Directional Femoral Ultrasound-Guided Compression Technique Using in Percutaneous Mechanical Thrombectomy for Acute Deep Vein Thrombosis: A Retrospective Cohort Study.

OBJECTIVE: The study aimed to investigate the early results of directional femoral ultrasound-guided compression technique (UCT) using in percutaneous mechanical thrombectomy (PMT) for acute deep vein thrombosis (DVT). METHODS: Consecutive single-center patients with acute iliofemoral DVT who underwent PMT from January 2020 to December 2021 were included. Directional femoral UCT was used to adjust the PMT catheter into the residual thrombus in the inguinal region by ultrasound compression to improve the thrombus clearance rate. Patients were retrospectively analyzed and divided into 2 groups based on PMT with or without directional femoral UCT. The primary efficacy outcome was the incidence of post-thrombotic syndrome (PTS) at 24-month follow-up. The secondary efficacy outcomes included common femoral venous thrombus removal grade, total thrombus removal grade, venous primary patency rate, and incidence of moderate-to-severe PTS at 24-month follow-up. The safety outcomes included complications, major bleeding events, and death at 24-month follow-up. RESULTS: A total of 96 patients were included in the study: 42 patients underwent PMT with directional femoral UCT and 54 patients underwent PMT without UCT. There was no significant difference in baseline characteristics between the 2 groups. The percentages of patients achieved common femoral venous thrombus removal grade 3 and total thrombus removal grade 3 were significantly higher in the PMT with UCT group than those in the PMT without UCT group (p<0.001). The 24-month primary patency rate was significantly higher in the PMT with UCT group than that in the PMT without UCT group (90.0% vs 71.2%, p=0.027). The incidence of PTS was significantly lower in the PMT with UCT group (10.0%) than that in the PMT without UCT group (28.8%) (p=0.027). CONCLUSION: PMT with directional femoral UCT could improve the thrombus clearance rate and primary patency rate of acute iliofemoral DVT and might decrease the incidence of PTS compared to traditional PMT treatment without UCT. CLINICAL IMPACT: Residual thrombus in common femoral vein is a difficult problem associated with higher incidence of PTS. Few studies have focused on common femoral venous thrombus clearance. PMT with directional femoral UCT could improve the thrombus clearance rate and primary patency rate of acute iliofemoral DVT, and might decrease the incidence of PTS compared to traditional PMT treatment without UCT. Directional femoral UCT is recommended in PMT treatment of acute iliofemoral DVT.

The Impact of Balloon Pre-dilatation Techniques on Drug-Coated Balloon Therapy for Femoropopliteal Artery Disease: Six-Month Results From the CIVILIAN Registry.

OBJECTIVE: The purpose of this study is to compare the initial outcomes of using the Chocolate balloon pre-dilatation (CLP) and sequential enlarging angioplasty pre-dilatation (sequential balloon pre-dilation [SP]) techniques versus the conventional balloon pre-dilatation (CP) method prior to drug-coated balloon (DCB) treatment for femoropopliteal (FP) lesions. METHODS: This was a retrospective analysis of prospectively collected data from the CIVILIAN (Clinical InVestigation of different lesIon preparation modaLIty followed by DCB in femoropopliteal Artery occlusioN disease) registry. Between March 2021 and November 2022, 3 pre-dilation techniques used prior to the DCB angioplasty were included. The study endpoint included intraoperative finial severe dissection after provisional stent placement, bailout stenting rate, the diameter of the largest pre-dilation balloon and DCB, as well as major adverse events (MAEs), including death, major limb amputation, or target vessel revascularization at 6 months. RESULTS: During the study period, 435 limbs (429 patients) were pre-dilated before DCB treatment in FP lesions, 166 limbs were pre-dilated with Chocolate balloons, 93 limbs with sequential enlarging balloon pre-dilation technique, and 176 limbs with CP. The largest pre-dilation balloon was significantly larger in CLP and SP groups than that in the CP group (CLP 4.74±0.52 mm vs CP 4.36±0.64 mm, p<0.001; SP 4.82±0.69 mm vs CP 4.36±0.63 mm, p<0.001). A consistent result was shown in DCB diameter (CLP 4.86±0.44 mm vs CP 4.71±0.51 mm, p=0.003; SP 4.90±0.58 mm vs CP 4.71±0.51 mm, p=0.006). The bailout stenting rate was significantly lower in the CLP group than that in the CP group (18.1% vs 30.1%, p=0.011). The rates of MAEs at 6 months in the CLP and SP groups were comparable to those in the CP group (7.2% and 8.6% vs 6.3%, p>0.05). The risk for intraoperative bailout stenting rate was related to TASC D classification (3.59, 95% CI: 1.83-7.05, p<0.001), chronic total occlusion (CTO) lesion (1.82, 95% CI: 1.07-3.10, p=0.028), as well as pre-dilated with the conventional balloon (1.64, 95% CI: 1.00-2.69, p=0.048). CONCLUSIONS: By utilizing chocolate balloon and sequential enlarging angioplasty, it becomes possible to use larger pre-dilation balloons and DCBs. In addition, the use of the chocolate balloon can significantly reduce the need for bailout stenting when compared with conventional balloons. CLINICAL IMPACT: The utilization of a chocolate balloon and sequential enlarging angioplasty has emerged as a promising technique for angioplasty procedures. This approach allows for the use of larger pre-dilation balloons and drug-coated balloons. The use of the chocolate balloon can significantly reduce the need for bail-out stenting when compared to conventional balloons. Further research is required to determine the impact of vessel preparation techniques on the primary patency.

