAs. METHODS: IIIAA cases between January 2009 and March 2019 at two hospitals were retrospectively reviewed. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed. RESULTS: Forty-two patients (37 men and 5 women) with a mean age of 71 years were included. Twenty-five patients (60%) had a history of hypertension. Twenty-two patients (52%) were asymptomatic, and 16 (38%) presented with abdominal pain (12 with ruptured aneurysms). The 42 included patients had 43 treated IIIAAs. The following surgical techniques were used: surgical resection (n = 6), endovascular coil embolization (n = 12), endovascular stent graft placement across the internal iliac artery origin (n = 8 with 9 aneurysms), and combined coil embolization and stent graft placement (n = 16). The immediate technical success rate was 67%, 67%, and 88% for embolization, stent graft placement, and combined method, respectively. Open surgery was associated with the longest operative time and hospital stay. Overall 30-day mortality was 5% for all patients and 17% for patients with ruptured IIIAAs. Buttock claudication occurred in 7 of 40 patients who survived (18%). The median follow-up time was 56 months. The combined approach was associated with the lowest rates of endoleak (6% vs 25% and 29%) and reintervention (6% vs 17% and 29%) of the three endovascular methods. CONCLUSIONS: Endovascular coil embolization with stent graft placement is a feasible, safe, and effective treatment approach for large IIIAAs without adequate aneurysm necks.

Endovascular treatment of spontaneous renal artery dissection.

OBJECTIVE: This study aimed to assess the outcomes of patients with spontaneous renal artery dissection (SRAD) after endovascular repair. METHODS: We performed a retrospective review of SRAD patients after endovascular treatment between January 2007 and August 2018. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed. RESULTS: Fourteen patients (12 men and 2 women) with a mean age of 47 years were included in this study. All the patients had hypertension, either new onset (78.6%) or pre-existent (21.4%). Sudden flank pain was the most common symptom. Fourteen patients had 15 affected renal arteries. Endovascular repair was successfully performed in 14 arteries. The technical success rate of endovascular repair was 93.3% (14/15), with no postoperative death. Endovascular repair significantly improved hypertension and renal function, and these improvements persisted during the follow-up period. The effective rate of endovascular repair for improving or curing hypertension was 85.7%. Follow-up imaging showed no sign of stent stenosis or occlusion in those patients who received endovascular repair. CONCLUSIONS: Endovascular repair is safe, feasible, and effective for SRAD treatment and should be a promising alternative to open revascularization.

Diagnosis and Treatment of Aortic Saddle Embolism.

BACKGROUND: Acute aortic occlusion is a rare but life-threatening medical condition that can result from aortic saddle embolism, thrombosis of an atherosclerotic aorta, or aortic dissection. Herein are described the diagnostic and therapeutic characteristics for a series of patients with aortic saddle embolism. METHODS: A retrospective review of medical records was performed for patients receiving treatment for aortic saddle embolism at a university hospital in China between January 2001 and September 2017. Demographic, clinical, ancillary testing, treatment, and outcome data were collected and analyzed. RESULTS: Eighteen patients (10 women and 8 men) with a mean age of 53.8 years were included. The most commonly associated cardiac diseases were atrial fibrillation or atrial flutter (89%); rheumatic heart disease, valvular heart disease, or both (72%); and congestive heart failure (56%). Rest pain was present in all patients, and sensory or motor deficits were present in 12 patients (67%). Computed tomography (CT) angiography was performed for all patients. Seventeen patients (94%) presented with aortic embolism below the renal arteries. Fifteen patients (83%) underwent bilateral transfemoral embolectomy, and 3 patients (17%) received no intervention. Fasciotomy was performed for 9 patients in 14 limbs. The overall mortality rate was 33%, with a postprocedure mortality rate of 20%. Major morbidity occurred in 60% of patients. Six lower extremities were amputated in 4 patients, and acute renal failure developed in 4 patients. The incidence of postembolectomy internal iliac artery embolism was 58% (11 of 19 iliac arteries), and pelvic ischemia developed in 1 young patient. CONCLUSIONS: Aortic saddle embolism is uncommon but associated with high morbidity and mortality. CT angiography is recommended for diagnosis, and bilateral transfemoral embolectomy is the preferred treatment. Postembolectomy internal iliac artery embolism was common, and prevention of pelvic ischemia should be considered for young patients.

