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1.
J Vasc Surg ; 76(3): 639-644.e2, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35550395

RESUMO

OBJECTIVES: The goals of medical management for uncomplicated acute type B aortic dissection (TBAD) are to prevent expansion of the false lumen and malperfusion syndrome. This is accomplished with antihypertensive agents, but medication selection and titration are typically provider-dependent. Given the paucity of data on evidence-based management of this population, we hypothesized that a standardized TBAD medical management protocol would reduce resource utilization and costs, without compromising patient outcomes. METHODS: A multidisciplinary team developed a goal-directed protocol to standardize the medical management of uncomplicated acute TBAD, with an emphasis on early initiation of oral medications, weaning of anti-hypertensive infusions, and frequent assessment for de-escalation of care. Implementation was in April 2018. A retrospective review of patients with acute TBAD presenting to our institution from April 2016 to April 2020 was performed. Patients requiring aortic or peripheral intervention were excluded. Included patients were analyzed based on treatment before or after protocol implementation. Patient demographics, systolic blood pressure, presence of acute kidney injury at presentation, length of stay, cost metrics, and 30-day mortality were compared. RESULTS: Thirty-nine patients were included, 21 pre- and 18 post-protocol implementation. Baseline demographics, systolic blood pressure, and presence of acute kidney injury at presentation were similar between the groups. Post-protocol patients had shorter total (8.6 vs 5.5 days; P = .02) and intensive care unit (3.2 vs 1.8 days; P = .002) length of stay. The protocol was associated with significantly decreased total hospital ($38,928 vs $28,066; P = .04), total variable ($23,115 vs $15,627; P = .02), and pharmacy ($5094 vs $1181; P < .001) costs, whereas inpatient care costs ($15,152 vs $11,467; P = .09) trended down. Post-protocol patients required fewer oral antihypertensive agents at discharge (3.8 vs 2.7; P = .005). No significant difference in 30-day mortality was observed. CONCLUSIONS: A goal-directed protocol reduces resource utilization and costs without compromising early mortality rates for patients with uncomplicated acute TBAD. Such a strategy may have broader application in medical management of acute aortic syndromes.


Assuntos
Injúria Renal Aguda , Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Injúria Renal Aguda/etiologia , Dissecção Aórtica/cirurgia , Anti-Hipertensivos/efeitos adversos , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
2.
Ann Vasc Surg ; 67: 90-99, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31705983

RESUMO

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has expanded access to descending thoracic aortic aneurysm (DTAA) repair particularly for elderly and frail patients. This high-risk population has limited long-term overall survival, such that appropriate patient selection is required to optimize patient benefit and resource utilization. Our objective is to develop and validate a frailty-based, procedure-specific risk score for patients undergoing elective TEVAR for DTAA. METHODS: Patients undergoing nonemergent TEVAR for DTAA during 2005-2016 were identified in the National Surgical Quality Improvement Program database. Those with concurrent cardiac or open aortic surgery, abdominal visceral intervention, or Zone 0 deployment were excluded. Patients were randomly divided between derivation and validation samples. The primary outcome was 30-day major adverse events (MAE), including mortality and major systemic complications. Using the derivation cohort, variables associated with MAE were identified by univariable analyses. Those with P < 0.05 were included in multivariable logistic regression analysis. Independent procedure-specific and frailty-related risk factors for MAE were used to develop a pragmatic score to assess risk for TEVAR. RESULTS: Overall, 1,784 patients were included. 14% of the derivation patients had MAE (14% major complications, 4% mortality). Independent risk factors for MAE were primarily associated with markers of frailty and TEVAR extent and complexity and included functional dependence (OR 2.9, 95% CI 1.6-5.4), pulmonary disease (1.6, 1.1-2.4), thoracoabdominal extent (2.2 (1.4-3.4), need for iliac access (2.1, 1.1-3.8), and Zone I or II deployment (OR 1.7, 1.1-2.5). According to their respective beta coefficients, each variable was assigned a single point. Based on total points, patients were stratified as low- (0 points), intermediate- (1 point), or high-risk (≥2 points), with stepwise increases in mortality (0%, 4%, and 9%) and major complications (7%, 11%, and 23%) between strata. Validation patients had similar characteristics, risk strata distribution, and outcomes as the derivation patients, and the risk model had similar performance in both groups. CONCLUSIONS: Markers of frailty and procedure complexity strongly predict MAE after TEVAR for DTAA and can improve patient selection by enabling patient and procedure-specific risk stratification. While TEVAR is safe in low-risk patients, intermediate-risk patients warrant careful discussion of the risks and benefits of aortic intervention; under certain circumstances, high-risk patients may not benefit. Further study is required to define the association between frailty and long-term outcomes.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Regras de Decisão Clínica , Procedimentos Endovasculares , Idoso Fragilizado , Fragilidade/diagnóstico , Fatores Etários , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Tomada de Decisão Clínica , Comorbidade , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fragilidade/mortalidade , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
3.
J Vasc Surg ; 69(1): 236-241, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30455051