Clinical Guidelines on Compression Therapy in Venous Diseases.

BACKGROUND: In recent years, compression therapy has attracted gradually increasing clinical attention in lower extremity venous diseases. However, basic concepts and clear nomenclature, standard treatment methods, and consistent product standards for pressure equipment are lacking. Therefore, developing clinical guidelines for compression therapy is essential to improving the treatment of venous diseases. METHODS: Our panel generated strong (grade I), moderate (grade IIa and IIb), and weak (grade III) recommendations based on high-quality (class A), moderate-quality (class B), and low-quality (class C) evidence, using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and the European Society of Cardiology (ESC) grading system. RESULTS: The panels made 30 recommendations from current evidence, focusing on 7 fields of lower extremity venous disease (venous thromboembolism, post-thrombotic syndrome (PTS), chronic venous insufficiency (CVI), varicose veins, hemangioma and vascular malformations, lymphedema, and venous ulcers) and 18 topics. CONCLUSIONS: Of the 30 recommendations made across the 18 topics, 7 were strong (grade I) and 17 were based on high-quality (class A) evidence, highlighting the need for further research of the use of compression therapy.

Novel Self-Expanding Interwoven Nitinol Stent for Treating Femoropopliteal Artery Disease: 12-Month Results of Single-Center First-in-Man Study.

PURPOSE: To evaluate the safety and efficacy of Innospring® stent, a novel self-expanding interwoven nitinol stent, in treating femoropopliteal atherosclerotic lesions. METHODS: A prospective, single-center, single-arm, first-in-human study enrolled 15 patients (mean age 73.1 years; 13 men) to evaluate the safety and efficacy of the Innospring® stent monitored by core laboratories. The inclusion criteria were claudication or ischemic rest pain, de novo lesions or nonstented restenosis, >70% stenosis, lesion length <20 cm, and a reference vessel diameter of 4-7 mm. The primary safety endpoint was 30-day major adverse events. The primary efficacy end point was stent patency at 12 months. Follow-up evaluations were conducted at 30 days, 6 months, and 12 months. RESULTS: The lesion length was 6.1 ± 3.5 mm. Fourteen (93.3%) patients had lesions of the superficial femoral artery and 3 (20.0%) patients had lesions of the popliteal artery. Nine (60.0%) patients had moderate-to-severe calcified lesion. Technical and procedural success was 100%. No patients experienced major adverse events in the first 30 days. The Rutherford category showed significant and sustained improvement at 6 and 12 months. The 12-month follow-up radiographs obtained in 13 patients confirmed the absence of stent fractures in 100% of examinations. The cumulative primary stent patency rate at 6 and 12 months were 93.3% and 84.6%, respectively. CONCLUSION: Stenting of the superficial femoral and popliteal arteries using the Innospring® stent is safe and effective. This competing interwoven nitinol stent may provide superior stent integrity and fracture-resistance as well as serve areas under extreme mechanical stress. CLINICAL IMPACT: Endovascular recanalization is a widely accepted and recommended treatment for symptomatic peripheral artery diseases. The Innospring® stent is a novel self-expanding interwoven stent containing eight nitinol wires with additional radial force, fracture-resistance, and visibility under fluoroscopy. This first-in-human study using the Innospring® stent in patients with femoropopliteal occlusive disease reported that stenting of the superficial femoral and popliteal arteries using the Innospring® stent is safe and effective. This competing interwoven nitinol stent may provide an impressive stent integrity and fracture-resistance as well as serve areas under extreme mechanical stress.

