Effectiveness and safety of adalimumab in patients with intestinal Behçet's disease: a real-world prospective observational study in South Korea.

BACKGROUND: Intestinal Behçet's disease (BD) is characterized by typical gastrointestinal ulcers in patients with BD followed by complications such as bleeding, perforation and fistula. Biologic agents are currently under active investigation to delay the disease course. Various data regarding infliximab are available, but there is relatively lack of data regarding adalimumab. METHODS: This was a multicenter, real-world prospective observational study to evaluate the effectiveness and safety of adalimumab in intestinal BD. The primary endpoint was disease activity at each follow up, including disease activity index for intestinal Behçet's disease (DAIBD), serum C-reactive protein (CRP) level, and endoscopic findings. The secondary endpoint was the incidence of adverse drug reactions (ADRs). RESULTS: A total of 58 patients were enrolled and 8 of them were excluded. Adverse events were reported in 72.0% of patients with 122 events. ADRs were reported in 24.0% with 28 events. For adverse events, arthralgia was most commonly reported (13.1%: 16/122) and only one experienced critical adverse event (0.82%, 1/122: death due to stroke). On multivariable regression analysis, a longer disease duration was significantly associated with decreased ADRs [Odds ratio 0.976 (0.953-0.999, 95% CI); p = 0.042]. Clinical response rates as assessed by DAIBD were 90.9% at Week 12 and 89.7% at Week 56, respectively. The mean serum CRP level at baseline was significantly decreased after 12 weeks (3.91 ± 4.93 to 1.26 ± 2.03 mg/dL; p = 0.0002). CONCLUSION: Adalimumab was found to be safe and effective in Korean patients with intestinal BD. A longer disease duration was significantly associated with decreased ADRs.

Aortoiliac diameter and length in a healthy cohort.

OBJECTIVE: Diameter is currently the only screening and diagnostic criterion for asymptomatic aneurysms. Therefore, aortic and lower-extremity arterial diameter has diagnostic, therapeutic, and prognostic importance. We aimed to determine aortic and lower-extremity arterial reference diameters in a general population and compare them according to age, sex, and other characteristics. METHODS: We evaluated consecutive 3,692 patients who underwent computed tomography as part of a general health checkup from 2015-2019 in a single tertiary center. Aortic and lower-extremity arterial diameters and the most important factor related to arterial diameters were evaluated. RESULTS: The mean diameter of the abdominal aorta was 17.490 ± 2.110 mm, while that of the common iliac artery was 10.851 ± 1.689 mm. The mean diameter of the abdominal aorta was 18.377 ± 1.766 mm in men and 15.884 ± 1.694 mm in women. Significant intersex differences were observed for all mean diameters and lengths. Multilinear regression analysis showed that age, sex, and body surface area impacted mean diameters of all measured sites except aorta and common iliac artery length. Between male and female patients matched for body surface area, there were significant intersex differences for all measured sites, except for common iliac artery length. CONCLUSIONS: The mean diameter of the abdominal aorta in this healthy cohort was 17.490 ± 2.110 mm overall, 18.377 ± 1.766 mm in men, and 15.884 ± 1.694 mm in women. Arterial diameter increased with male sex, older age, and increased body surface area, and aortic diameters were larger in men than in women with the same body surface area.

Similar long-term outcomes between endovascular aneurysm repair and open surgical repair for abdominal aortic aneurysms in octogenarian patients: a single-center study.

Purpose: Endovascular aneurysm repair (EVAR) has lower perioperative mortality and morbidity rates and shorter hospital stays when compared to open surgical repair (OSR) in octogenarian patients. However, its long-term results remain unclear. Hence, we aimed to analyze and compare the long-term outcomes of OSR and EVAR in this aging population. Methods: This single-center, retrospective, observational study analyzed the data of patients older than 80 years who underwent primary repair of an abdominal aortic aneurysm (AAA) between 2011 and 2016 in our hospital. The primary outcomes were in-hospital complications and 30-day mortality, while the secondary outcomes included all-cause mortality and reintervention rate. Results: Among the 48 patients with elective AAA repair, 13 underwent OSR and 35 underwent EVAR. In-hospital complications occurred in 10 patients (20.8%), 5 for OSR (38.5%) and 5 for EVAR (14.3%) with no significant difference between the groups (P = 0.067). In the OSR group, pulmonary complications were the most common events; in the EVAR group, 2 patients had ischemic colitis diagnosed with sigmoidoscopy and recovered by conservative treatment. The 1- and 5-year survival rates were 77.8% and 55.6% in the OSR group, and 66.0% and 54.9% in the EVAR group, respectively. The reintervention rate was 8.6% for the EVAR group; none of the OSR group were readmitted. Conclusion: The difference in procedures did not affect patient survival. Therefore, OSR does not necessarily have a worse prognosis than EVAR. Individual risk stratification must be preceded before the selection of an appropriate treatment method.

Expression of miRNAs Targeting ATP Binding Cassette Transporter 1 (ABCA1) among Patients with Significant Carotid Artery Stenosis.