A Modified Loop Snare Technique for Difficult Retrievals of Inferior Vena Cava Filter and Migrated Coil.

The aim of this study was to evaluate the safety and efficacy of a modified loop snare technique for retrieval of difficult inferior vena cava (IVC) filters and migrated coils.A retrospective review of Günther Tulip filter retrievals between January 2014 and February 2017 was performed. A total of 316 IVC filter retrievals were attempted. In 25 cases, the standard technique had failed and our modified loop snare technique was subsequently attempted in 21 of these patients.The retrievals were successful in 20 cases (mean dwell time, 42.6 days, range, 14-102 days). The dwell time of the one failure was 46 days. The retrieval rate increased from 92.1% with the standard technique to 98.4% with the combination of the standard and modified loop snare technique. Unsuccessful retrieval was due to migration and endothelialization of the filter. This technique can also be used to remove migrated coils which cannot be captured by standard techniques. There were no complications from the retrievals.Tilt and endothelialization of filters are the main factors resulting in unsuccessful retrievals with the standard technique. In the present study, we describe an alternative technique for difficult IVC filter retrievals, which can also be used to capture migrated coils and occluders in the aorta and heart.

Blockade of HMGB1 preserves vascular homeostasis and improves blood perfusion in rats of acute limb ischemia/reperfusion.

Acute limb ischemia is one of the most common peripheral arterial disease, while surgical restoration of blood flow often results in ischemia/reperfusion (I/R) injury. Our previous study revealed the inflammation intensity in arterial tissue, characterized by expression of high mobility group box protein 1 (HMGB1), was contrary to the fluctuation of hemodynamics in reperfusion limbs in a rat model. This study meant to clarify the role of HMGB1 during this process. Laser Doppler perfusion imaging evaluated limb hemodynamics in mean and max perfusion unit (PU). Femoral arterial tissue was collected for molecular biology examination. The results revealed that HMGB1 promoted vascular structure remodeling and vasomotor dysfunction during acute I/R, characterized by degradation of collagenous fibers, disruption of elastic lamellae, intensive inflammation and phenotype transfer of smooth muscle cells. Blockade of HMGB1 preserved vascular homeostasis and improved PUs (PmeanPU<0.001, PmaxPU<0.001). The elevated expression of TNF-α, IL-6, ICAM, VCAM, MMP-2, MMP-9, α-SM actin correlated with HMGB1 positively. In conclusion, HMGB1 promoted vascular remodeling and dysfunction via initiating an inflammation cascade during I/R. Blockade of HMGB1 would preserve vascular homeostasis and facilitate the blood perfusion of ischemic limb.

Endovascular stent-graft placement and coil embolization for an anomalous splenic artery aneurysm.

Aneurysms of the splenic artery originating anomalously from the superior mesenteric artery are extremely rare; however, they are clinically important because of the potential for fatal rupture and particular anatomical location. Most previous cases were managed by open surgical intervention. We present a case of an anomalous splenic artery aneurysm, which was successfully treated with endovascular stent graft placement and coil embolization. This appears to be a promising minimally invasive approach to manage this rare entity. Also, we review the literature of aneurysms of the splenic artery arising from the superior mesenteric artery.

Therapeutic management of superior mesenteric artery aneurysms.