Stent Graft vs Drug-Coated Balloon in Endovascular Treatment of Complex Femoropopliteal Artery Lesions: A 2-Center Experience.

OBJECTIVE: Both stent grafts (SG) and drug-coated balloons (DCBs) have shown to be effective treatments for long and complex femoropopliteal (FP) lesions. However, there has not been a clinical trial comparing the 2 treatments directly. This study aims to compare the primary patency (PP) and clinical outcomes of SG and DCB for endovascular treatment of complex FP Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions in patients. METHODS: From July 2013 to May 2019, a retrospective study was conducted at 2 medical centers to compare the clinical outcomes of Viabahn SG and DCB angioplasty in patients with TASC C/D FP lesions. The study used overlap weighting to adjust for differences in baseline characteristics and to reduce the impact of confounding factors and selection bias between the 2 groups. The primary endpoint was PP through 24 months, and the secondary endpoints included freedom from clinical-driven target lesion revascularization (CD-TLR), all-cause of death rate, and major amputation rate. RESULTS: A total of 161 limbs in 150 patients with TASC C/D FP lesions were treated either with Viabahn SGs (67 limbs, 65 patients) or DCBs (94 limbs, 85 patients). In the DCB group, 22 target vessels (23.4%) underwent directional atherectomy before DCB angioplasty and 37 target vessels (39.4%) underwent bail-out bare-metal stent implantation for early recoil or severe dissection. The SG group had significantly higher PP rates at both the 12 and 24 months than in the DCB group (75.8% vs 39.2%, p=0.02; 64.1% vs 31.9%, p=0.02), respectively. However, there were no significant differences between the 2 groups in terms of CD-TLR, death rate, and major amputation rate. According to the results of multivariate analysis, DCB angioplasty was the only independent predictor associated with restenosis (hazard ratio [HR]=0.264, 95% confidence interval [CI]=0.100-0.696, p=0.007). CONCLUSIONS: This study showed that SG was associated with a significantly higher PP rate in complex long FP lesions compared with DCB angioplasty. However, there was no significant difference in the freedom from CD-TLR and major amputation rate. It is important to follow the criteria for using SG strictly to avoid early restenosis, which can lead to acute thrombosis and severe limb ischemia. Closer monitoring is recommended for patients who undergo SG implantation. CLINICAL IMPACT: There has no head-to-head clinical trial that compares DCB and SG in complex long FP lesions. This study showed that SG following the criteria was associated with a significantly higher PP rate compared with DCB angioplasty. Closer monitoring is recommended for patients with SG to avoid acute thrombosis. Randomized controlled trials comparing SG and DCB are necessary.

Blood oxygenation level-dependent cardiovascular magnetic resonance of the skeletal muscle in healthy adults: Different paradigms for provoking signal alterations.

PURPOSE: Stress blood oxygenation level-dependent (BOLD) cardiovascular magnetic resonance allows for quantitative evaluation of blood flow reserve in skeletal muscles. This study aimed to prospectively compare three commonly used skeletal BOLD cardiovascular magnetic resonance paradigms in healthy adults: gas inhalation, cuff compression-induced ischemia and postocclusive reactive hyperemia, and exercise. METHODS: Twelve young (22 ± 0.9 years) and 10 elderly (58 ± 5.0 years) healthy subjects underwent BOLD cardiovascular magnetic resonance under the three paradigms. T2∗ signal intensity time curves were generated and quantitative parameters were calculated. Meanwhile, stress transcutaneous oxygen pressure measurements were obtained as comparison. Measurement reproducibility was assessed with intraclass correlation coefficients. Differences in the T2∗ BOLD variation, the correlation with transcutaneous oxygen pressure, and the age-related change between paradigms were statistically analyzed. RESULTS: Minimum ischemic value and maximum hyperemic peak value showed the highest interobserver and interscan reproducibilities (intraclass correlation coefficient >0.90). The plantar dorsiflexion exercise paradigm elicited the largest T2∗ BOLD variation (15.48% ± 10.56%), followed by ischemia (8.30% ± 6.33%). Negligible to weak changes were observed during gas inhalation. Correlations with transcutaneous oxygen pressure measurements were found in the ischemic phase (r = 0.966; P < .001) and in the postexercise phase (r = -0.936; P < .001). Minimum ischemic value, maximum hyperemic peak value, maximum postexercise value, and slope of postexercise signal decay showed significant differences between young and elderly subjects (P < .01). CONCLUSION: Ischemia and reactive hyperemia have superior reproducibility, and exercise could induce the largest T2∗ variation. Key parameters from the two paradigms show age-related differences.

