Nonenhanced arterial spin labeled carotid MR angiography using three-dimensional radial balanced steady-state free precession imaging.

PURPOSE: To optimize and preliminarily evaluate a three-dimensional (3D) radial balanced steady-state free precession (bSSFP) arterial spin labeled (ASL) sequence for nonenhanced MR angiography (MRA) of the extracranial carotid arteries. MATERIALS AND METHODS: The carotid arteries of 13 healthy subjects and 2 patients were imaged on a 1.5 Tesla MRI system using an undersampled 3D radial bSSFP sequence providing a scan time of ∼4 min and 1 mm(3) isotropic resolution. A hybridized scheme that combined pseudocontinuous and pulsed ASL was used to maximize arterial coverage. The impact of a post label delay period, the sequence repetition time, and radiofrequency (RF) energy configuration of pseudocontinuous labeling on the display of the carotid arteries was assessed with contrast-to-noise ratio (CNR) measurements. Faster, higher undersampled 2 and 1 min scans were tested. RESULTS: Using hybridized ASL MRA and a 3D radial bSSFP trajectory, arterial CNR was maximized with a post label delay of 0.2 s, repetition times ≥ 2.5 s (P < 0.05), and by eliminating RF energy during the pseudocontinuous control phase (P < 0.001). With higher levels of undersampling, the carotid arteries were displayed in ≤ 2 min. CONCLUSION: Nonenhanced MRA using hybridized ASL with a 3D radial bSSFP trajectory can display long lengths of the carotid arteries with 1 mm(3) isotropic resolution.

Resection of intracaval leiomyomatosis using abdominal approach and venovenous bypass.

BACKGROUND: Intravenous leiomyomatosis is the venous involvement of a histologically benign uterine tumor. This uncommon tumor can present contemporaneously with the primary uterine tumor or in a delayed fashion. Tumor extends up the venous system, via the iliac or ovarian veins, and can involve portions or all of the inferior vena cava and can extend into the heart as well. Complete resection of this tumor is the therapeutic goal. Previous reports have described the use of combined thoracic and abdominal approaches, cardiopulmonary bypass, circulatory arrest, and a single report of an entirely abdominal approach to resection without bypass. METHODS AND RESULTS: We present a review of the existing literature describing surgical intervention for intravenous leiomyomatosis and describe two cases of tumor extending up the intra-abdominal vena cava. Using venovenous bypass without need for thoracotomy, we were able to resect both tumors with minimal blood loss and no hemodynamic instability. CONCLUSIONS: We suggest that venovenous bypass is an excellent tool in resection of these tumors and should be considered for many cases in lieu of full cardiopulmonary bypass or circulatory arrest.

Identification of Diarylurea Inhibitors of the Cardiac-Specific Kinase TNNI3K by Designing Selectivity Against VEGFR2, p38α, and B-Raf.

A series of diarylurea inhibitors of the cardiac-specific kinase TNNI3K were developed to elucidate the biological function of TNNI3K and evaluate TNNI3K as a therapeutic target for the treatment of cardiovascular diseases. Utilizing a structure-based design, enhancements in kinase selectivity were engineered into the series, capitalizing on the established X-ray crystal structures of TNNI3K, VEGFR2, p38α, and B-Raf. Our efforts culminated in the discovery of an in vivo tool compound 47 (GSK329), which exhibited desirable TNNI3K potency and rat pharmacokinetic properties as well as promising kinase selectivity against VEGFR2 (40-fold), p38α (80-fold), and B-Raf (>200-fold). Compound 47 demonstrated positive cardioprotective outcomes in a mouse model of ischemia/reperfusion cardiac injury, indicating that optimized exemplars from this series, such as 47, are favorable leads for discovering novel medicines for cardiac diseases.

Local and systemic consequences of large retroperitoneal clot burdens.