Background: Carotid artery stenosis is a dynamic process associated with an increased risk of cardiovascular events. However, knowledge of biomarkers useful for identifying and quantifying high-risk carotid plaques associated with the increased incidence of cerebrovascular events is insufficient. Therefore, the objectives of this study were to evaluate the expression of ATP binding cassette transporter 1 (ABCA1) and validate its target microRNA (miRNA) candidates in human carotid stenosis arteries to identify its potential as a biomarker. Methods: In human carotid stenosis arterial tissues and plasma, the expression of ABCA1 and its target miRNAs (miRNA-33a-5p, 33b-5p, and 148a-3p) were evaluated by quantitative real time-polymerase chain reaction (qRT-PCR), immunohistochemistry, and enzyme-linked immunosorbent assay (ELISA). Results: The expression of ABCA1 was significantly decreased in the plasma of stenosis patients, but its expression was not different in arterial tissues (p < 0.05). However, significantly more target miRNAs were secreted by stenosis patients than normal patients (p < 0.05). Interestingly, lipotoxicity induced by the oleic and palmitic acid (OAPA) or lipopolysaccharide (LPS) treatment of human umbilical vein endothelial cells (HUVECs) dramatically enhanced the gene expression of adipogenic and inflammatory factors, whereas ABCA1 expression was significantly decreased. Conclusions: Therefore, miRNA-33a-5p, 33b-5p, and 148a-3p represent possible biomarkers of carotid artery stenosis by directly targeting ABCA1.

Effectiveness of Surgical Treatment with Complete Cyst Excision for Cystic Adventitial Disease of the Popliteal Artery.

BACKGROUND: Cystic adventitial disease is a rare, nonatherosclerotic disease that affects various arteries and veins, involving the formation of a mucinous cyst within the adventitia. The etiology of the cystic adventitial disease is currently unclear, with several hypotheses having been suggested. The purpose of this retrospective observational study was to evaluate the etiology of popliteal cystic adventitial disease based on imaging and surgical findings and to evaluate the efficacy of surgical treatment. METHODS: From April 2013 to January 2020, nine patients were diagnosed with the popliteal cystic adventitial disease and underwent surgical treatment. We performed complete resection of the cyst and the affected segment of the popliteal artery, followed by interposition with autologous reversed small saphenous vein or great saphenous vein. RESULTS: The resected adventitial cyst tissue was multilobular, filled with high-viscosity mucus. Pathologic examination of the surgical specimen revealed intramural cysts filled with gelatinous material located between the media and the adventitia, consistent with the clinical diagnosis of cystic adventitial disease. The median follow-up period was 27.5 months (range: 2-91 months). All patients underwent cyst excision with graft interposition, and the overall graft patency was 80.9 months (95% CI: 62.2-99.6 months). CONCLUSIONS: Computed tomography, magnetic resonance imaging, and surgical findings confirmed communication between the synovial cyst and arterial adventitia. It is recommended that priority be given to surgical resection and graft interposition because this can eliminate the disease's cause and reduce its recurrence.

Outcomes of arteriovenous access among cancer patients requiring chronic haemodialysis.

BACKGROUND: There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer. METHODS: In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement. RESULTS: Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P <  0.001). CONCLUSIONS: Although AV access patency rates were similar among patients with and without cancer in the death-censored analysis, cancer patients were more prone to early AVF failure, mainly due to cancer-associated deaths, and this consideration needs to be carefully balanced against individual patients' life expectancies, according to cancer type and stage.

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping.

BACKGROUND: Juxtarenal abdominal aortic aneurysm (AAA) comprises 15-20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs. METHODS: Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included. RESULTS: All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6-54.2). Mean survival time was 51.4 months (95% CI: 48.6-54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025-1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225-4.553; P = .010) were substantially associated with in-hospital complications. CONCLUSIONS: Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

Effect of arteriovenous access closure and timing on kidney function in kidney transplant recipients.

This study aimed to determine whether the closure of a functioning arteriovenous (AV) access affects the estimated glomerular filtration rate (eGFR) and to compare outcomes according to the timing of AV access closure after kidney transplantation (KT). From 2009 to 2015, medical records were retrospectively reviewed for 142 kidney transplant recipients (KTRs) who underwent AV access closure. The 142 KTRs were categorized into three groups: AV access closure was performed within 6 months after KT in Group 1 (n = 45), at 6-12 months after KT in Group 2 (n = 49), and at 12-24 months after KT in Group 3 (n = 48). The baseline (at the time of AV access closure) and follow-up eGFR values during the 3-year follow-up period were compared. Linear mixed model analysis revealed no significant association between longitudinally observed eGFR values and the amount of time elapsed after AV access closure in the study population (P = 0.36). There was no significant association between 3-year eGFR values and the timing of AV access closure (P = 0.58). In conclusion, after successful KT, AV access closure did not affect the eGFR significantly, and the timing of AV access closure was not significantly associated with outcomes.