OBJECTIVE: Superior mesenteric artery (SMA) aneurysms are rare but life-threatening entities. This study summarizes our experience in providing therapeutic management for true aneurysms of the SMA. METHODS: Between February 1998 and March 2010, 10 patients were diagnosed with true SMA aneurysms in our hospital. Medical data for demographics, clinical presentation, diagnosis, aneurysm characteristics, treatment modalities, outcomes, and follow-up were retrospectively analyzed. RESULTS: Ten patients (six women, four men) were enrolled with a mean age of 56.7 years (range, 42-69 years). One patient (10%) had aneurysm rupture and presented with abdominal pain, and seven (70%) were asymptomatic. The size of nonruptured aneurysms ranged from 1.2 to 8.0 cm (mean, 3.5 cm). Of 10 patients, five received endovascular stent graft repair, two were treated surgically, two were observed, and one with aneurysm rupture died of hemorrhagic shock before surgery. The two surgical patients underwent SMA reconstruction after aneurysmectomy, and segmental bowel resection was performed in one patient after reconstruction. The overall mortality rate was 10%. Postoperative gastroparesis was identified in one patient (14.3%). Mean operation time was 3.6 hours in the surgical group and 1.3 hours in the endovascular group. Mean postoperative hospital stay for the two groups was 20.0 days and 2.2 days, respectively. Mean follow-up was 30.9 months (range, 3-72 months). Endoleak was found in one patient 3 months after endovascular repair. CONCLUSION: True SMA aneurysms are uncommon entities with definite rupture risk and mortality. Compared with surgical intervention, endovascular stent graft placement is associated with less trauma and rapid recovery. It may be a promising alternative to surgical intervention. The most appropriate treatment depends on the characteristics of the lesion and the condition of the patient.

Spontaneous retroperitoneal hematoma associated with iliac vein rupture.

OBJECTIVE: Spontaneous retroperitoneal hematoma (SRH) associated with iliac vein rupture is a rare but life-threatening emergency with high operative mortality. This study summarizes our experience in providing diagnostic and therapeutic management for this rare clinical entity. METHODS: Between May 2002 and May 2009, nine patients were admitted to our hospital for SRH and acute deep venous thrombosis (DVT). Medical data for demographics, clinical presentation, auxiliary examinations, treatment modalities, outcomes, and follow-up were retrospectively analyzed. RESULTS: Nine patients (8 women, 1 man) were enrolled in this study. All were aged>45 years (range, 46-70 years). The common clinical manifestations were sudden onset of left lower abdominal or lumbar pain, swelling of the left lower extremity, anemia, and hypotension. Most patients were diagnosed by duplex ultrasound imaging and computed tomography scan. Three patients were treated conservatively, and six underwent surgical or combined treatments, comprising 2 repairs of iliac vein, 1 iliac vein ligation and Palma-Dale bypass graft, 1 pelvic vein ligation, 1 removal of hematoma, and 1 repair of iliac vein, thrombectomy, and endovascular stent placement. The iliac vein ruptured in five patients. May-Thurner syndrome was found in three patients. One patient died after surgery (operative mortality, 16.7%). Postoperative morbidity was 50%. Mean volume of perioperative blood transfusion was 900±640 mL (range, 0-2000 mL). Mean lengths of stay were 2.7±1.4 days (range, 2-5 days) in the intensive care unit and 16.9±2.4 days (range, 14-21 days) in the hospital. Eight patients were postoperatively treated with 6 months of warfarin. Mean follow-up was 30.5±15.0 months (range, 6-50 months). The occurrence rate of chronic venous insufficiency was 87.5% during follow-up. CONCLUSIONS: SRH with concomitant DVT, especially in women aged >45, should be considered in patients with sudden lower abdominal or lumbar pain, leg swelling, anemia, and shock. Spontaneous iliac vein rupture and the presence of May-Thurner syndrome should be considered in these patients. Surgical interventions were associated with high mortality and morbidity. In our experience, conservative therapy was safer than open surgical procedures.

Baicalin ameliorates atherosclerosis by inhibiting NLRP3 inflammasome in apolipoprotein E-deficient mice.

