Ascending aortobifemoral and adjunct carotid bypass grafts.

We describe a case of simultaneous ascending aortobifemoral and right common carotid artery bypass to treat a symptomatic brachiocephalic artery and juxtarenal chronic total occlusion in a 68-year-old female patient with unfavorable characteristics for endovascular and standard aortofemoral procedures. Mid-term follow-up revealed sustained remission of symptoms, quality of life quality of life improvement, and patent bypass grafts. In highly selected patients, this solution can be useful when treating other intrathoracic diseases, as well as allowing the simultaneous revascularization of two remote arterial beds.

Simultaneous sequencing of genetic and epigenetic bases in DNA.

DNA comprises molecular information stored in genetic and epigenetic bases, both of which are vital to our understanding of biology. Most DNA sequencing approaches address either genetics or epigenetics and thus capture incomplete information. Methods widely used to detect epigenetic DNA bases fail to capture common C-to-T mutations or distinguish 5-methylcytosine from 5-hydroxymethylcytosine. We present a single base-resolution sequencing methodology that sequences complete genetics and the two most common cytosine modifications in a single workflow. DNA is copied and bases are enzymatically converted. Coupled decoding of bases across the original and copy strand provides a phased digital readout. Methods are demonstrated on human genomic DNA and cell-free DNA from a blood sample of a patient with cancer. The approach is accurate, requires low DNA input and has a simple workflow and analysis pipeline. Simultaneous, phased reading of genetic and epigenetic bases provides a more complete picture of the information stored in genomes and has applications throughout biomedicine.

Intravascular foreign body retrieval.

INTRODUCTION: Intravascular foreign body (IFB) embolization is a potential complication of any vascular procedure. Intravascular foreign body retrieval (IFBR) can be achieved using percutaneous techniques, open surgery, or both combined. METHODS: We completed a retrospective review of patients who underwent endovascular or open IFBR since 2011 on our institution. Primary end-point was technical retrieval success, and secondary end-points were procedure-related compli- cations and 30-days survival. RESULTS: Twenty-seven patients underwent IFBR. Median time from intravascular device loss and retrieval was less than one day. 67% were non-endovascular guidewires and sheath fragments (N=28). 59% of IFBs were lost during their deployment (N=16); 41% during their removal attempts (N=11). 44% were lost in the arterial system (N=12) and 52% in the venous system (N=14). An endovascular procedure was used as the first approach in IFBR in 56% of patients (N=15) and open procedure in 44% (N=12). In the presence of IFB on the thoracic or abdominal cavity, it was always tried a first-endo approach; if IFB was present on the neck or limbs, 75% were retrieved by open surgery (N=20; p<0.001). Success rates were 100% for open and 87% for endovascular procedures. IFB caused five acute complications: one IJV thrombosis, two strokes and three acute limb ischemia. There were no IFBR-related complications. 30 days-survival was 100%. CONCLUSION: Embolization of IFBs can be minimized with proper device selection, deployment and removal. In this study, open and endovascular retrieval had high success rates and minimal morbidity. Its choice is surgeon-dependent and restrained by devices availability.

Cystic Adventitial Disease of the Popliteal Vein, a Rare Cause of Lower Limb Deep Vein Thrombosis.

Introduction: Cystic adventitial disease (CAD) is characterised by the accumulation of gelatinous fluid within the adventitial layer of a blood vessel. Over 90% of CAD occurs in the arterial system. Venous CAD most commonly involves the iliofemoral rather than the popliteal segments. Report: This is the report of a 49 year old female patient with a previous right leg deep vein thrombosis (DVT). She presented to a vascular outpatient appointment with recurrent right lower extremity swelling. Venous duplex ultrasound showed an ectatic and incompetent right popliteal vein. Computed tomography (CT) venography showed focal ectasia of the right popliteal vein resulting from an eccentric low density cyst with a diameter of 15 mm. Under general anaesthesia, the patient was placed in the prone position. A lazy S incision was performed in the right popliteal fossa. The popliteal vein had an eccentrically thickened lateral bulge. After heparinisation, a longitudinal venotomy, endophlebectomy, and en bloc cyst removal were performed sequentially. Popliteal patch venoplasty was performed subsequently using the ipsilateral small saphenous vein. After six months, the patient remains on rivaroxaban. A follow up venous duplex ultrasound showed vein reflux through a standard calibre popliteal vein without evidence of cyst recurrence. Conclusion: Venous CAD is a rare disease and should be considered if previous DVT or symptoms mimicking DVT occur. Cyst resection and reconstruction with vein patch, venous or synthetic graft is the most commonly used strategy and has lower rates of cyst recurrence and need for re-operation.