RESUMO

BACKGROUND: Attrition in surgical programs remains a significant problem resulting in trainee dissatisfaction and wasted time and educational dollars. Attrition rates in general surgery training programs approximate 5% per year (30% cumulative). Attrition rates in cardiovascular surgery training for the traditional vascular surgery fellowship (VSF), the vascular surgery residency (VSR), and the corresponding programs in cardiothoracic surgery have yet to be described, although they are assumed to be similar to those associated with general surgery training. METHODS: A retrospective review of the Association of American Medical Colleges Annual Physician Specialty Data Book was performed. Data from consecutive academic years 2007-2008 to 2013-2014 were analyzed. The number of total residents, the number who did not complete their training, and those who successfully completed the program were recorded. Attrition rates were then calculated for VSF, VSR, general surgery residency (GSR), cardiothoracic surgery fellowship (CTF), and cardiothoracic surgery integrated residency (CTR). RESULTS: Annually, between 2007-2008 and 2013-2014, there were zero to two vascular surgery residents who failed to complete the program (0%-5.9%). In the last 4 years of the study, whereas the absolute number of residents who failed to complete the program remained constant at 1 or 2 per year, the attrition rate decreased to 1 of 171 trainees (0.6%) in 2013-2014 as the total number of programs (and numbers of vascular surgery residents) significantly increased. During the same 7-year period, the number of vascular surgery fellows who did not complete their training ranged from one to six annually (0.4%-2.5%). Compared with the VSF, the VSR data show a relatively low and constant rate of attrition. In contrast, the number of general surgery residents who did not complete their program during the study period varied from 255 to 388 residents annually (3.3%-5.2%). During its first 3 years of inception, the CTR program had an attrition rate of 0%, and it was not until 2012-2013 that trainees failed to complete the program, resulting in an annual attrition rate of 1.2% to 3.2% from that point on. The annual attrition rate of CTF training programs ranged from 7 to 15 fellows (2.9%-6.8%) during the study period. CONCLUSIONS: The inception of VSR and CTR programs dramatically changed the paradigms for training in these highly specialized surgical fields. Comparisons of attrition rates between these two programs and the traditional VSF and CTR as well as GSR suggests lesser rates of attrition in the integrated programs. These data may prove reassuring to VSR and CTR program directors, whose significantly smaller programs are more vulnerable to the loss of even a single trainee than general surgery training programs are. In addition, the VSF program has stable and lower attrition rates compared with the CTF and GSR programs.


Assuntos
Procedimentos Cirúrgicos Cardíacos/educação , Educação de Pós-Graduação em Medicina/métodos , Bolsas de Estudo , Internato e Residência , Especialização , Cirurgiões/educação , Procedimentos Cirúrgicos Torácicos/educação , Procedimentos Cirúrgicos Vasculares/educação , Atitude do Pessoal de Saúde , Escolha da Profissão , Currículo , Escolaridade , Humanos , Satisfação no Emprego , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Cirurgiões/psicologia
4.
J Vasc Surg ; 67(6): 1659-1663, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29276106

RESUMO

OBJECTIVE: This study investigated the growth and behavior of the ascending aorta in patients with descending thoracic aortic disease. METHODS: We examined 200 patients with descending thoracic aortic disease including acute type B dissection (n = 95), chronic type B dissection (n = 38), intramural hematoma (n = 23), and thoracoabdominal aortic aneurysms (n = 44). Images from computed tomography and magnetic resonance imaging were evaluated after three-dimensional reconstruction to examine the growth rate in those with >1 year of imaging follow-up (n = 108). Survival data were derived from all 200 patients in this study. RESULTS: Average proximal aortic dimensions at the index image were relatively small, measuring 3.65 ± 0.51 cm in the root, 3.67 ± 0.48 cm in the ascending aorta, and 3.50 ± 0.44 cm in the proximal arch. Average growth rate was low for the aortic root, ascending aorta, and proximal arch at 0.36 ± 0.64 mm/y, 0.26 ± 0.44 mm/y, and 0.25 ± 0.44 mm/y, respectively. There was no difference in baseline proximal aortic dimensions and growth rate between the four subgroups. An index aortic diameter ≥4.1 cm grew faster than those <4.1 cm at the ascending aorta (P = .028) and proximal arch (P = .019). There was no difference in aortic growth rates at the aortic root (P = .887). After the index scan, five patients underwent six ascending aortic replacement procedures, leading to a 3% ascending aortic intervention rate. Overall median life expectancy was 86.15 years. CONCLUSIONS: Native ascending aortic growth in patients with descending thoracic aortic disease is slow. We suggest regular follow-up for index ascending aorta ≥4.1 cm because of its larger initial size and more rapid growth.


Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico , Imageamento Tridimensional , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Estudos Retrospectivos , Fatores de Tempo
5.
J Surg Res ; 213: 39-45, 2017 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-28601330

RESUMO

BACKGROUND: This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections. MATERIALS AND METHODS: From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements. RESULTS: Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044). CONCLUSIONS: RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely.


Assuntos
Aneurisma Aórtico/diagnóstico por imagem , Dissecção Aórtica/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Dissecção Aórtica/patologia , Aneurisma Aórtico/patologia , Feminino , Seguimentos , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
6.
Am J Pathol ; 184(1): 148-58, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24332015

RESUMO

It is hypothesized that differential AKT phosphorylation between sexes is important in abdominal aortic aneurysm (AAA) formation. Male C57BL/6 mice undergoing elastase treatment showed a typical AAA phenotype (80% over baseline, P < 0.001) and significantly increased phosphorylated AKT-308 (p308) and total-AKT (T-AKT) at day 14 compared with female mice. Elastase-treated Raw cells produced increased p308 and significant amounts of matrix metalloproteinase 9 (MMP-9), and these effects were suppressed by LY294002 treatment, a known AKT inhibitor. Male and female rat aortic smooth muscle cells treated with elastase for 1, 6, or 24 hours demonstrated that the p308/T-AKT and AKT-Ser-473/T-AKT ratios peaked at 6 hours and were significantly higher in the elastase-treated cells compared with controls. Similarly, male cells had higher phosphorylated AKT/T-AKT levels than female cells. LY294002 also inhibited elastase-induced p308 formation more in female smooth muscle cells than in males, and the corresponding cell media had less pro-MMP-9. AKT siRNA significantly decreased secretion of pro-MMP-9, as well as pro-MMP-2 and active MMP-2 from elastase-treated male rat aortic smooth muscle cells. IHC of male mice AAA aortas showed increased p308, AKT-Ser-473, and T-AKT compared with female mice. Aortas from male AAA patients had a significantly higher p308/T-AKT ratio than female AAA tissues. These data suggest that AKT phosphorylation is important in the upstream regulation of MMP activity, and that differential phosphorylation may be important in sex differences in AAA.


Assuntos
Aneurisma da Aorta Abdominal/metabolismo , Proteínas Proto-Oncogênicas c-akt/metabolismo , Caracteres Sexuais , Animais , Western Blotting , Modelos Animais de Doenças , Inibidores Enzimáticos/farmacologia , Feminino , Humanos , Imuno-Histoquímica , Masculino , Metaloproteinase 2 da Matriz/metabolismo , Metaloproteinase 9 da Matriz/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Músculo Liso Vascular/metabolismo , Miócitos de Músculo Liso/metabolismo , Fosforilação , RNA Interferente Pequeno , Transfecção
8.
J Vasc Surg ; 61(4): 972-6, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25601505

RESUMO

OBJECTIVE: Spontaneous celiac artery dissection is rare, and its natural history is not well studied. The objective of this study was to review our experience with the evaluation and management of this condition. METHODS: During the last 8 years, 19 patients (14 men, five women) presented with the diagnosis of spontaneous celiac artery dissection. Each patient's clinical course was retrospectively reviewed, and patients were contacted for assessment of current symptoms. RESULTS: All patients had computed tomography scans documenting a celiac artery dissection without concomitant aortic dissection. Ages ranged from 39 to 76 years. Seven patients presented with abdominal pain, and 12 were diagnosed incidentally. All patients were initially treated with observation because none had threatened end organs. Patients presenting with aspirin or clopidogrel therapy were continued on these medications, but no patients were prescribed any medications due to their dissection. Three patients continued to have abdominal pain and eventually underwent celiac artery stenting. Pain improved after the intervention in all three. One patient with aneurysmal degeneration of the celiac artery underwent surgical repair. No other patients required intervention. Eighteen patients had follow-up within a year of data collection in the clinic or over the phone. The average time from the initial diagnosis to follow-up for the entire cohort was 46 months. None had abdominal or back pain related to the celiac dissection, had lost weight, or had to change their eating habits. CONCLUSIONS: Celiac artery dissection can be safely managed initially with observation. If abdominal pain is persistent, endovascular stenting may stabilize or improve the pain, and surgical reconstruction can be done for aneurysmal degeneration or occlusion, both unusual events. Long-term anticoagulation does not appear necessary in these patients.