One-Year Clinical Outcome and Risk Factor Analysis of Directional Atherectomy Followed With Drug-Coated Balloon for Femoropopliteal Artery Disease.

PURPOSE: This study investigated the 1-year clinical outcomes of directional atherectomy combined with drug-coated balloon (DA + DCB) in femoropopliteal artery disease (FPAD) from real-world experience. MATERIALS AND METHODS: A retrospective study was conducted of patients treated between July 2016 and June 2019 using DA + DCB for FPAD. Patients' demographics, comorbidities, clinical characteristics and outcomes, and angiography and duplex ultrasound findings were analyzed. The 6-month and 1-year primary patency, primary assisted patency, secondary patency, and freedom from clinically-driven target lesion revascularization (CD-TLR) were evaluated. Univariate and multivariate analyses were performed to identify risk factors of primary patency loss or CD-TLR. RESULTS: Seventy-nine consecutive patients (83 lesions, mean age 70.9 years, 52 men) were included. Twenty-seven limbs had lifestyle-limiting claudication and 56 limbs had critical limb ischemia. There were 73 and 10 limbs with de novo lesion and in-stent restenosis, respectively. The mean lesion length of all the patients was 22.1 cm. The mean length of chronic total occlusions (CTOs) was 8.3 cm. Severe calcification was found in 32.5% cases. The 1-year primary patency rate was 80.8% and freedom from CD-TLR was 92.2%. The bailout stenting rate was 2.4%. Patients with CTO >10 cm had significantly lower 1-year primary patency rate and freedom from CD-TLR than did patients with CTO ≤10 cm. Total length of CTO (stratified as ≤5 cm, 5-10 cm, >10 cm) was identified as an independent risk factor of 1-year primary patency loss and CD-TLR. CONCLUSION: DA + DCB appears to be a safe and effective endovascular therapy to treat FPAD in real-world clinical practice, with a promising 1-year patency rate with a low rate of bailout stenting.

Viabahn Stent Graft for the Endovascular Treatment of Occlusive Lesions in the Femoropopliteal Artery: A Retrospective Cohort Study with 4-Year Follow-Up.

BACKGROUND: The polytetrafluoroethylene-covered Viabahn stent may be effective for the endovascular treatment of patients with femoropopliteal artery occlusive lesions. However, the long-term efficacy of Viabahn stent remains unclear. The aim of the study is to evaluate the long-term patency of Viabahn stent grafts in patients with occlusive lesions in the femoropopliteal artery. METHODS: Consecutive patients with occlusive lesions in the femoropopliteal artery who had been treated with Viabahn stent grafts during the period from June 2013 to December 2016 at our center were retrospectively included. Accumulative incidences of primary patency and secondary patency were estimated by Kaplan-Meier survival analysis, and the predictors of primary patency were evaluated by Cox regression analysis. RESULTS: A total of 66 patients underwent successful endovascular treatment and were included in the study. Endovascular treatment with a Viabahn stent was associated with a complication rate of 9.1% and a 30-day mortality rate of 1.5%. Sixty-one patients were followed for a mean duration of 29.5 months. The 1-year, 2-year, 3-year, and 4-year primary patency rates were 81.7%, 74.7%, 67.6%, and 58.9%, respectively. The secondary patency rates were 94.9%, 92.9%, 90.1%, and 90.1%, respectively. The overall major amputation rate was 5.0%. The results of multivariate Cox regression analyses showed that stent location was the only independent predictor of primary patency (P = 0.001). Implantation of a Viabahn stent above the knee, compared with implantation below the knee, was associated with a higher rate of primary patency. CONCLUSIONS: The Viabahn stent graft is associated with a satisfactory rate of long-term patency for the endovascular treatment of occlusive lesions in the femoropopliteal artery, especially for those located above the knee.

Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio Predict Severity and Prognosis of Lower Limb Arteriosclerosis Obliterans.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are 2 markers of inflammation, which are associated with worse cardiovascular disease outcomes. Here, we aimed to determine the association between these ratios and disease severity and evaluate predictive validity of the NLR and PLR in lower limb arteriosclerosis obliterans (ASO). METHODS: We evaluated 211 patients with a diagnosis of ASO from January 2016 to December 2018 at Shanghai Jiaotong University Renji Hospital. The NLR and PLR were accessed from routinely drawn peripheral venous blood at the ward of vascular surgery during hospitalization. The association between the NLR and PLR with baseline characteristics, disease severity, and one-year outcomes were determined, respectively. RESULTS: Both the NLR and PLR showed significant values on predicting disease severity. A higher NLR (P = 0.001) and PLR (P < 0.001) were associated with lower ankle-brachial index and worse clinical presentation. Both the NLR and PLR are positively correlated with one-year readmission rate (P < 0.001, P = 0.001, respectively). Both the NLR and PLR also positively correlated with the tissue loss rate and one-year mortality (P = 0.007, P = 0.034, respectively). CONCLUSIONS: The NLR and PLR show a positive association with the severity of lower extremity peripheral artery disease, both higher ratios correlate with poor prognosis, especially, the risk of one-year readmission. A higher NLR also correlates with one-year mortality.

Clinical Features and Outcomes of Patients With Acute Mesenteric Ischemia and Concomitant Colon Ischemia: A Retrospective Cohort Study.

BACKGROUND: Early identification of patients with acute mesenteric ischemia (AMI) involving the large bowel may play a decisive role in improving the prognosis of AMI. This study aims to compare the outcomes between patients with isolated AMI and AMI patients with colon involvement (CI) and to identify the predictors of worse outcomes. The different surgical modalities for AMI patients with CI were also evaluated. METHODS: This retrospective cohort study included 199 AMI patients admitted from January 2005 to January 2014. Based on colonoscopy and pathology reports, 39 patients were diagnosed as AMI with CI, and 160 were AMI patients without CI. The clinical outcomes and different surgical modalities were compared. Risk factors of 30-d mortality and short bowel syndrome (SBS) were identified. RESULTS: The 30-d mortality (10% versus 49%, P < 0.01) and SBS incidence (19% versus 49%, P < 0.01) were higher in AMI patients with CI than AMI patients without CI. AMI patients with CI have higher rate of bowel resection (68% versus 95%, P < 0.001) and second-look laparotomy (25% versus 54%, P < 0.001) than patients with AMI alone. For AMI patients with CI, emergent laparotomy was associated with shorter hospital stay (P = 0.04) and less incidence of SBS (74% versus 25%, P < 0.001) than initial endovascular therapy. Patients with ostomy had less repeated bowel resection (11% versus 63%, P = 0.001) and rate of SBS (21% versus 79%, P < 0.001) than patients with primary bowel anastomosis. Serum procalcitonin level and colon ischemia were risk factors of 30-d mortality and SBS for AMI. CONCLUSIONS: AMI patients with CI represent a special cohort of AMI patients with higher risk of poor outcome. Compared to initial endovascular therapy, emergent laparotomy was associated with shorter length of hospital stay and reduced incidence of SBS.

Time course study of intestinal epithelial barrier disruption in acute mesenteric venous thrombosis.