BACKGROUND: There is a paucity of data regarding the impact of retroperitoneal hematoma (RPH) volumes, as detected by computed tomography (CT) scanning, on patient morbidity and mortality. Therefore, we wanted to determine the natural history of RPHs and the effect of size on local and systemic outcomes. METHODS: We performed a volumetric analysis of CT-documented RPHs managed at our institution between 1985 and 2006 along with a retrospective chart review. RESULTS: We included 81 cases of RPH in this study. The mean Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score was 12.8 +/- 0.72 (score +/- SE). By univariate analysis, the size of the hematoma showed a significant correlation with the development of local mass effects, delayed mass effects, 6-month mortality, major morbidity, pulmonary complications, fluid overload, and the requirement for operative evacuation (p < 0.05). Receiver operating characteristic analysis revealed that a size > or = 1600 cm(3) was > 80% sensitive and specific for predicting a delayed mass effect or an increase in 6-month mortality. Multivariate analysis controlling for factors such as APACHE II and packed red blood cells transfused showed that the volume of the RPH was an independent predictor for the development of local mass effects, pulmonary insufficiency, and fluid overload. CONCLUSIONS: Large RPHs are clearly associated with worse patient outcomes. Surgical intervention may be warranted for the treatment of RPHs > or = 1600 cm(3).

WITHDRAWN: Reappraisal of internal carotid artery stenosis velocity thresholds utilizing high-resolution B-mode ultrasound validated with computed tomography angiography (CTA).

This article has been withdrawn consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

The use of arterial closure devices for incidental arterial injury.

Incidental arterial injury is one of the main mechanical complications associated with central venous catheter placement. These injuries can result in significant morbidity and mortality. The use of arterial closure devices to repair these injuries offers a less invasive alternative than open repair and a safer approach than manual compression. We present 3 cases of critically ill patients treated with arterial closure devices when attempted central venous catheterization failed and inadvertent arterial cannulation occurred. A brief review of the various closure devices and there indications is discussed.

Effects of the CRF receptor antagonist D-Phe CRF(12-41) and the alpha2-adrenergic receptor agonist clonidine on stress-induced reinstatement of nicotine-seeking behavior in rats.

Tobacco dependence is a chronic disorder that is characterized by relapse after periods of abstinence. It has been hypothesized that the activation of brain stress systems mediates stress-induced relapse to smoking. The aim of these experiments was to investigate the role of corticotropin-releasing factor (CRF) and norepinephrine in stress-induced reinstatement of extinguished nicotine-seeking behavior. Rats were allowed to self-administer nicotine under a fixed-ratio 5 schedule for 14 days and then nicotine-seeking behavior was extinguished by substituting saline for nicotine. In experiment 1, footshocks reinstated extinguished nicotine-seeking behavior. In experiment 2, there was a trend for the CRF(1/2) receptor antagonist D-Phe CRF((12-41)) (5, 25microg, icv) to decrease stress-induced reinstatement of nicotine-seeking behavior. Footshock-induced reinstatement of nicotine-seeking behavior was observed only in a subset of stress-responsive rats (71%). D-Phe CRF((12-41)) significantly attenuated stress-induced reinstatement of nicotine-seeking behavior in this subset of rats. In experiment 3, the alpha2-adrenergic receptor agonist clonidine (20, 40microg/kg, sc) attenuated footshock-induced reinstatement of nicotine-seeking behavior. In experiment 4, the effects of D-Phe CRF((12-41)) and clonidine on responding for chocolate-flavored food pellets was investigated in order to determine if these compounds have sedative effects. D-Phe CRF((12-41)) did not affect responding for food pellets. Clonidine slightly, but significantly, decreased responding for food pellets. Clonidine decreased responding for food to a lesser degree than it decreased stress-induced reinstatement of nicotine-seeking behavior. These data provide support for the hypothesis that an increased activity of brain CRF and norepinephrine systems mediates stress-induced relapse to nicotine-seeking behavior.

Angiographic access site complications in the era of arterial closure devices.

