Management of spontaneous isolated visceral artery dissection.

BACKGROUND: Spontaneous isolated dissection of the celiac artery (CA) or the superior mesenteric artery (SMA) is rare but increasingly recognized because of widespread use of advanced abdominal imaging technology. Indications for specific therapeutic options and long-term outcomes are not well defined. This study analyzed clinical features, management strategies, and outcomes for patients with spontaneous visceral artery dissections. METHODS: Medical records of all patients diagnosed with CA or SMA dissections at 2 institutions (Scripps Green Hospital and San Diego Kaiser Medical Center) between January 2005 and January 2014 were retrospectively reviewed. Patient demographics included age, symptoms, associated comorbidities, and type of intervention. Anatomic features including length of dissection and entry point were measured. Efficacy of the various treatments was compared on the basis of symptom resolution and clinical course. RESULTS: Over an 8-year period, 23 patients with a diagnosis of visceral artery dissection were identified. Eighteen (78%) patients were men. Most patients (78%) were symptomatic on initial presentation with abdominal or back pain. Treatment included observation in 4, anticoagulation in 13, and endovascular stenting in 6 patients. The mean follow-up was 23.8 months. No patient required bowel resection. Twenty of twenty-three patients reported resolution of symptoms at follow-up. CONCLUSIONS: In this series, all patients with isolated visceral artery dissection had favorable outcomes, with no significant morbidity or mortality. Conservative management with anticoagulation is recommended as the first-line therapy. When conservative management fails, endovascular therapy is the treatment of choice.

Carotid endarterectomy in academic versus community hospitals: the national surgical quality improvement program data.

BACKGROUND: Carotid endarterectomy (CEA) is among the most commonly performed vascular operations in both academic and community hospital settings. The excellent results of the large prospective studies (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study) have been criticized because of a widely held impression that community hospitals could not duplicate the excellent surgical results achieved in high volume university hospitals or clinics. The purpose of this study was to use the National Surgical Quality Improvement Program data to evaluate the outcomes of CEA in academic versus community hospitals. METHODS: All patients undergoing CEA were identified in the National Surgical Quality Improvement Program database conducted between January 1, 2005 and October 30, 2009. The patients were stratified on the basis of the hospital of care: academic hospital or community hospital. All postoperative outcomes were analyzed. RESULTS: A total of 17,388 CEAs met the inclusion criteria, among which 9,649 cases were performed at an academic institution and 7,739 cases were performed at a community hospital. There were more women in the community hospital cohort (42.5% vs. 40.2%, p = 0.0197). Preoperatively, the community hospital cohort had more patients with dyspnea (22.8% vs. 18.1%, p < 0.0001), chronic obstructive pulmonary disease (COPD) (10.7% vs. 9.7%, p = 0.0322), angina (2.6% vs. 1.9%, p = 0.0021), previous stroke with no deficit (9.0% vs. 7.6%, p = 0.0009), and past transient ischemic attacks (28.3% vs. 25.1%, p < 0.0001). The academic hospital cohort had more patients with recent alcohol use (4.5% vs. 3.8%, p = 0.0245), cardiac surgery (24.0% vs. 22.5%, p = 0.0206), and hemiplegia (4.8% vs. 4.1%, p = 0.0288). Postoperatively, there was no difference in the two groups in 30-day stroke rate (1.2% vs. 1.5%, p = 0.1035), 30-day myocardial infarction rate (0.5% vs. 0.6%, p = 0.2149), or 30-day mortality rate (0.5% vs. 0.6%, p = 0.6335). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (2.2% vs. 2.7%, p = 0.0568). In the asymptomatic patient cohort, there were a total of 9,285 cases, with 5311 cases performed at an academic institution and the remainder at community hospitals. Preoperatively, the community hospitals had more patients with dyspnea (78.3% vs. 82.1%, p < 0.0001). The academic cohort had more patients with acute renal failure (0.3% vs. 0.1%, p = 0.0426). Postoperatively, there was no difference in the two groups in 30-day stroke rate (0.9% vs. 1.1%, p = 0.2899), 30-day myocardial infarction rate (0.4% vs. 0.5%, p = 0.4348), or 30-day mortality rate (0.5% vs. 0.4%, p = 0.6370). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (1.8% vs. 2.0%, p = 0.4394). CONCLUSION: CEA is widely performed in both academic and community hospital settings. This study demonstrates that the results are equivalent and have equally good 30-day outcomes in both asymptomatic and combined populations.

Intraluminal pancreatic serine protease activity, mucosal permeability, and shock: a review.

Shock states are characterized by a pronounced activation of numerous cell types that lead to an acute inflammatory reaction. The exact mechanism by which these inflammatory cells are activated is not known. Numerous studies have implicated the gastrointestinal tract as one of the main sites for the generation of inflammatory mediators and initiation of an acute systemic response. The pancreas is known to secrete powerful digestive enzymes, and we hypothesize that they may play a leading role in the pathogenesis of multiorgan failure after the onset of shock. We carried out a search in PubMed for all relevant studies related to the role of the pancreas in shock. Studies that included information concerning the role of pancreatic enzymes in shock were then summarized. Our article serves to review the current hypotheses on how digestive enzymes produced by the pancreas may play a pivotal role in initiating the systemic inflammatory response. We further hypothesize how these enzymes and/or their products may ultimately contribute to multiorgan failure and death.

Physiologic response to hemorrhagic shock depends on rate and means of hemorrhage.

BACKGROUND: Traditional models of shock classify severity based on the volume of hemorrhage. Clinically, hemorrhage occurs at a variable rate, usually slowing as blood pressure drops; however most animal experimental models use a constant rate of hemorrhage. Our hypothesis was that rapid bleeding followed by slower bleeding using a fixed total volume would result in a greater physiologic insult. MATERIALS AND METHODS: Yorkshire pigs (S and S Farms, Ranchita, CA) underwent placement of jugular and femoral catheters after anesthesia. All animals were hemorrhaged a total of 30 mL/kg. The animals were divided into constant rate hemorrhage over 10 min (Constant-10) (3 mL/kg/min), constant rate hemorrhage over 20 min (Constant-20) (1.5 mL/kg/min), or a varying rate of hemorrhage of 2.15 mL/kg/min over 7 min, and then 1.15 mL/kg/min over the remaining 13 min (Physiologic-20). Shock, mean arterial pressure (MAP) < or = 20 mmHg, was maintained for 60 min. Resuscitation was performed with Ringer's lactate (RL) and shed blood (2:1 ratio), until shed blood was exhausted and then only RL to maintain a MAP > or =60 mmHg for 3 h. RESULTS: Physiologic-20 shock resulted in significantly increased maximal heart rate, peak serum lactate, and volume of required RL resuscitation. Adequacy of resuscitation was ensured by MAP, urine output, and clearance of serum lactate. CONCLUSIONS: A more physiologic method of fixed volume hemorrhagic shock results in a significantly increased physiologic response as demonstrated by increased volume of fluid resuscitation. This differential physiologic response may represent an improved hemorrhagic shock model, and could have implications for future hemorrhagic shock studies.