BACKGROUND: Acute superior mesenteric venous thrombosis (ASMVT) is an abdominal vascular condition. Early recanalization is essential to successful treatment. The aim of the study was to establish rabbit models of ASMVT and assess the time course of intestinal epithelial barrier disruption. METHODS: After surgical exposure of superior mesenteric vein (Sham group), large-vessel (L-group) and small-vessel (S-group) models were established by endothelium damage, stenosis creation, and thrombin injection. At baseline, 6, 9, and 12 h, hemodynamic and serum parameters were tested. Serum from ASMVT patients diagnosed at 24, 36, 48, and 60 h from symptom onset was collected. Intestinal barrier disruption was assessed by tight junction (TJ) protein expression, morphology changes, and bacterial translocation. Mesenteric arteriospasm was measured by flow velocity and intestinal wet/dry weight ratio. The serum level of intestinal fatty acid-binding protein and endotoxin in patients was also measured as an indicator for intestinal barrier function. RESULTS: Severe acidosis and lacticemia were observed in both the groups. The L-group experienced greater hemodynamic alteration than the S-group. Intestinal barrier disruption was detected by significantly decreased TJ protein expression, histology and ultrastructure injury of TJ, increased permeability, and bacterial translocation, at 9 h in the S-group and 12 h in the L-group. Secondary mesenteric arteriospasm occurred at the same time of complete intestinal barrier disruption and could be a significant cause of bowel necrosis. Significant increased level of intestinal fatty acid-binding protein and endotoxin was found in patients at 48 h in the S-group type and 60 h in the L-group type. CONCLUSIONS: The ASMVT animal models of both the types were first established. The loss of intestinal barrier function occurred at 6 h in the S-group model and 9 h in the L-group model. For clinical patients, the time window extended to 36 h in the S-group type and 48 h in the L-group type.

Evaluation of skeletal muscle microvascular perfusion of lower extremities by cardiovascular magnetic resonance arterial spin labeling, blood oxygenation level-dependent, and intravoxel incoherent motion techniques.

BACKGROUND: Noninvasive cardiovascular magnetic resonance (CMR) techniques including arterial spin labeling (ASL), blood oxygenation level-dependent (BOLD), and intravoxel incoherent motion (IVIM), are capable of measuring tissue perfusion-related parameters. We sought to evaluate and compare these three CMR techniques in characterizing skeletal muscle perfusion in lower extremities and to investigate their abilities to diagnose and assess the severity of peripheral arterial disease (PAD). METHODS: Fifteen healthy young subjects, 14 patients with PAD, and 10 age-matched healthy old subjects underwent ASL, BOLD, and IVIM CMR perfusion imaging. Healthy young and healthy old participants were subjected to a cuff-induced ischemia experiment with pressures of 20 mmHg and 40 mmHg above systolic pressure during imaging. Perfusion-related metrics, including blood flow, T2* relaxation time, perfusion fraction f, diffusion coefficient D, and pseudodiffusion coefficient D*, were measured in the anterior, lateral, soleus, and gastrocnemius muscle groups. Friedman, Mann-Whitney, Wilcoxon signed rank, and Spearman rank correlation tests were used for statistical analysis. RESULTS: In cases of significant differences determined by the Friedman test (P < 0.05), blood flow, T2*, and D values gradually decreased, while f values showed a tendency to increase in healthy subjects under cuff compression. No significant correlations were found among the ASL, BOLD, and IVIM parameters (all P > 0.05). Blood flow and T2* values showed significant positive correlations with transcutaneous oxygen pressure measurements (ρ = 0.465 and 0.522, respectively; both P ≤ 0.001), while f values showed a significant negative correlation in healthy young subjects (ρ = - 0.351; P = 0.018). T2* was independent of age in every muscle group. T2* values were significantly decreased in PAD patients compared with healthy old subjects and severe PAD patients compared with mild-to-moderate PAD patients (all P < 0.0125). Significant correlations were found between T2* and ankle-brachial index values in all muscle groups in PAD patients (ρ = 0.644-0.837; all P < 0.0125). Other imaging parameters failed to show benefits towards the diagnosis and disease severity evaluation of PAD. CONCLUSIONS: ASL, BOLD, and IVIM provide complementary information regarding tissue perfusion. Compared with ASL and IVIM, BOLD may be a more reliable technique for assessing PAD in the resting state and could thus be applied together with angiography in clinical studies as a tool to comprehensively assess microvascular and macrovascular properties in PAD patients.

Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital.