Influence of Interhospital Transfer on Outcomes of Symptomatic and Ruptured Abdominal Aortic Aneurysms.

INTRODUCTION: Symptomatic or ruptured abdominal aortic aneurysms (rAAA) maintains a high mortality index despite technical advances in its treatment. The influence of patients' geographic location on rAAA outcomes, when the rupture occurs or when the AAA becomes symptomatic, has not been a commonly studied issue. Due to the lack of research on this matter, the impact of interhospital transfer on mortality is ambiguous. OBJECTIVE: Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: During the defined period of 80 months, a total of 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery. Most patients had a ruptured AAA (90.4%, n=122), while symptomatic AAA represented a minority (9.6%, n=13). All patients (91.1% male gender, mean age 74±10 years) were submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation (n=41), all in the endovascular group. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. In this cohort, in-hospital mortality was 31.5% in transferred patients and 34.9% in not transferred patients. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that transfer of patients for urgent repair of AAA was not associated with an increased mortality. The hypothetical increased mortality due to transfer might have been compensated by endovascular treatment and local anesthesia in some cases. Further studies must be carried out, particularly comparing endovascular and open repair in emergency setting.

Infrarenal Abdominal Penetrating Aortic Ulcer, an Atypical Location of a Rare Disease.

INTRODUCTION: Penetrating aortic ulcer (PAU) is classically included in acute aortic syndromes, together with aortic dissection and intramural hematoma. These three disorders are considered different stages of the same disease. PAU is the result of medial degeneration with disruption of the intima, mainly due to atherosclerotic risk factors. Most of them are located on descending thoracic aorta and only a few small series and case reports demonstrate location on infrarenal abdominal aorta. Clinical presentation varies in spectrum, from asymptomatic to fatal aortic rupture. Treatment options include medical therapy, particularly strict blood pressure control, and surgical approach. Nowadays endovascular exclusion is commonly performed, although open surgical reconstruction remains the gold standard. METHODS: Report a case of endovascular repair of an infrarenal abdominal PAU. RESULTS: A 72-year-old man, with hypertension, type 2 diabetes, hypercholesterolemia, lumbar osteoarthrosis, was referred to Vascular Surgery outpatient clinic with the diagnosis of infrarenal abdominal PAU on a Computed Tomography Angiography (CTA). This exam was performed due to chronic lumbar complaints from lumbar osteoarthrosis. The patient denied any other complaint. Physical examination was normal. A thoraco-abdomino-pelvic CTA revealed two sites of PAU in the infrarenal aorta with 10mm and 21mm of depth and associated aortic enlargement of 39mm maximum diameter. This exam revealed an enlargement of the depth of the PAU and the aorta diameter in 2 and 3mm, respectively, in the course of 2 months. An EVAR was performed, in a standard aorto-biiliac fashion. The post-operative period was uneventful and the patient discharged 3 days later. 1 month after the surgery, patient remained asymptomatic and the follow-up CTA demonstrated exclusion of both PAU, no endoleaks and stability of aortic diameter. A long term follow-up should be maintained, as for regular EVAR. CONCLUSION: PAU is a rare clinical entity, with infrarenal abdominal aorta location even scarcer. Asymptomatic patient must be regularly followed and threshold to treatment low, bearing in mind the possible catastrophic evolution of the disease. Endovascular approach should be considered as a first approach, considering the technical feasibility and the comorbidities associated with this elderly population.

Implementation of communication-mediating domains for non-ribosomal peptide production in Saccharomyces cerevisiae.

Saccharomyces cerevisiae has in several cases been proven to be a suitable host for the production of natural products and was recently exploited for the production of non-ribosomal peptides. Synthesis of non-ribosomal peptides (NRPs) is mediated by NRP synthetases (NRPSs), modular enzymes, which are often organized in enzyme complexes. In these complexes, partner NRPSs interact via communication-mediating domains (COM domains). In order to test whether functional interaction between separate NRPS modules is possible in yeast we constructed a yeast strain expressing two modules with compatible COM domains from two plasmids. Successful production as well as secretion of the expected dipeptide was detected. This opens the possibility of using yeast as a eukaryotic platform for fast assessment of new module combinations for the development of novel NRP compounds.