Assuntos
Dissecção Aórtica/terapia , Implante de Prótese Vascular , Artéria Celíaca/cirurgia , Procedimentos Endovasculares , Conduta Expectante , Dor Abdominal/etiologia , Adulto , Idoso , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/cirurgia , Anticoagulantes/uso terapêutico , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Artéria Celíaca/diagnóstico por imagem , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Achados Incidentais , Masculino , Michigan , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Retrospectivos , Stents , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
9.
J Surg Res ; 186(1): 467-74, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23993200

RESUMO

BACKGROUND: Estrogen receptor alpha (ERα) has been identified in the vessel wall, offering vasoprotective effects when upregulated. Estrogens are known to mediate the inflammatory milieu, and inflammation has long been associated with abdominal aortic aneurysm (AAA) formation. Therefore, it is theorized that increased estrogen receptor in females contributes to their relative resistance to AAAs. The objective of this study was to determine gender differences in ERα levels during experimental AAA formation. METHODS: Infrarenal aortas of male and female C57 mice (n = 18 and n = 16, respectively) were infused with 0.4% elastase. Diameters were measured at days 0 and 14. Aortic messenger RNA expression of ERα was determined on day 3 by reverse transcription-polymerase chain reaction, whereas ERα protein levels were measured via Western blot. Immunohistochemistry using rabbit antibody for ERα was performed on day 14 samples and quantified. Zymography was done for matrix metalloproteinases (MMP)2 and 9 activity levels. Samples of human AAAs were collected and Western blot performed. Data were compared for significance using a student t-test. RESULTS: Infrarenal aortic diameter increased in elastase-perfused males (ME) by 80% at 14 days after perfusion, whereas females (FE) increased by only 35% (P = 0.0012). FE had ×10 greater ERα messenger RNA expression compared with ME at day 3 (P = 0.003). Similarly, ERα protein levels were 100% higher in FE compared with those in ME on day 14 (P = 0.035). ERα protein levels were 80% higher in female human patients with AAA than those in their male counterparts (P = 0.029). ERα visualized via immunohistochemistry was 1.5 fold higher in FE than ME (P = 0.029). MMP2 and 9 activity levels were decreased in female compared with male aortas. CONCLUSIONS: This study demonstrates an increase in aortic wall ERα in females compared with males that correlates inversely with MMP activity and AAA formation. These findings, coupled with observations that exogenous estrogen inhibits AAA formation in males, further suggest that estrogen supplementation may be important to prevent AAA formation and growth.


Assuntos
Aneurisma da Aorta Abdominal/metabolismo , Receptor alfa de Estrogênio/fisiologia , Animais , Aneurisma da Aorta Abdominal/etiologia , Estradiol/fisiologia , Receptor alfa de Estrogênio/análise , Receptor alfa de Estrogênio/genética , Feminino , Humanos , Imuno-Histoquímica , Masculino , Metaloproteinase 2 da Matriz/análise , Metaloproteinase 9 da Matriz/análise , Camundongos , Camundongos Endogâmicos C57BL , Caracteres Sexuais
10.
Int J Comput Assist Radiol Surg ; 19(7): 1349-1357, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38748053

RESUMO

PURPOSE: In this paper, we present a novel approach to the automatic evaluation of open surgery skills using depth cameras. This work is intended to show that depth cameras achieve similar results to RGB cameras, which is the common method in the automatic evaluation of open surgery skills. Moreover, depth cameras offer advantages such as robustness to lighting variations, camera positioning, simplified data compression, and enhanced privacy, making them a promising alternative to RGB cameras. METHODS: Experts and novice surgeons completed two simulators of open suturing. We focused on hand and tool detection and action segmentation in suturing procedures. YOLOv8 was used for tool detection in RGB and depth videos. Furthermore, UVAST and MSTCN++ were used for action segmentation. Our study includes the collection and annotation of a dataset recorded with Azure Kinect. RESULTS: We demonstrated that using depth cameras in object detection and action segmentation achieves comparable results to RGB cameras. Furthermore, we analyzed 3D hand path length, revealing significant differences between experts and novice surgeons, emphasizing the potential of depth cameras in capturing surgical skills. We also investigated the influence of camera angles on measurement accuracy, highlighting the advantages of 3D cameras in providing a more accurate representation of hand movements. CONCLUSION: Our research contributes to advancing the field of surgical skill assessment by leveraging depth cameras for more reliable and privacy evaluations. The findings suggest that depth cameras can be valuable in assessing surgical skills and provide a foundation for future research in this area.


Assuntos
Competência Clínica , Gravação em Vídeo , Humanos , Técnicas de Sutura/educação , Técnicas de Sutura/instrumentação , Imageamento Tridimensional/métodos
11.
J Vasc Surg Venous Lymphat Disord ; 11(3): 642-647, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36935080