BACKGROUND: Local anesthesia (LA) has been reported to be the best choice for elective open inguinal hernia repair because it is cost efficient, with less post-operative pain and enables more rapid recovery. However, the role of LA in emergency inguinal hernia repair is still controversial. The aim of this study is to investigate the safety and effectiveness of LA in emergency inguinal hernia repair. METHODS: All patients underwent emergency inguinal hernia repair in our hospital between January 2010 and April 2014 were analyzed retrospectively in this study. Patients were divided into LA and general anesthesia (GA) group according to the general conditions of the patients decided by anesthetists and surgeons. The outcome parameters measured included time to recovery, early and late postoperative complications, total expense and recurrence. RESULTS: This study included a total of 90 patients from 2010 to 2015. 32 patients (35.6%) were performed under LA, and 58 (64.4%) were performed under GA. LA group has less cardiac complications (P = 0.044) and respiratory complications (P = 0.027), shorter ICU stay (P = 0.035) and hospital stay (P = 0.001), lower cost (P = 0.000) and faster recovery time (P = 0.000) than GA group. CONCLUSION: LA could provide effective anesthesia and patient safety in emergency inguinal hernia repair.

PDIA2 has a dual function in promoting androgen deprivation therapy induced venous thrombosis events and castrate resistant prostate cancer progression.

Androgen deprivation therapy (ADT) is the first line of treatment for metastatic prostate cancer (PCa) that effectively delays the tumor progression. However, it also increases the risk of venous thrombosis event (VTE) in patients, a leading cause of mortality. How a pro-thrombotic cascade is induced by ADT remains poorly understood. Here, we report that protein disulfide isomerase A2 (PDIA2) is upregulated in PCa cells to promote VTE formation and enhance PCa cells resistant to ADT. Using various in vitro and in vivo models, we demonstrated a dual function of PDIA2 that enhances tumor-mediated pro-coagulation activity via tumor-derived extracellular vehicles (EVs). It also stimulates PCa cell proliferation, colony formation, and xenograft growth androgen-independently. Mechanistically, PDIA2 activates the tissue factor (TF) on EVs through its isomerase activity, which subsequently triggers a pro-thrombotic cascade in the blood. Additionally, TF-containing EVs can activate the Src kinase inside PCa cells to enhance the AR signaling ligand independently. Androgen deprivation does not alter PDIA2 expression in PCa cells but enhances PDIA2 translocation to the cell membrane and EVs via suppressing the clathrin-dependent endocytic process. Co-recruitment of AR and FOXA1 to the PDIA2 promoter is required for PDIA2 transcription under androgen-deprived conditions. Importantly, blocking PDIA2 isomerase activity suppresses the pro-coagulation activity of patient plasma, PCa cell, and xenograft samples as well as castrate-resistant PCa xenograft growth. These results demonstrate that PDIA2 promotes VTE and tumor progression via activating TF from tumor-derived EVs. They rationalize pharmacological inhibition of PDIA2 to suppress ADT-induced VTE and castrate-resistant tumor progression.

Neutrophil Extracellular Traps Delay Diabetic Wound Healing by Inducing Endothelial-to-Mesenchymal Transition via the Hippo pathway.

Diabetic foot ulcers (DFUs) are among the most frequent complications of diabetes with significant morbidity and mortality. Diabetes can trigger neutrophils to undergo histone citrullination by protein arginine deiminase 4 (encoded by Padi4 in mice) and release neutrophil extracellular traps (NETs). The specific mechanism of NETs-mediated wound healing impairment in diabetes remains unknown. In this study, we show neutrophils are more susceptible to NETosis in diabetic wound environments. Via in vitro experiments and in vivo models of wound healing using wide-type and Padi4 -/- mice, we demonstrate NETs can induce the activation of PAK2 via the membrane receptor TLR-9. Then PAK2 phosphorylates the intracellular protein Merlin/NF2 to inhibit the Hippo-YAP pathway. YAP binds to transcription factor SMAD2 and translocates from the cytoplasm into the nucleus to promote endothelial-to-mesenchymal transition (EndMT), which ultimately impedes angiogenesis and delays wound healing. Suppression of the Merlin/YAP/SMAD2 pathway can attenuate NET-induced EndMT. Inhibition of NETosis accelerates wound healing by reducing EndMT and promoting angiogenesis. Cumulatively, these data suggest NETosis delays diabetic wound healing by inducing EndMT via the Hippo-YAP pathway. Increased understanding of the molecular mechanism that regulates NETosis and EndMT will be of considerable value for providing cellular targets amenable to therapeutic intervention for DFUs.