Coronary and peripheral angiography is associated with a low but significant risk of access site complications. While percutaneous devices have been shown to permit more rapid puncture site closure, previous reports have suggested the incidence and severity of complications associated with these devices are greater than with manual compression. This study compares access site complications with and without closure devices in the current era. The authors conducted a retrospective review of patients with access site complications after coronary or peripheral angiography between 1998 and 2000. Forty-five complications requiring vascular surgical consultation were identified in the 4,800 procedures performed during this time period. Fourteen complications occurred in 1,536 procedures (0.9%) using suture-mediated or collagen devices and 31 occurred in 3,264 procedures without devices (0.9%). The types of procedures and catheter sizes (mean 7 Fr) used were not different in the 2 groups. Other than complications involving a retained device, there was no difference between device and manual compression with respect to incidence or types of complication,requirement for operation, type of operation, or outcome. Access site complications identified included pseudoaneurysm (n = 22; 49%), bleeding or hematoma (n = 8;18%), arteriovenous fistula (n=5;11%), arterial thrombosis (n = 4;9%), infection (n = 4;9%), and retained device (n = 2;4%). Twenty-four patients (71% vs 45%; p = NS) required operative intervention including pseudoaneurysm repair, hematoma drainage, and thrombectomy. Eleven patients (26%) underwent successful ultra-sound-guided pseudoaneurysm compression and 9 patients (21%) required no intervention. These data demonstrate that closure devices facilitate arterial puncture site repair without an increase in access site complications. These devices can be safely utilized when rapid hemostasis is desired after coronary or peripheral angiography.

Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy.

Although early postoperative duplex scanning has become routine after carotid endarterectomy (CEA), it is unclear whether the results of these scans alter clinical management. The purpose of this study was to critically examine the usefulness of early postoperative duplex scans in evaluating the ipsilateral carotid artery (for technical perfection) as well as the contralateral carotid artery (for potential velocity changes after improvements in ipsilateral flow). Consecutive patients undergoing CEA between January 1995 and June 1999 in a tertiary hospital setting were studied. Patients underwent early postoperative duplex scanning according to the discretion of the operating surgeon and the availability of the patient. In 212 patients 236 CEAs were performed with selective use of patch closure (49%), intraluminal shunting (19%), and intraoperative completion imaging studies (14%). Neurologic complications included 3 transient ischemic attacks (TIAs) (1.3%), 3 nondisabling strokes (1.3%), and 3 disabling strokes (1.3%). There was 1 30-day death from myocardial infarction. Patients were followed up for a median of 18 months (range 0-72 months). Sixty-five percent of patients undergoing uncomplicated CEA (147/227) underwent early duplex surveillance within 6 months of operation. Unsuspected sonographic abnormalities were discovered in 8 patients (5%), including 7 cases of mild internal carotid artery (ICA) stenosis (>50% by velocity criteria) and 1 case of common carotid artery (CCA) stenosis (intimal flap). None of the patients with ICA stenosis developed symptoms or required operation at any time. The CCA intimal flap was electively repaired without complication. Postoperative changes in velocity in the contralateral ICA were found in 8/48 (17%) cases. There were 3 cases of increased velocity, upgrading 1 from 0-49% to 50-79% stenosis and upgrading 2 from 50-79% to 80-99% stenosis. The latter patients both underwent uneventful contralateral CEA. There were 6 cases of decreased velocity, resulting in downgrading of stenoses from 50-79% to 0-49% (n=5) or from 80-99% to 50-79% (n=1). Only the latter patient underwent contralateral CEA; the remainder have been followed up without intervention. Early scanning appeared to offer no clinical benefit; survival and neurologic outcome were the same in the 135 patients scanned within the first 6 months as in the 68 patients whose first postoperative scan occurred later (4-year neurologic event rate 0% in both groups; patient survival with early duplex 98 +/- 1.5%, without early duplex 96 +/- 2.6%; = NS). Early ipsilateral duplex abnormalities following CEA are infrequent in asymptomatic patients and, even if found, rarely alter management. Patients with bilateral stenosis being considered for contralateral CEA should undergo repeat duplex scanning after the first operation, because of the significant rate (19%) of contralateral velocity changes induced by ipsilateral CEA.

Complications of indwelling retrievable versus permanent inferior vena cava filters.