RESUMO

OBJECTIVES: The current guidelines recommend routine postoperative duplex ultrasound (DUS) screening after endovenous ablation (EVA). This is a grade 2C recommendation, and several contemporary reports have called for revision of this recommendation as there is insufficient evidence to support universal DUS screening after EVA. There are currently no studies that evaluate outcomes among EVA patients who did not have DUS screening. The aim of our study is to present outcomes from our single-center experience among patients who did not have DUS routinely performed after EVA. METHODS: We performed a single-center, prospective cohort study that included consecutive patients who underwent EVA of the great saphenous vein at our institution between September 30, 2021, and March 15, 2022. At 30 days after the procedure, electronic medical records were queried to identify patients who may have presented for the evaluation of venous thromboembolism (VTE) symptoms. RESULTS: Over the study period, a total of 80 lower extremity EVA procedures (71 endovenous laser ablation and 9 radiofrequency ablation) were performed among 76 patients. Postoperative DUS was performed on 24 patients, of whom none were identified as having endovenous heat-induced thrombosis. Of the 54 patients who did not have DUS, a 30-day postprocedure chart review revealed that none of these patients were seen for symptoms of VTE. We estimate total cost savings of $14,289 by eliminating routine DUS without impact to clinical outcomes after EVA. CONCLUSIONS: Postoperative DUS assessment after EVA comes with associated health care cost and has low yield given that the incidence of clinically significant endovenous heat-induced thrombosis (3 and 4) is rare. In our experience, eliminating routine DUS had no impact on clinical outcomes, improved vascular lab access, and had a positive financial impact in our organization. Limiting DUS screening to EVA patients who exhibit symptoms of VTE can be a cost-effective approach that limits unnecessary imaging, time, and resources with no potential change in clinical outcomes based on our data. Further research is required, and a randomized controlled trial would be ideal to answer this question.


Assuntos
Ablação por Cateter , Terapia a Laser , Trombose , Varizes , Insuficiência Venosa , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Resultado do Tratamento , Estudos Prospectivos , Ultrassonografia Doppler Dupla , Trombose/etiologia , Terapia a Laser/efeitos adversos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Veia Safena/diagnóstico por imagem , Veia Safena/cirurgia , Insuficiência Venosa/diagnóstico por imagem , Insuficiência Venosa/cirurgia , Varizes/diagnóstico por imagem , Varizes/cirurgia , Varizes/etiologia , Estudos Retrospectivos
12.
Am J Physiol Heart Circ Physiol ; 302(7): H1378-86, 2012 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-22307671

RESUMO

The serine proteases, along with their inhibitor plasmin activator inhibitor-1 (PAI-1), have been shown to play a role in abdominal aortic aneurysm (AAA) formation. The aim of this study is to determine if PAI-1 may be a protective factor for AAA formation and partially responsible for the gender difference observed in AAAs. Male and female wild-type (WT) C57BL/6 and PAI-1(-/-) mice 8-12 wk of age underwent aortic perfusion with porcine pancreatic elastase. Animals were harvested 14 days following perfusion and analyzed for phenotype, PAI-1 protein levels, and matrix metalloproteinase (MMP)-9 and -2 activity. WT males had an average increase in aortic diameter of 80%, whereas females only increased 32% (P < 0.001). PAI-1(-/-) males increased 204% and females 161%, significantly more than their WT counterparts (P < 0.001). Western blot revealed 61% higher PAI-1 protein levels in the WT females compared with the WT males (P = 0.01). Zymography revealed higher levels of pro-MMP-2 and active MMP-2 in the PAI-1(-/-) males and females compared with their WT counterparts. PAI-1(-/-) females had significantly higher serum plasmin levels compared with WT females (P = 0.003). In conclusion, WT female mice are protected from aneurysm formation and have higher levels of PAI-1 compared with males during experimental aneurysm formation. Additionally, both male and female PAI-1(-/-) animals develop significantly larger aneurysms than WT animals, correlating with higher pro- and active MMP-2 levels. These findings suggest that PAI-1 is protective for aneurysm formation in the elastase model of AAA and plays a role in the gender differences seen in AAA formation.


Assuntos
Aneurisma da Aorta Abdominal/prevenção & controle , Inibidor 1 de Ativador de Plasminogênio/fisiologia , Animais , Aorta Abdominal/patologia , Aneurisma da Aorta Abdominal/genética , Aneurisma da Aorta Abdominal/patologia , Western Blotting , Densitometria , Feminino , Fibrinolisina/análise , Fibrinolisina/metabolismo , Imuno-Histoquímica , Macrófagos/efeitos dos fármacos , Macrófagos/metabolismo , Masculino , Metaloproteinase 2 da Matriz/biossíntese , Metaloproteinase 2 da Matriz/genética , Metaloproteinase 9 da Matriz/biossíntese , Metaloproteinase 9 da Matriz/genética , Camundongos , Camundongos Knockout , Elastase Pancreática/metabolismo , Inibidor 1 de Ativador de Plasminogênio/genética , RNA Mensageiro/biossíntese , RNA Mensageiro/genética , Reação em Cadeia da Polimerase em Tempo Real , Caracteres Sexuais , Ativador de Plasminogênio Tipo Uroquinase/metabolismo
13.
J Surg Res ; 176(2): 687-95, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22316675