Neutrophil extracellular traps induce abdominal aortic aneurysm formation by promoting the synthetic and proinflammatory smooth muscle cell phenotype via Hippo-YAP pathway.

The neutrophil plays an important role during abdominal aortic aneurysm (AAA) formation by undergoing histone citrullination with peptidyl arginine deiminase 4 (encoded by Padi4) and releasing neutrophil extracellular traps (NETs). However, the specific role of NETs during AAA formation is elusive. We found the levels of NET components in serum and tissues were found to be significantly associated with the clinical outcome of AAA patients. Furthermore, we reported that NETs induced the synthetic and proinflammatory smooth muscle cells (SMCs) phenotype and promoted AAA formation in a Hippo-YAP pathway-dependent manner by in vitro and in vivo experiments. Padi4 or Yap global knockout mice, exhibited significantly less synthetic and proinflammatory phenotypes of SMCs and developed AAA with lower frequency and severity compared with those of controls. Further studies indicated that the phenotypic switch of SMCs was associated with NETs-regulated enrichment status of H3K4me3 and H3K27me3 at promoters of synthetic and proinflammatory genes in SMCs. Cumulatively, these data suggest that NETs contribute to AAA formation by promoting the synthetic and proinflammatory phenotype of SMCs via inhibiting the Hippo-YAP pathway. A better understanding of the molecular mechanisms that regulate NETs and SMC phenotype is important to provide suitable cellular targets to prevent AAA.

Lymphocytes, Mean Platelet Volume, and Albumin in Critically Ill COVID-19 Patients with Venous Thromboembolism.

As one of the frequent complications leading to poor prognosis in hospitalized COVID-19 patients, a better understanding of venous thromboembolism (VTE) in COVID-19 patients is needed. We conducted a single-center, retrospective study on 96 COVID-19 patients admitted to the intensive care unit (ICU) from April to June 2022, in Shanghai Renji Hospital. Records of these COVID-19 patients upon admission were reviewed for demographic information, co-morbidities, vaccinations, treatment, and laboratory tests. VTE occurred in 11 (11.5%) cases among 96 COVID-19 patients despite the standard thromboprophylaxis since ICU admission. In COVID-VTE patients, a significant increase in B cells and a decrease in Ts cells were observed and a strong negative correlation (r = -0.9524, P = .0003) was found between these two populations. In COVID-19 patients with VTE, increased MPV and decreased albumin levels were seen in addition to the common VTE indicators of D-dimer abnormalities. The altered lymphocyte composition in COVID-VTE patients is noteworthy. In addition to D-dimer, MPV and albumin levels might be novel indicators for the risk of VTE in COVID-19 patients.

Disulfiram accelerates diabetic foot ulcer healing by blocking NET formation via suppressing the NLRP3/Caspase-1/GSDMD pathway.

Diabetic foot ulcer (DFU) is among the most frequent complications of diabetes and is associated with significant morbidity and mortality. Excessive neutrophil extracellular traps (NETs) delay wound healing in diabetic patients. Therefore, interventions targeting NET release need to be developed to effectively prevent NET-based wound healing impairment. Gasdermin D (GSDMD), a pore-forming protein acts as a central executioner of inflammatory cell death and can activate inflammasomes in neutrophils to release NETs. A precise understanding of the mechanism underlying NET-mediated delay in diabetic wound healing may be valuable in identifying potential therapeutic targets to improve clinical outcomes. In this study, we reported that neutrophils were more susceptible to NETosis in diabetic wound environments of patients with DFU. By in vitro experiments and using in vivo mouse models of diabetic wound healing (wide-type, Nlrp3-/-, Casp-1-/-, and Gsdmd-/- mice), we demonstrated that NLRP3/caspase-1/GSDMD pathway on activation controls NET release by neutrophils in diabetic wound tissue. Furthermore, inhibition of GSDMD with disulfiram or genic deletion of Gsdmd abrogated NET formation, thereby accelerating diabetic wound healing. Disulfiram could inhibit NETs-mediated diabetic foot ulcer healing impairment by suppressing the NLRP3/Caspase-1/GSDMD pathway. In summary, our findings uncover a novel therapeutic role of disulfiram in inhibiting NET formation, which is of considerable value in accelerating wound healing in patients with DFU.