OBJECTIVE: Retrievable inferior vena cava (IVC) filters are appealing because they are designed for either retrieval or long-term use. However, the long-term safety of indwelling retrievable compared with permanent filters is largely unknown. This study was undertaken to compare complication rates and types associated with indwelling retrievable and permanent filters. METHODS: A retrospective review identified 1234 IVC filters (449 retrievable, 785 permanent) placed in 1225 patients from 2005 to 2010. Patients with retrievable filters removed electively were excluded, yielding 383 patients in whom retrievable filters were left in place. These patients with indwelling retrievable filters were compared with those with permanent filters with respect to demographics, comorbidities, survival, and complication rate and type. Differences in patient characteristics were tested with χ(2), Fisher exact, and Wilcox rank-sum tests. Logistic regression was used to identify predictors of complications. Because there were differences in the characteristics of the patients with indwelling retrievable filters and permanent filters, an additional propensity score analysis was performed yielding 319 patients in each group. RESULTS: Patients with indwelling retrievable filters were younger than those with permanent filters (mean age, 62 vs 75 years; P < .0001). Patients with indwelling retrievable filters had significantly more complications than those with permanent filters (9% vs 3.0%; P < .0001) after mean follow-up of 20 months (range, 0-86 months). Filter complications were categorized as thrombotic, device related, or systemic. While the most common complication type with both indwelling retrievable and permanent filters was thrombotic (4.4% vs 2.2%; P = NS), device-related complications were significantly more common with indwelling retrievable filters compared with permanent filters (3% vs 0.5%; P < .006). Propensity score analysis demonstrated that even in the matched groups, indwelling retrievable filters were associated with significantly more complications than permanent filters (9.1% vs 3.5%; P = .0035). CONCLUSIONS: Indwelling retrievable IVC filters were associated with significantly higher complication rates than permanent filters. Both thrombotic and device-related complications were more common with retrievable filters. Long-term use of retrievable filters should be avoided, especially considering the younger population in whom they are placed.

Is atherectomy the best first-line therapy for limb salvage in patients with critical limb ischemia?

OBJECTIVE: To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. METHODS: Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. RESULTS: A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). CONCLUSIONS: Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.

Reappraisal of velocity criteria for carotid bulb/internal carotid artery stenosis utilizing high-resolution B-mode ultrasound validated with computed tomography angiography.

OBJECTIVE: Reliability of the most commonly used duplex ultrasound (DUS) velocity thresholds for internal carotid artery (ICA) stenosis has been questioned since these thresholds were developed using less precise methods to grade stenosis severity based on angiography. In this study, maximum percent diameter carotid bulb ICA stenosis (European Carotid Surgery Trial [ECST] method) was objectively measured using high resolution B-mode DUS validated with computed tomography angiography (CTA) and used to determine optimum velocity thresholds for > or =50% and > or =80% bulb internal carotid artery stenosis (ICA). METHODS: B-mode DUS and CTA images of 74 bulb ICA stenoses were compared to validate accuracy of the DUS measurements. In 337 mild, moderate, and severe bulb ICA stenoses (n = 232 patients), the minimal residual lumen and the maximum outer bulb/proximal ICA diameter were determined on longitudinal and transverse images. This in contrast to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method using normal distal ICA lumen diameter as the denominator. Severe calcified carotid segments and patients with contralateral occlusion were excluded. In each study, the highest peak systolic (PSV) and end-diastolic (EDV) velocities as well as ICA/common carotid artery (CCA) ratio were recorded. Using receiver operating characteristic (ROC) analysis, the optimum threshold for each hemodynamic parameter was determined to predict > or =50% (n = 281) and > or =80% (n = 62) bulb ICA stenosis. RESULTS: Patients mean age was 74 +/- 8 years; 49% females. Clinical risk factors for atherosclerosis included coronary artery disease (40%), diabetes mellitus (32%), hypertension (70%), smoking (34%), and hypercholesterolemia (49%). Thirty-three percent of carotid lesions (n = 110) presented with ischemic cerebrovascular symptoms and 67% (n = 227) were asymptomatic. There was an excellent agreement between B-mode DUS and CTA (r = 0.9, P = .002). The inter/intraobserver agreement (kappa) for B-mode imaging measurements were 0.8 and 0.9, respectively, and for CTA measurements 0.8 and 0.9, respectively. When both PSV of > or =155 cm/s and ICA/CCA ratio of > or =2 were combined for the detection of > or =50% bulb ICA stenosis, a positive predictive value (PPV) of 97% and an accuracy of 82% were obtained. For a > or =80% bulb ICA stenosis, an EDV of > or =140 cm/s, a PSV of > or =370 cm/s and an ICA/CCA ratio of > or =6 had acceptable probability values. CONCLUSION: Compared with established velocity thresholds commonly applied in practice, a substantially higher PSV (155 vs 125 cm/s) was more accurate for detecting > or =50% bulb/ICA stenosis. In combination, a PSV of > or =155 cm/s and an ICA/CCA ratio of > or =2 have excellent predictive value for this stenosis category. For > or =80% bulb ICA stenosis (NASCET 60% stenosis), an EDV of 140 cm/s, a PSV of > or =370 cm/s, and an ICA/CCA ratio of > or =6 are equally reliable and do not indicate any major change from the established criteria. Current DUS > or =50% bulb ICA stenosis criteria appear to overestimate carotid bifurcation disease and may predispose patients with asymptomatic carotid disease to untoward costly diagnostic imaging and intervention.

Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck.

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.

B-mode ultrasonographic characterization of carotid atherosclerotic plaques in symptomatic and asymptomatic patients.

OBJECTIVE: To identify features on B-mode ultrasonography (US) prevalent in symptomatic plaques and correlate these findings with histopathologic markers of plaque instability. METHODS: Carotid endarterectomy (CEA) plaques from symptomatic and asymptomatic patients with critical stenoses (>70%) were qualitatively assessed using preoperative B-mode US for echolucency and calcific acoustic shadowing. US echolucency was quantitated ex vivo using computerized techniques for gray-scale median (GSM) analysis. Histopathologic correlates for US plaque echolucency (percentage of necrotic core area) and acoustic shadowing (percentage of calcification area) were determined. RESULTS: Fifty CEA plaques were collected from 48 patients (46 unilateral and two bilateral); 26 of these plaques were from symptomatic patients. Age, degree of stenosis, and atherosclerotic risk factors were similar for the symptomatic and asymptomatic patients. Using preoperative B-mode US, 58%, 35%, and 7% of symptomatic plaques and 18%, 41%, and 41% of asymptomatic plaques were found to be echolucent, echogenic, and calcific, respectively (P < .05). Using ex-vivo B-mode US and GSM analysis, symptomatic plaques were more echolucent (41 +/- 19) than asymptomatic plaques (60 +/- 13), P < .03. A strong inverse correlation was found between the percent plaque necrotic area core and GSM (R = -0.9, P < .001). Percentage of calcification area in plaques with acoustic shadowing was 66% and only 27% in those without acoustic shadowing (P < .05). CONCLUSIONS: Using B-mode US, symptomatic plaques are more echolucent and less calcified than asymptomatic plaques and are associated with a greater degree of histopathologic plaque necrosis. Such features are indicative of plaque instability and should be considered in the decision-making algorithm when selecting patients with high-grade asymptomatic carotid stenosis for intervention.

Interleukin-6 causes endothelial barrier dysfunction via the protein kinase C pathway.

BACKGROUND: Elevated levels of interleukin-6 (IL-6) have been identified in a variety of systemic inflammatory states that are associated with endothelial barrier dysfunction, but the specific effect of IL-6 on endothelial permeability and the mechanism of action have not been fully examined. The current study evaluated the effect of IL-6 on endothelial permeability and on the distribution of the tight junctional protein ZO-1 and cytoskeletal actin. We also assessed the role of protein kinase C (PKC) in this process. METHODS: Confluent monolayers of human umbilical vein endothelial cells (n = 6) were exposed to IL-6 (50-500 ng/ml) in the presence or absence of the PKC inhibitor Gö6976 (0.1 microM). Transendothelial electrical resistance (TEER) was measured at the onset of exposure and at 6-h intervals and compared with that of control cells using ANOVA with a Bonferroni multiple comparison test. Additional monolayers were exposed to IL-6, stained for ZO-1 and F-actin, and evaluated via fluorescence microscopy. RESULTS: Interleukin-6 increased endothelial permeability as measured by TEER in a dose- and time-dependent manner. In the presence of PKC inhibitor, the IL-6-mediated increase in permeability was attenuated (18-h TEER 73% of control with IL-6 exposure vs 95% of control with IL-6 + Gö6976 inhibitor, P < 0.01). Microscopy revealed that permeability changes were accompanied by a redistribution of the tight junctional protein ZO-1 and cytoskeletal actin, increased cell contraction, and disorganization of the intercellular borders. Conclusions. The inflammatory cytokine IL-6 is an important mediator of increased endothelial permeability via alterations in the ultrastructural distribution of tight junctions and morphologic changes in cell shape. PKC is a critical intracellular messenger in these IL-6-mediated changes. A better understanding of this mechanism should allow the determination of rational treatment strategies for endothelial barrier dysfunction which occurs in inflammatory states.