RESUMO

BACKGROUND: In humans, there is a 4:1 male:female ratio in the incidence of abdominal aortic aneurysms (AAAs). c-Jun-N-terminal kinase (JNK) is an important upstream regulator of several enzymes involved in AAA formation, including the matrix metalloproteinases (MMPs). The purpose of this study was to determine if there is a gender difference between males and females in JNK during AAA formation. MATERIALS AND METHODS: Male and female C57/B6 mice underwent aortic perfusion with elastase or heat inactivated elastase with aortas harvested at d 3 and 14 for phenotype determination, RT-PCR, Western blot, and zymography. Additionally, in vitro experiments using siRNA were conducted to define JNK regulation of matrix metalloproteinases (MMPs). A t-test was used to compare between groups. RESULTS: Males formed larger AAAs at d 14 compared with females (P < 0.001), with significantly higher levels of JNK1 protein, proMMP9, proMMP2, and active MMP2. At d 3, males had more JNK1 mRNA, protein, and MMP activity. Knockdown of JNK 1 or 2 in vitro decreased MMP activity, while knockdown of JNK 1 and 2 together blocked all MMP activity. CONCLUSION: Alterations in JNK between genders is partially responsible for the differential rates of experimental AAA formation, likely through differential regulation of MMPs.


Assuntos
Aorta Abdominal/enzimologia , Aneurisma da Aorta Abdominal/metabolismo , Sistema de Sinalização das MAP Quinases/fisiologia , Proteína Quinase 8 Ativada por Mitógeno/metabolismo , Proteína Quinase 9 Ativada por Mitógeno/metabolismo , Caracteres Sexuais , Animais , Aorta Abdominal/citologia , Células Cultivadas , Modelos Animais de Doenças , Feminino , Humanos , Masculino , Metaloproteinase 2 da Matriz/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Proteína Quinase 8 Ativada por Mitógeno/genética , Proteína Quinase 9 Ativada por Mitógeno/genética , Músculo Liso Vascular/citologia , Músculo Liso Vascular/efeitos dos fármacos , Músculo Liso Vascular/enzimologia , Elastase Pancreática/farmacologia , RNA Interferente Pequeno/genética
14.
J Surg Res ; 178(2): 1038-45, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22651981

RESUMO

BACKGROUND: The objective of this study was to test a novel model of inducing abdominal aortic aneurysms (AAAs) in different mouse strains and genders. MATERIALS AND METHODS: Male and female C57BL/6 and B6129 mice (n = 5 per group) underwent periaortic dissection and porcine pancreatic elastase (30 µL) or inactivated elastase application (5 min) to the aorta. Aortic measurements were taken on days 0 and 14. Aortic samples were analyzed for histology and zymography for matrix metalloproteinase (MMP) activity. Comparison statistics were performed using unpaired t-test. RESULTS: AAA phenotype (50% aortic increase) occurred in external elastase-treated males (100%) and females (90%). No control animals developed AAAs. The aortic diameter was larger in C57BL/6 and B6129 elastase-treated versus control males (P = 0.0028 and P < 0.0001, respectively) and females (P < 0.0001 and P = 0.0458, respectively). Histology verified phenotype via disrupted internal elastic laminae. Macrophage counts in elastase-treated animals were >6-fold higher than in controls (all groups significant). MMP9 activity was greater in elastase-treated males and females in C57BL/6 (P = 0.0031, P = 0.0004) and B6129 (P = 0.025, P = 0.2) mice; MMP2 activity was greater in C57BL/6 versus B6129 male elastase-treated mice. CONCLUSIONS: This rodent model produced AAAs in both genders and strains of mice. This model is simple, has little variability, and occurs in the infrarenal aorta, substantiating the external elastase model for future studies.


Assuntos
Aneurisma da Aorta Abdominal/etiologia , Animais , Modelos Animais de Doenças , Feminino , Macrófagos/fisiologia , Masculino , Metaloproteinase 9 da Matriz/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Elastase Pancreática , Fenótipo , Caracteres Sexuais , Especificidade da Espécie , Linfócitos T/fisiologia
15.
Ann Thorac Surg ; 112(2): 652-660, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-32971063

