Early outcomes of native and graft-related abdominal aortic infection managed with orthotopic xenopericardial grafts.

OBJECTIVE: Reconstruction of infected aortic cases has shifted from extra-anatomic to in situ. This study reports the surgical strategy and early outcomes of abdominal aortic reconstruction in both native and graft-related aortic infection with in situ xenopericardial grafts. METHODS: Included in the analysis are 21 consecutive patients (mean age, 69 years; 20 male) who underwent abdominal xenopericardial in situ reconstruction of native aortic infection (4) and endovascular (4) or open (13) graft aortic infection between July 2017 and September 2019. All repairs were performed on an urgent basis, but none were ruptured. All patients were followed up with clinical and biologic evaluation, ultrasound at 3 months, and computed tomography scan at 6 months and 1 year. RESULTS: Technical success was 100%; 8 patients were treated with xenopericardial tubes and 13 with bifurcated grafts. Thirty-day mortality was 4.7% (one death due to pneumonia with respiratory hypoxic failure in critical care.). Six patients (28%) developed acute kidney injury, four (19%) requiring temporary dialysis; five fully recovered and one died. Four patients (19%) required a return to the operating room. After a median follow-up of 14 months (range, 1-26 months), overall mortality was 19% (n = 4). Two patients presented with recurrent sepsis after reconstruction, leading to death due to multiorgan failure. Other patients (17/21) have discontinued antibiotics with no evidence of recurrence of infection clinically, radiologically, or on blood tests. Computed tomography scans at 1 year demonstrated no stenosis or graft dilation and one asymptomatic left graft branch thrombosis. Primary patency is 95%. CONCLUSIONS: In situ xenopericardial aortic reconstruction is a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results. The graft demonstrates appropriate resistance to infection such that reliable eradication of infection in this vascular bed is possible. Longer follow-up is required in future studies to determine the durability of the reconstruction and need for reinterventions.

Asymptomatic Internal Carotid Aneurysm: An Uncommon Disease of the Carotid Arteries.

Despite a low-incidence extracranial carotid artery aneurysm (ECAA) disease has important clinical repercussion that obliges understanding and knowledge of correct treatment. The 2 dominant etiologies are atherosclerotic degeneration and pseudoaneurysm. The natural history of ECAAs is understood. Neck pain, a pulsatile mass and central or peripheral neurological manifestations are the most common symptoms. Recommendations for diagnosis and treatment are not uniform and still under discussion, representing a challenge for clinicians. We discuss a case of 2.5 cm asymptomatic saccular atherosclerotic ECAA treated surgically in light of the most recent literature.

Immune globulin subcutaneous, human 20% solution (Xembify®), a new high concentration immunoglobulin product for subcutaneous administration.

Immune globulin subcutaneous, human 20% solution (IGSC-C 20%, Xembify®)-a new 20% immunoglobulin (IgG) liquid product for subcutaneous (SC) administration-has been developed by Grifols. The IGSC-C 20% formulation is based on knowledge acquired from the formulation of Immune Globulin Injection (Human),10% Caprylate/Chromatography Purified (IGIV-C 10%, Gamunex®-C). The protein concentration was increased from 10% to 20% to provide a smaller volume for SC administration. The IGSC-C 20% manufacturing process employs the same caprylate/chromatography purification steps as IGIV-C 10%, with the addition of an ultrafiltration step so that the product can be formulated at a higher protein concentration. IGSC-C 20% has been produced at full industrial scale to support clinical studies and licensure. These batches were characterized using a comprehensive panel of analytical testing. The new IGSC-C 20% product maintains the same composition, neutralizing activity, purity, and quality characteristics found in IGIV-C 10%.

Filter-Associated Inferior Vena Cava Thrombosis with Duodenal Perforation: Case Report and Literature Review.

BACKGROUND: The aim of this article is to report a case of filter-associated inferior vena cava (IVC) thrombosis with perforation of the duodenum and penetration of a vertebral body by the filter struts. CASE REPORT: A 37-year-old woman with a medical history of Behcet's disease treated with corticosteroids underwent placement of a retrievable IVC filter because of recurrent iliofemoral venous thrombosis regardless of therapeutic levels of anticoagulation. Despite a correct positioning of the filter, the second follow-up computed tomography scan, performed at 1 year, showed a complete thrombosis of the infrarenal IVC segment, with perforation of the vessel wall by the filter struts and penetration in the duodenum. The patient remained asymptomatic. Open surgical removal of the filter with resection of the affected vena cava without vascular reconstruction was planned. The operation was performed under general anesthesia, surgical exposure was performed through a small midline laparotomy, and a duodenal Kocher maneuver was then performed to expose the IVC. The filter struts were found to have completely passed the cava wall in multiple directions. 2 struts penetrated through the duodenal serosa and 1 strut was embedded in the L3 periosteum. The IVC filter was successfully removed en bloc with the segment of the thrombosed and retracted IVC. The stumps were closed with 3-0 running polypropylene sutures and the duodenal lesions were closed with vicryl seromuscular sutures. No vascular reconstruction was necessary due to the marked development of collateral venous circulation. The patient was discharged home on postoperative day 6 and is doing well 6 months after surgery. CONCLUSIONS: Patients with IVC penetration of filter struts are usually asymptomatic, as was our patient. However, a high level of clinical suspicion for perforation should be maintained when facing nonspecific abdominal or back pain, and in episodes of gastrointestinal bleeding in patients with an IVC filter. We recommend that patients with implanted IVC filters, even those who are asymptomatic, should receive regular imaging follow-up, and retrievable filters should be removed as soon as they are no longer needed.