BACKGROUND: NLR family pyrin domain containing 3 (NLRP3) inflammasome has been implicated in the development of atherosclerosis and several studies have suggested that inhibiting NLRP3 inflammasome could be a potential therapeutic approach to treat atherosclerosis. Baicalin is a flavone glycoside with anti-inflammation, anti-oxidative activities. The inhibition of NLRP3 inflammasome activation by baicalin has also been described. Therefore, the effects of baicalin on NLRP3 inflammasome activation and atherosclerosis were evaluated in present study. METHODS: We established the apolipoprotein E-deficient atherosclerosis mice model. After baicalin treatment, the IL-1, IL-18, and reactive oxygen species (ROS) production, and the plaque area was monitored. We also measured the NLRP3, ASC, caspase-1, ICAM-1, and VCAM-1 expression in atherosclerosis mice after baicalin treatment. We silenced NLRP3 by administration of lentivirus expressing NLRP3 shRNA to atherosclerosis mice and monitored the IL-1, IL-18, and ROS production, and NLRP3 inflammasome activation. RESULTS: Baicalin remarkably inhibited the production of IL-1, IL-18, mitochondria ROS, total ROS, ICAM-1, and VCAM-1. Baicalin reduced the expression of NLRP3 inflammasome and suppressed its activation. Baicalin significantly reduced the plaque area. Silencing NLRP3 resulted in decreased production of IL-1, IL-18, mitochondria ROS, total ROS, ICAM-1, and VCAM-1, and inhibition of NLRP3 inflammasome activation. CONCLUSION: Baicalin ameliorated atherosclerosis by inhibiting NLRP3 inflammasome.

Intravenous Leiomyomatosis of the Uterus: A Retrospective Single-Center Study in 14 Cases.

PURPOSE: This study aimed to retrospectively review the diagnosis and surgical treatment of uterine intravenous leiomyomatosis (IVL). METHODS: The clinical data of 14 patients with uterine IVL admitted to our hospital between 2013 and 2018 were retrospectively analyzed, including their demographics, imaging results, surgical procedures, perioperative complications, and follow-up results. RESULTS: The tumors were confined to the pelvic cavity in 7 patients, 1 into the inferior vena cava, 4 into the right atrium, and 2 into the pulmonary artery (including 1 into the superior vena cava). Only one case was misdiagnosed as right atrial myxoma before the operation, which was found during the surgery and was treated by staging surgery; all the other patients underwent one-stage surgical resection. Three patients underwent complete resection of the right atrial tumor through the abdominal incision, and one patient died of heart failure in the process of resection of heart tumor without abdominal surgery. During the 6-60 months of follow-up, 4 patients developed deep venous thrombosis of the lower extremity, and 1 patient developed ovarian vein thrombosis and pulmonary embolism. After anticoagulation treatment, the symptoms disappeared. One patient refused hysterectomy and the uterine fibroids recurred 4 years after the operation. CONCLUSION: Specific surgical plans for uterine IVL can be formulated according to cardiac ultrasound and computed tomography (CT). For the first type of tumor involving the right atrium, the right atrium tumor can be completely removed through the abdominal incision alone to avoid thoracotomy. The disease is at high risk of thrombosis and perioperative routine anticoagulation is required.

Expression levels of cathepsin L and cystatin C in a hyperglycemic environment were associated with aortic aneurysm development in a mouse model.

OBJECTIVES: Diabetes mellitus (DM) attenuates the development of aortic aneurysms (AA). This study investigated the expression of cathepsin L and cystatin C in a hyperglycemic environment, and the influence of these proteins on AA development. METHODS: Mice were divided into AA and DM+AA groups ( n=30 per group). DM was induced by injection of streptozotocin; AA was induced by injection of angiotensin II. Doppler examination was used to measure aortic diameter, and Weigert's elastic stain was used to detect elastin degradation. Cathepsin L and cystatin C in aortic tissue were examined by western blotting, immunohistochemistry, and polymerase chain reaction. RESULTS: Aortic diameter in the DM+AA group was less than that in the AA group, and elastin fragmentation grade of the aortic wall was reduced in the DM+AA group. More cathepsin L-positive cells were observed in the AA group than in the DM+AA group; conversely, more cystatin C-positive cells were observed in the DM+AA group than in the AA group. Both protein and mRNA levels of cathepsin L and cystatin C showed similar trends to those observed in immunohistochemistry. CONCLUSIONS: Expression levels of cathepsin L and cystatin C in a hyperglycemic environment were associated with AA development in a mouse model.