RESUMO

BACKGROUND: A high-fidelity simulator that uses a perfused porcine heart, cannulae, and tubing has been demonstrated to be a useful training adjunct. We hypothesized that multimodal assessment of cardiopulmonary bypass (CPB) skills within this high-fidelity simulated environment could discern expert from trainee performance. METHODS: Three traditional fellows (postgraduate year 6-8) and 3 attending surgeons each performed 3 aortic cannulations. The third sequence included venous cannulation, commencement of CPB, and placement of a cardioplegia catheter and aortic cross-clamp. Performance across 20 cognitive and 21 technical domains was evaluated. Surgeon and assistant hand movements and economy of motion were assessed by electromagnetic motion sensors worn under sterile gloves. RESULTS: Analysis showed a significant difference in cognitive (6.7 ± 2.3 vs 4.6 ± 2.7, P = .03) but not technical (6.2 ± 2.5 vs 5.8 ± 2.2, P = .7) scores favoring the experts. In addition, experts showed higher efficiency by spending 64 ± 14 seconds to construct a nonpledgeted aortic purse-string suture and secure it with a Rummel, while trainees spent 82 ± 30 seconds to complete this task (P = .03). Motion analysis revealed similar path lengths between experts and trainees for cannulation and CPB but significantly shorter path lengths for experts in cross-clamp (47.5 ± 15.5 m vs 91.9 ± 20.3 m, P = .04). CONCLUSIONS: Multimodal assessment using cognitive, technical, and motion analysis of basic CPB tasks using a high-fidelity simulation environment is a valid system to measure performance and discriminate experts from trainees. This construct may allow for development of "competence thresholds" with important implications for training and certification in cardiothoracic surgery.


Assuntos
Ponte Cardiopulmonar/educação , Competência Clínica , Simulação por Computador , Educação de Pós-Graduação em Medicina/métodos , Treinamento com Simulação de Alta Fidelidade/métodos , Internato e Residência/métodos , Cirurgiões/educação , Humanos
16.
Vasc Endovascular Surg ; 54(7): 573-578, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32643559

RESUMO

OBJECTIVE: The attempt to repair a ruptured abdominal aortic aneurysm carries a significant risk of perioperative mortality. The relationship between body mass index (BMI) and outcomes after repair of ruptured abdominal aortic aneurysms (AAAs) has not been well defined. We report the association of BMI with outcomes after ruptured AAA repair. METHODS: Patients undergoing ruptured AAA repairs between 2008 and 2017 at 2 tertiary academic centers were included in this retrospective study. Demographics (including BMI), type of repair, length of stay, and admission mortality risk scores were gathered and analyzed using bivariate and multivariate logistic regressions. Adjusted odds ratio (AOR) was reported with 95% CIs and P values from the multivariate analysis. The primary outcome was 30-day mortality. Akaike information criterion (AIC) and c-statistics were used to assess the predictive power of models including physiologic score with or without BMI. RESULTS: A total of 202 patients underwent repair of ruptured AAA. In bivariate relationship, increased BMI was significantly associated with 30-day mortality. With multivariate analysis, adjusting for demographics, type of procedure, and physiologic score, for each kg/m2 increase in BMI, an 8% increase in the likelihood of perioperative mortality (AOR = 1.08, 95% CI: 1.01-1.17; P = .04) was observed. CONCLUSION: When adjusted for admission risk score, type of procedure, and demographics, obesity was associated with increased 30-day mortality. With BMI as an additional data point, the c-statistics and AIC comparisons indicated that we would have a greater ability to preoperatively estimate mortality after ruptured AAA repair. Consideration could be made to include BMI in future mortality risk scoring systems for ruptured AAA.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Índice de Massa Corporal , Obesidade/diagnóstico , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Feminino , Humanos , Indiana , Masculino , Pessoa de Meia-Idade , Obesidade/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Washington
17.
J Thorac Dis ; 9(9): 2966-2973, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29221269

RESUMO

BACKGROUND: Whether primary tear size impacts extent of type A dissection is unclear. Using statistical groupings based on dissection morphology, we examined its relationship to primary tear area. METHODS: We retrospectively reviewed 108 patients who underwent acute ascending dissection repair from 2000-2016. Dissection morphology was characterized using 3-dimensional (3D) reconstructions of computed tomography (CT) scan images. Two-step cluster analysis was performed to group the dissections by examining the true lumen area as a fraction of the total aortic area at various levels. RESULTS: Cluster analysis defined two distinct categories. This first grouping corresponds to DeBakey type I (n=71, 65.7%) with a dissection extending from the ascending aorta to the aortic bifurcation. The second grouping conforms more closely to DeBakey type II dissection (n=37, 34.3%). It differs however from the classic type II definition as the dissection may extend up to the distal arch from the ascending aorta. Compared to type I, this "extended" DeBakey type II had no malperfusion (P<0.05), a larger primary tear area (6.6 vs. 3.7 cm2, P=0.009), and a greater burden of atherosclerotic coronary artery disease (P<0.05). A smaller aortic valve annulus (P=0.025) and a smaller root false lumen area (P=0.017) may explain less aortic valve insufficiency (P<0.05) in extended type II dissections. No differences in complications or survival were seen. CONCLUSIONS: In this series, limited distal extension of DeBakey type II dissections appears to be related to a larger primary tear area and greater atherosclerotic disease burden. It is also associated with less malperfusion and aortic valve insufficiency.