Outcomes of cold-stored venous allograft for below-knee bypasses in patients with critical limb ischemia.

OBJECTIVE: Critical limb ischemia (CLI), the most advanced form of peripheral arterial disease, is associated with strikingly high morbidity and mortality rates. Autogenous single-segment great saphenous vein (GSV) remains the optimal conduit for infrainguinal revascularization. Unfortunately, GSV is unavailable in up to 20% of patients. There is no consensus about the alternative graft that should be used for infragenicular bypass grafting when the GSV is unavailable. Currently, there are no outcome data for cold-stored venous allograft use in regard to recent safety and efficacy objective performance goals described by the Society for Vascular Surgery. METHODS: This is a retrospective analysis of 118 infragenicular revascularizations performed for CLI with cold-stored venous allografts obtained from varicose vein stripping surgery in a single institution from November 2002 to August 2013. RESULTS: Mean age (± standard deviation) was 75 ± 12 years (male, 76%; diabetes, 73%; dialysis, 16%), and 38% (n = 45) had a history of failed ipsilateral revascularization. None had suitable autogenous conduit for even composite vein bypass. The distal anastomosis was performed to an infrapopliteal artery in 85 cases (72%). At 30 days, perioperative death rate was 6.8%, major adverse cardiovascular event rate was 7.6%, and major adverse limb event rate was 11.9%. Mean follow-up was 34 ± 29 months (range, 1-113 months). At 1 year, freedom from major adverse limb event or perioperative death, limb salvage, survival, amputation-free survival, and secondary patency rates were, respectively, 64.9%, 82.5%, 85.4%, 73.3%, and 58.3%. Ejection fraction <45% and dialysis were the most significant factors predicting failure of revascularization. CONCLUSIONS: Cold-stored venous allografts may be used for performing infragenicular revascularization for CLI with acceptable safety and efficacy results despite poor long-term patency. Their level of performance remains inferior to autologous vein sources but seems comparable to alternative allografts or prosthetic conduit. Their availability is a major advantage compared with other biologic alternative sources.

Spatio-temporal dynamics of replication and transcription sites in the mammalian cell nucleus.

To study when and where active genes replicated in early S phase are transcribed, a series of pulse-chase experiments are performed to label replicating chromatin domains (RS) in early S phase and subsequently transcription sites (TS) after chase periods of 0 to 24 h. Surprisingly, transcription activity throughout these chase periods did not show significant colocalization with early RS chromatin domains. Application of novel image segmentation and proximity algorithms, however, revealed close proximity of TS with the labeled chromatin domains independent of chase time. In addition, RNA polymerase II was highly proximal and showed significant colocalization with both TS and the chromatin domains. Based on these findings, we propose that chromatin activated for transcription dynamically unfolds or "loops out" of early RS chromatin domains where it can interact with RNA polymerase II and other components of the transcriptional machinery. Our results further suggest that the early RS chromatin domains are transcribing genes throughout the cell cycle and that multiple chromatin domains are organized around the same transcription factory.

Topiramate and adrenocorticotropic hormone (ACTH) as initial treatment for infantile spasms.

Historically, adrenocorticotropic hormone was used as a first-line treatment for infantile spasms; however, there has been increasing use of topiramate as initial therapy. Here, we report a retrospective study of adrenocorticotropic hormone (ACTH) and topiramate as initial treatment for infantile spasms. The neurology patient database at the Children's Hospital of Philadelphia was searched using the International Classification of Diseases, Ninth Revision code for infantile spasms, and 50 patients were randomly chosen for chart review. We identified 31 patients receiving either adrenocorticotropic hormone or topiramate monotherapy (adrenocorticotropic hormone n = 12, topiramate n = 19) as a first-line treatment for infantile spasms. A total of 26 patients were symptomatic and 5 cryptogenic. Six patients treated with adrenocorticotropic hormone had resolution of clinical spasms and hypsarrhythmia within a month, but 3 relapsed. Of the 19 patients treated with topiramate, 4 patients eventually, though over a period of 0, 1, 8, or 69 months, had resolution of spasms and hypsarrhythmia.