Impact of the Lumbar Arteries on Aneurysm Diameter and Type 2 Endoleak after Endovascular Aneurysm Repair.

BACKGROUND: Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated. METHODS: Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated. RESULTS: T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P = 0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P = 0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P = 0.014). CONCLUSIONS: The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR.

Inhaled nitric oxide improves pulmonary hypertension and organ functions after adult heart valve surgeries.

OBJECTIVES: Pulmonary hypertension during cardiac surgery is associated with increased morbidity and mortality. Inhaled nitric oxide serves as a selective pulmonary vasodilator and has other potential extrapulmonary protective roles. Its effects on pulmonary hypertension and organ functions after adult valve surgeries were evaluated. METHODS: From April 2017 to March 2000, 30 patients received inhaled nitric oxide therapy for pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery (iNO group). The group was compared with a control group of 65 patients who developed pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery and received conventional therapy from April 2014 to March 2017. Intraoperative hemodynamic changes and postoperative Sequential Organ Failure Assessment (SOFA) score were evaluated. RESULTS: The inhalation of nitric oxide lowered the pulmonary-to-systemic pressure ratio (Pp/Ps) (p < 0.0001) in the iNO group, and this ratio after the inhalation was significantly lower than that in the control group (p = 0.015). Moreover, norepinephrine requirement was lower in the iNO group than in the control group (p = 0.0060). The SOFA total scores, respiratory scores, coagulation scores, and the increase of renal scores within postoperative 2 days were lower in the iNO group than in the control group (p < 0.0001, p = 0.0002, p = 0.0013, and p = 0.037). CONCLUSIONS: Inhaled nitric oxide therapy ameliorated pulmonary hypertension and improved postoperative respiratory, coagulation, and renal functions in adult valve surgeries.

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection.

OBJECTIVE: This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique. METHODS: In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively. RESULTS: Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64). CONCLUSIONS: This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.

Full PETTICOAT in acute type B aortic dissection with patent false lumen may offer positive remodeling for the distal aorta.

OBJECTIVE: The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. METHODS: In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1 year after surgery. RESULTS: Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. CONCLUSIONS: This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

Hypertrophic obstructive cardiomyopathy and mitral regurgitation in Libman-Sacks endocarditis.

Hypertrophic obstructive cardiomyopathy in Libman-Sacks endocarditis is quite rare and the correct etiological relationship between them is unknown. Some changes may cause a secondary disorganization of the ordinary muscle structure, making a disarray pattern with irregular interwoven myocyte fibers. This case report describes one of the first cases of ventricular septal myectomy and mitral valve replacement for hypertrophic obstructive cardiomyopathy and mitral valve regurgitation associated with Libman-Sacks endocarditis.

Atraumatic splenic rupture in a peritoneal dialysis patient.

Splenic hemorrhage is a potentially life-threatening complication usually occurring after blunt trauma to the abdomen. Atraumatic splenic rupture (ASR) is an uncommon condition, and mostly results from pathology affecting the spleen, such as tumor infiltration or infection. Here, we report a case of atraumatic rupture of a normal spleen in a patient undergoing peritoneal dialysis, and review similar cases in the literature. The case involved a 58-year-old man with nephrotic syndrome who had been undergoing peritoneal dialysis for 1 year. He presented to the hospital with abdominal pain, nausea, and blood-stained dialysate. Laboratory data revealed severe anemia, with a hemoglobin of 4.3 g/dL. An abdominal computed tomography (CT) scan demonstrated a high-density area around the spleen and malposition of the catheter. Laparoscopy revealed large amounts of coagulated blood surrounding the spleen. The patient was diagnosed with atraumatic splenic bleeding. He improved with bed rest and blood transfusion, and could continue with peritoneal dialysis. It was considered that the etiology of bleeding was directly from the spleen. However, due to the temporary malposition of the peritoneal catheter, catheter-induced splenic trauma could not be ruled out. ASR is a rare entity that needs a high index of suspicion for diagnosis. Using CT scanning and peritoneal fluid analysis, these modalities may assist in the diagnosis. Emergency intervention is required upon definitive diagnosis. Increased awareness of ASR can enhance the early diagnosis and effective treatment.

Stepwise Total Aortic Repairs With Fenestrated Endografts in a Patient With Loeys-Dietz Syndrome.

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder (CTD) caused by mutations in the gene encoding transforming growth factor-ß receptors Ⅰ and Ⅱ. Patients with LDS manifest spontaneous aneurysms and dissections of the aorta and peripheral artery. We report a successful treatment with a hybrid endovascular repair for a rapidly expanding thoracoabdominal aneurysm in a 41-year-old woman affected by LDS. To overcome the difficulties of anatomical and surgical repair, we applied an original strategy using surgeon-modified fenestrated endografts.

Role of asymmetrical dimethylarginine in renal microvascular endothelial dysfunction in chronic renal failure with hypertension.