Role of AIB1 for tamoxifen resistance in estrogen receptor-positive breast cancer cells.

OBJECTIVES: The p160 nuclear receptor coactivator, AIB1 (amplified in breast cancer 1), is frequently overexpressed in human breast cancer and has been shown to be associated with tamoxifen resistance. The present study aimed to investigate the role of AIB1 in tamoxifen resistance of breast cancer cells. METHODS: We reconstructed the RNA interference expression vector, pGenesil-1-U6, specially targeting AIB1 mRNA, and it was stably transfected into the human breast cancer cell line BT474. Cell proliferation and cell cycle distribution were assessed in the cells transfected with scramble control shRNA (BT474/shControl) and AIB1 shRNA (BT474/shAIB1) to explore the possible functions of AIB1 in breast cancer progression. The expression of AIB1, ERalpha, HER2 and pS2 was analyzed in the presence of 17beta-estradiol or 4-hydroxytamoxifen (Tam) by Western blot analysis. RESULTS: Compared with the parental BT474 and the BT474/shControl cells, the levels of AIB1 mRNA and protein were significantly reduced in BT474/shAIB1 cells. A knockdown of AIB1 levels restored the inhibitory effect of tamoxifen on cell proliferation. CONCLUSIONS: Tam behaves like an estrogen agonist in ER-positive breast cancer cells that express high levels of AIB1 and HER2, resulting in de novo resistance. Knockdown of AIB1 can eliminate this cross talk and restore the antitumor effects of tamoxifen.

Duodenal-Jejunal bypass improves glucose homeostasis in association with decreased proinflammatory response and activation of JNK in the liver and adipose tissue in a T2DM rat model.

BACKGROUND: There is accumulating evidence that obesity leads to a proinflammatory state, which plays crucial roles in insulin resistance and development of type 2 diabetes mellitus (T2DM). Previous studies demonstrated that weight loss after bariatric surgery was accompanied by a suppression of the proinflammatory state. However, the effect of bariatric surgery on the proinflammatory state and associated signaling beyond weight loss is still elusive. The objective of this study was to investigate the effect of duodenal-jejunal bypass (DJB) on glucose homeostasis, the proinflammatory state and the involving signaling independently of weight loss. METHODS: A high-fat diet and low-dose streptozotocin administration were used to induce T2DM in male Sprague-Dawley rats. The diabetic rats underwent DJB or sham surgery. The blood glucose, glucose tolerance and insulin resistance were determined to evaluate the glucose homeostasis. Serum insulin, GLP-1 and hsCRP were detected by ELISA. The gene expression of TNF-α, IL-6, IL-1ß and MCP-1 in liver and fat was determined by quantitative real-time RT-PCR. The JNK activity and serine phosphorylation of IRS-1 in liver and adipose tissue were determined by Western blotting. RESULTS: Compared to the S-DJB group, DJB induced significant and sustained glycemic control with improved insulin sensitivity and glucose tolerance independently of weight loss. DJB improved the proinflammatory state indicated by decreased circulating hsCRP and proinflammatory gene expression in the liver and adipose tissue. The JNK activity and serine phosphorylation of IRS-1 in liver and adipose tissue were significantly reduced after DJB. CONCLUSIONS: DJB achieved a rapid and sustainable glycemic control independently of weight loss. The data indicated that the improved proinflammatory state and decreased JNK activity after DJB may contribute to the improved glucose homeostasis.

Endovascular stent graft repair of a penetrating aortic injury.

We report the endovascular stent graft repair of a penetrating aortic injury with active hemorrhage. A 72-year-old man was admitted after getting stabbed in his back. He had a history of coronary heart disease and cardiac infarction. Computed tomography revealed thoracoabdominal aortic rupture. Endovascular repair was performed successfully. The patient recovered uneventfully, and did not complain of discomfort after a 1-year follow-up. Endovascular treatment may be a valuable and lifesaving option for patients sustaining penetrating aortic injury with contraindications to surgery.