19.
Surgery ; 152(2): 238-46, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22828146

RESUMO

BACKGROUND: Our aim was to establish a novel model of abdominal aortic aneurysms (AAA) in mice using application of peri-adventitial elastase. METHODS: C57BL/6J male mice underwent infrarenal peri-adventitial application of either (1) sodium chloride (control; n = 7), (2) porcine pancreatic elastase (PPE; n = 14), or (3) PPE and doxycycline (PPE + doxycycline 200 mg/kg; n = 11) for 14 days. Aortas were analyzed by video micrometry, immunohistochemistry, qualitative polymerase chain reaction, and zymography. Groups underwent Mann-Whitney U comparisons. RESULTS: At day 14 compared with baseline, control animals had minimal aortic dilation, whereas fusiform aneurysms were seen in PPE (control, 20 ± 3%; PPE, 82 ± 15%; P ≤ .003). Doxycycline abrogated aneurysm formation (PPE, 82 ± 15%; PPE + doxycycline, 37 ± 10%; P ≤ .03). Compared with control and PPE + doxycycline, immunohistochemistry demonstrated greater elastin fiber degradation, macrophage infiltration, and matrix metalloproteinase-9 expression in PPE. Ki-67 and cleaved caspase-3 were lower in control versus PPE. The loss of smooth muscle marker expression seen with PPE was preserved in PPE + doxycycline. Zymography confirmed that both MMP-2 and -9 were more active in PPE than PPE + doxycycline. CONCLUSION: Peri-adventitial application of elastase is a simple, reproducible in vivo model of aneurysm formation leading to consistent infrarenal aortic aneurysm development by day 14, with inflammatory cell infiltration and MMP upregulation. Doxycycline inhibits AAA progression in this model via limiting matrix degradation and preserving differentiated smooth muscle cells.


Assuntos
Aneurisma da Aorta Abdominal/induzido quimicamente , Modelos Animais de Doenças , Animais , Antibacterianos/uso terapêutico , Aneurisma da Aorta Abdominal/tratamento farmacológico , Aneurisma da Aorta Abdominal/enzimologia , Doxiciclina/uso terapêutico , Masculino , Metaloproteinase 2 da Matriz/metabolismo , Metaloproteinase 9 da Matriz/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Elastase Pancreática , Suínos
20.
J Am Coll Surg ; 215(5): 668-680.e1, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22917644

RESUMO

BACKGROUND: It is hypothesized that activation of extracellular signal-related kinase (ERK) is critical in activating matrix metalloproteinases (MMPs) during abdominal aortic aneurysm (AAA) formation. STUDY DESIGN: C57BL/6 male mice underwent either elastase or heat-inactivated elastase aortic perfusion (n = 9 per group). Mouse aortic smooth muscle cells were transfected with ERK-1 and 2 siRNA along with or without elastase treatment. Mouse and human aortic tissue were analyzed by Western blots, zymograms, and immunohistochemistry, and statistical analysis was done using Graphpad and Image J softwares. RESULTS: Western blot and immunohistochemistry documented increased phospho-mitogen-activated protein kinase kinase-1/2 (pMEK-1/2; 153%, p = 0.270 by Western) and pERK (171%, p = 0.004 by Western blot) in the elastase perfused aortas. Male ERK-1(-/-) mice underwent elastase perfusion, and aortic diameter was determined at day 14. ERK-1(-/-) mice failed to develop AAA, and histologic analysis depicted intact collagen and elastin fibers in the aortas. Zymography of aortas of elastase-treated ERK-1(-/-) mice showed lower levels of proMMP2 (p < 0.005) and active MMP2 (p < 0.0001), as well as proMMP9 (p = 0.037) compared with C57BL/6 mice. siRNA transfection of ERK-1 and -2 significantly reduced formation of pro- and active MMP2 (p < 0.01 for both isoforms) in aortic smooth muscle cells treated with elastase in vitro. Human AAA tissue had significantly elevated levels of pMEK-1/2 (150%, p = 0.014) and pERK (159%, p = 0.013) compared with control tissues. CONCLUSIONS: The MAPK (mitogen-activated protein kinase)/ERK pathway is an important modulator of MMPs during AAA formation. Targeting the ERK pathway by reagents that inhibit either the expression or phosphorylation of ERK isoforms could be a potential therapy to prevent AAA formation.


Assuntos
Aorta Abdominal/metabolismo , Aneurisma da Aorta Abdominal/metabolismo , Sistema de Sinalização das MAP Quinases/fisiologia , Proteína Quinase 1 Ativada por Mitógeno/metabolismo , Proteína Quinase 3 Ativada por Mitógeno/metabolismo , Animais , Aneurisma da Aorta Abdominal/etiologia , Biomarcadores/metabolismo , Western Blotting , Células Cultivadas , Precursores Enzimáticos/metabolismo , Gelatinases/metabolismo , Humanos , Imuno-Histoquímica , Masculino , Metaloproteinase 2 da Matriz/metabolismo , Metaloproteinase 9 da Matriz/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Transfecção
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