Operative intervention for recurrent stenosis after carotid stent angioplasty: a report.

Carotid artery angioplasty and stenting is gaining popularity, yet the natural history and optimal treatment for recurrent stenoses within stents are not known. Recurrent stenosis rates are not well characterized, with rates between 0 and 33% reported within the first year. Treatment of these lesions with repeat angioplasty may not be feasible or desirable, leading to operative interventions. We present two cases of asymptomatic high-grade in-stent restenosis treated successfully with carotid artery bypass using PTFE.

Gender does not influence outcomes after iliac angioplasty.

The current study was undertaken to evaluate the potential influence of gender on iliac angioplasty outcomes. All iliac angioplasty procedures performed at a tertiary care center from 1994 to 1999 were reviewed. One hundred four angioplasties with or without stenting were performed in 44 women (56 limbs) and 40 men (48 limbs). Age and atherosclerotic risk factors were similar in men and women. Iliac angioplasty was performed for limb salvage in 41% of patients (39% female vs. 44% male; p = 0.65). There were no differences in degree of stenosis, lesion length, or initial angioplasty site. Female iliac arteries were more likely to be occluded (21% vs. 6%; p = 0.03); mean iliac artery luminal diameter was smaller in women than in men (6.5 +/- 0.5 mm vs. 8.2 +/- 0.6 mm; p < 0.001). After a median follow-up of 13 months, there were no significant differences in 2-year primary patency, endovascular primary-assisted patency, or limb salvage rates between women and men. Despite having smaller iliac arteries and a higher incidence of arterial occlusion before treatment, women had outcomes similar to those of men after iliac angioplasty. The current results support the initial use of angioplasty to treat common and external iliac artery occlusive disease in both women and men.

Paravisceral aortic thrombus as a source of peripheral embolization--report of three cases and review of the literature.

Spontaneous embolization resulting in peripheral arterial occlusion remains a significant cause of morbidity and limb loss. Accurate localization and correction of the embolic source is paramount for the prevention of further episodes and for the preservation of long-term patency and limb salvage. Common well-recognized embolic sources include intracardiac thrombus or myxoma, and thrombus within arterial aneurysms or complex atherosclerotic plaques. Less common is thrombus arising de novo in an otherwise normal aorta, possibly as a result of prior trauma, occult arteriopathy, and/or hypercoagulability. Reported herein are three cases of peripheral or mesenteric embolization arising from large thrombi within the visceral aortic segment, with minimal evidence for atherosclerosis or other aortic pathology. Each patient was treated with visceral aortic thrombectomy using a direct surgical approach.

Spontaneous perforation of a non-aneurysmal visceral aorta.

A 77 year-old woman with mild osteoarthritis and Sjögren's Syndrome presented to an outside hospital with mild abdominal and back pain. The initial computed tomography (CT) scan was essentially negative. The repeat CT scan after 1 week of medical therapy was suspicious for a contained rupture of the visceral aorta. She was emergently transferred to the University of Chicago. Emergent aortography confirmed the diagnosis and revealed wide patency of the visceral and renal arteries. Upon exploration, there was obvious rupture of the entire right posterior aortic wall at the level of the celiac axis with a large right retroperitoneal hematoma. Aorto-aortic bypass was performed. The visceral and renal vessels were revascularized using separate jump grafts to this 'parallel aorta'. The patient tolerated the procedure well and was discharged after 12 days. Pathologic examination of the aortic wall was essentially negative. She is well on follow-up after 20 months. To our knowledge, this is the second reported case of spontaneous contained rupture of the visceral aorta.