We examined whether endothelial function of the renal microcirculation was impaired in a model of chronic renal failure (CRF), and further assessed the role of asymmetrical dimethylarginine (ADMA) and its degrading enzyme, dimethylarginine dimethylaminohydrolase (DDAH), in mediating the deranged nitric oxide (NO) synthesis in CRF. CRF was established in male mongrel dogs by subtotal nephrectomy, and the animals were used in experiments after a period of 4 weeks. The endothelial function of the renal afferent and efferent arterioles was evaluated according to the response to acetylcholine, using an intravital needle-lens charge-coupled device camera. Intrarenal arterial infusion of acetylcholine (0.01 microg/kg/min) elicited 22+/-2% and 20+/-2% dilation of the afferent and efferent arterioles in normal dogs. In dogs with CRF, this vasodilation was attenuated (afferent, 12+/-2%; efferent, 11+/-1%), and the attenuation paralleled the diminished increments in urinary nitrite+nitrate excretion. In the animals with CRF, plasma concentrations of homocysteine (12.2+/-0.7 vs. 6.8+/-0.4 micromol/l) and ADMA were elevated (2.60+/-0.13 vs. 1.50+/-0.08 micromol/l). The inhibition of S-adenosylmethionine-dependent protein arginine N-methyltransferase by adenosine dialdehyde decreased plasma ADMA levels, and improved the acetylcholine-induced changes in urinary nitrite+nitrate excretion and arteriolar vasodilation. Acute methionine loading impaired the acetylcholine-induced renal arteriolar vasodilation in CRF, but not normal dogs, and the impairment in CRF dogs coincided with the changes in plasma ADMA levels. Real-time polymerase chain reaction revealed downregulation of the mRNA expression of DDAH-II in the dogs with CRF. Collectively, these results provide direct in vivo evidence of endothelial dysfunction in canine CRF kidneys. The endothelial dysfunction was attributed to the inhibition of the NO production by elevated ADMA, which involved the downregulation of DDAH-II. The deranged NO metabolic pathway including ADMA and DDAH is a novel mechanism for the aggravation of renal function.

Cervical peridural calcification in patients undergoing long-term hemodialysis. Report of two cases.

The authors report on two patients undergoing long-term hemodialysis in whom cervical myelopathy was caused by calcification related to the cervical dural sac. The lesions were demonstrated on plain computerized tomography (CT) scans as dotted curvilinear bands outlining the dural sacs in almost the whole of their cervical spines. During posterior decompressive surgery in both cases, the CT scanning--documented curvilinear bands were identified as calcified plaques infiltrating the fibrous membranes beneath the ligamenta flava, constricting the cervical dural tube. In each case, the spinal cord could not be decompressed by merely enlarging the osseous spinal canal; rather, it required removal of the calcified membrane from the posterior surface of the dura. Based on the operative findings, the lesion should be described as cervical peridural calcification.

[Is intravenous contrast enhancement effective in improving CT diagnosis of hepatic disease?].

PURPOSE: The purpose of this study was to evaluate the effectiveness of contrast enhancement in the diagnosis of hepatic disease. MATERIALS AND METHODS: 2761 cases involving CT of the liver and abdomen were analyzed using logistic analysis. CT was either helical-CT (SDCT) or multi-detector CT (MDCT), with power injector. RESULTS: Contrast enhancement use was 92% in liver disease and 95% in tumor cases. A typical case involved a 66-year-old man given 2-4 ml/sec of contrast material using dual injection. CT imaging was done in the equilibrium stage. The use of contrast material was effective for the diagnosis of liver tumor except in the qualitative diagnosis of hepatocellular carcinoma with SDCT where the odds ratio was 0.084. CONCLUSION: Intravenous contrast enhancement was effective for the CT diagnosis of hepatic tumor. Dynamic CT was effective using MDCT, and dual injection of contrast material was also valid for SDCT. Multiphasic studies were needed for detecting liver tumors not only on MDCT but also on SDCT. CT imaging during the equilibrium phase alone is inadequate to document diagnosis of metastatic liver tumors. The addition of various phasic contrast materials during CT was effective in evaluating liver tumors that showed angiogenesis.

Distinct role of intrarenal cyclooxygenase-1/2 in chronic unilateral renal ischemia.

AIMS: The role of cyclooxygenase (COX)-1/2-induced prostaglandins (PG) in unilateral chronic renal ischemia of anesthetized dogs was examined. METHODS: Ischemic kidneys were established by reducing renal blood flow of left renal artery to 10% of baseline with an adjustable clip. After 4 weeks, changes in intrarenal contents of PGE2/PGI2 and angiotensin (Ang) II were evaluated with renal microdialysis and biopsy. Furthermore, the effect of a non-specific COX inhibitor (sulpyrine), a COX-2-specific inhibitor (NS398), and an Ang receptor antagonist (CS866) on renal function and renal PG contents were evaluated. RESULTS: Unilateral renal artery clipping reduced renal plasma flow (RPF) in clipped (from 59 +/- 2 to 17 +/- 1 ml/min, n = 18) and nonclipped kidneys (from 59 +/- 2 to 44 +/- 2 ml/min) and natriuresis. Intrarenal PGE2 increased only in clipped kidneys (from 114 +/- 7 to 375 +/- 25 pg/ml), whereas 6-keto-PGF1alpha increased in both kidneys. Sulpyrine reduced intrarenal PG contents, and decreased RPF, GFR, and urinary sodium excretion (UNaV), whereas NS398 reduced UNaV in clipped (from 4.0 +/- 0.9 to 1.7 +/- 0.2 microEq/min) and nonclipped kidneys (from 5.4 +/- 0.5 to 2.9 +/- 0.3 microEq/min), without affecting renal hemodynamics. Intrarenal Ang II contents increased in clipped (from 0.70 +/- 0.06 to 2.32 +/- 0.33 pg/mg, n = 18) and nonclipped kidneys (from 0.65 +/- 0.06 to 2.45 +/- 0.33 pg/mg, n = 18), and CS866 improved renal hemodynamics and natriuresis. The elevated intrarenal Ang II content was suppressed by NS398 only in clipped kidneys. CONCLUSION: Unilateral renal ischemia elevates intrarenal PGE2 contents in clipped kidneys, which serves to countervail the aggravation of renal function. Furthermore, intrarenal COX isoforms may play differential roles, with COX-1 participating in modulation of renal hemodynamics, and COX-2 contributing to sodium excretion and Ang II formation.