Gender disparities in patients with aortoiliac disease requiring open operative intervention.

OBJECTIVE: Peripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease. METHODS: Patients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders. RESULTS: Of 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of -0.02 (95% confidence interval, -0.03 to -0.01; P < .001). CONCLUSIONS: Although there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.

Iliac vein recanalisation and stenting accelerate healing of venous leg ulcers associated with severe venous outflow obstruction.

Obstruction involving the iliac veins and/or inferior vena cava is highly comorbid in patients with chronic venous leg ulcers and is a barrier to healing. Intervention with venous stenting is recommended to promote wound healing; however, there is limited data to quantify the effects of venous outflow restoration on wound healing. We retrospectively identified patients with venous ulcers and comorbid venous outflow obstruction. Data regarding demographics, wound size, degree of obstruction, interventions, wound healing and recurrence were collected. Intervention was performed when possible and patients were grouped based on whether or not the venous outflow was reopened successfully and maintained for at least 1 year. Outcomes, including time to wound healing, wound recurrence, stent patency and ulcer-free time, were measured. Patients who maintained a patent venous outflow tract experienced higher rates of wound healing (79.3%) compared to those with persistent outflow obstruction (22.6%) at 12 months (p < 0.001). Ulcer-free time for the first year was also greater with patent venous outflow (7.6 ± 4.4 months versus 1.8 ± 3.0 months, p < 0.0025). Patients with severe obstruction of the venous outflow tract experience poor healing of VLUs despite appropriate wound care. Healing time is improved and ulcer-free time increased after venous intervention with stenting to eliminate obstruction.

Protein Farnesyltransferase Catalyzes Unanticipated Farnesylation and Geranylgeranylation of Shortened Target Sequences.

Protein prenylation is a posttranslational modification involving the attachment of a C15 or C20 isoprenoid group to a cysteine residue near the C-terminus of the target substrate by protein farnesyltransferase (FTase) or protein geranylgeranyltransferase type I (GGTase-I), respectively. Both of these protein prenyltransferases recognize a C-terminal "CaaX" sequence in their protein substrates, but recent studies in yeast- and mammalian-based systems have demonstrated FTase can also accept sequences that diverge in length from the canonical four-amino acid motif, such as the recently reported five-amino acid C(x)3X motif. In this work, we further expand the substrate scope of FTase by demonstrating sequence-dependent farnesylation of shorter three-amino acid "Cxx" C-terminal sequences using both genetic and biochemical assays. Strikingly, biochemical assays utilizing purified mammalian FTase and Cxx substrates reveal prenyl donor promiscuity leading to both farnesylation and geranylgeranylation of these sequences. These findings expand the substrate pool of sequences that can be potentially prenylated, further refine our understanding of substrate recognition by FTase and GGTase-I, and suggest the possibility of a new class of prenylated proteins within proteomes.

Operative strategies for inferior vena cava repair in oncologic surgery.

OBJECTIVE: Tumor involvement of the inferior vena cava (IVC) can result from primary caval leiomyosarcoma, local invasion by retroperitoneal malignant neoplasm, or metastases. Whereas ligation of the IVC may be well tolerated if collateral circulation can be adequately preserved, collaterals must often be ligated during oncologic resection. Reconstruction of the IVC may be performed by primary repair, patch angioplasty, or interposition graft. The purpose of our study was to describe different strategies of IVC reconstruction and to measure outcomes associated with IVC reconstruction among patients with retroperitoneal malignant disease. METHODS: All patients undergoing IVC reconstruction at our quaternary care hospital between November 2004 and February 2018 were identified using billing data (Current Procedural Terminology code 34502). Patients who underwent resection of the IVC for tumor involvement were enrolled in our study; data were collected on demographics, operative intervention, type of reconstruction, postoperative course, and 1-year outcomes. Patency rates were assessed by reviewing postoperative imaging including computed tomography, magnetic resonance imaging, ultrasound, and venography. Two-year mortality and patency were calculated using Kaplan-Meier analysis methods. RESULTS: We identified 52 (46% female) patients who underwent IVC reconstruction for retroperitoneal malignant disease. The mean age was 53.6 years (range, 23-80 years). Procedures performed included primary repair (n = 17 [33%]), patch angioplasty (n = 18 [35%]), and interposition grafting (n = 17 [33%]). The mean length of stay was 16 days and did not vary significantly by group. Patients undergoing interposition graft were discharged on aspirin 81 mg daily. The 30-day survival rate was 96.2% (95% confidence interval [CI], 90.9-100), 1-year survival rate was 75.1% (95% CI, 62.8-87.4), and 2-year survival rate was 64.7% (95% CI, 50.5-78.9). There were no intraoperative deaths. The 30-day primary patency rate was 96% (95% CI, 90.7-100.0), 1-year primary patency rate was 88.8% (95% CI, 79.4-98.2), and 2-year primary patency rate was 77.5% (95% CI, 63.0-92.0). Seven patients (14%) developed nonocclusive thrombus within the IVC, and 16 patients (30%) developed postoperative symptoms of venous obstruction. CONCLUSIONS: IVC reconstruction is a safe option for patients requiring IVC resection during oncologic surgery as evidenced by 1-year survival of 75% and 1-year primary patency approaching 90%. The overall rate of postoperative thrombus development was low and similar across all groups. In the management of primary and secondary retroperitoneal malignant disease with IVC infiltration, IVC reconstruction should be considered to achieve appropriate oncologic resection while minimizing possible complications from caval interruption.