Comparison of outcomes between type 2 diabetic and non-diabetic incident hemodialysis patients with functioning arteriovenous fistulas.

This study compared clinical outcomes of patient survival and arteriovenous fistula (AVF) patency between incident hemodialysis patients with and without type 2 diabetes mellitus (T2DM).Between January 2011 and December 2013, 384 consecutive incident hemodialysis patients with confirmed first upper-extremity AVF placement were divided into a T2DM group (n = 180, 46.9%) and a non-DM group (n = 204, 53.1%) and analyzed retrospectively. The primary outcome was all-cause mortality, and secondary outcome was AVF patency.Patients in the T2DM group had a higher prevalence of hypertension (P = .02), smoking (P < .01), cardiovascular disease (P < .01), history of cerebrovascular accident (CVA) (P < .01), and peripheral arterial occlusive disease (P < .01) than those in the non-DM group. On Kaplan-Meier survival analysis, the overall survival and AVF patency rates were significantly higher in the non-DM group relative to the T2DM group (both P < .01). In the adjusted model, older age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .01), T2DM (HR, 1.76; 95% CI, 1.12-2.77; P = .014), and history of CVA (HR, 1.76; 95% CI, 1.04-2.98; P = .04) were significantly associated with an increased risk of mortality. Older age and T2DM were independently associated with decreased primary (HR, 1.03; 95% CI, 1.02-1.04; P < .01, HR, 1.69; 95% CI, 1.22-2.33; P < .01, respectively) and secondary (HR, 1.03; 95% CI, 1.01-1.04; P < .01, HR, 2.07; 95% CI, 1.42-3.00; P < .01, respectively) AVF patency during follow-up.Compared with patients in the non-DM group, patients in the T2DM group had a higher mortality rate and worse AVF patency rates.

Effects of patient age on patency of chronic hemodialysis vascular access.

BACKGROUND: In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population. METHODS: The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency. RESULTS: Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P <  0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P <  0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P <  0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P <  0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency. CONCLUSIONS: Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.

Clinical Outcomes of Surgical Resection for Leiomyosarcoma of the Inferior Vena Cava.

BACKGROUND: Leiomyosarcoma of the inferior vena cava (IVC) is a rare mesenchymal tumor with poor prognosis. Surgical resection is currently the only potential curative treatment. This study analyzed long-term outcomes of patients who underwent surgical resection of leiomyosarcoma of the IVC. METHODS: The charts of 12 patients who underwent surgical resection of leiomyosarcoma of the IVC from January 1999 to December 2017 at a single center were retrospectively reviewed. RESULTS: Of the 12 patients, 10 (83.3%) were women. Median age at diagnosis was 63 years (range 42-67). Leiomyosarcoma involved the middle segment of the IVC in 9 patients (75.5%) and the lower segment in 3 (25.0%). Ten patients underwent IVC resection, followed by reconstruction with polytetrafluoroethylene in 9 patients and a bovine patch in 1. Two patients underwent IVC resection followed by ligation of the IVC. Eleven patients (91.7%) underwent grossly radical resection, with 1 (8.3%) having peritoneal seeding at the first operation. After resection, 8 patients received adjuvant chemotherapy and 7 received adjuvant radiotherapy. No patient experienced regional recurrence at the resection margins of the IVC, but 9 patients (75.5%) experienced distant metastases to sites such as the lungs, liver, bones, pelvis, peritoneum, and scalp. Median follow-up was 41 months (range 6-149). Median disease-free survival (DFS) was 49 months (range 8-88), and median overall survival (OS) was 127 months (range 25-149). The 3- and 5-year DFS rates were 77.9% and 39.0%, respectively, and the 3-, 5-, and 10-year OS rates were 87.5%, 75.0%, and 56.3%, respectively. CONCLUSIONS: Although there is no established treatment for leiomyosarcoma of the IVC and metastasis after surgery is frequent, surgical resection followed by chemotherapy and/or radiotherapy can enhance long-term survival.

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation.

In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.

Impact of transvenous cardiac implantable electronic devices in chronic hemodialysis patients: a single-center, observational comparative study.

BACKGROUND: We investigated the impact of a transvenous cardiac implantable electronic device (CIED) placement on outcomes and arteriovenous vascular access (VA) patency among chronic hemodialysis patients. METHODS: This is a single-center, observational comparative study between chronic hemodialysis patients with ipsilateral and contralateral CIED and VA. Forty-two consecutive patients who underwent both CIED placement and upper-extremity VA for hemodialysis, regardless of the sequence and time interval between these 2 procedures, were identified between January 2001 and December 2017. Patients with ipsilateral (n = 22, 52%, the ipsilateral group) and contralateral (n = 20, 48%, the contralateral group) CIED and VA were compared retrospectively; the primary outcome was any-cause mortality and cardiac mortality or the composite of any systemic complications, defined as central venous stenosis or occlusion, any device infections or tricuspid regurgitation; the secondary outcome was CIED or VA malfunction. RESULTS: During the median follow-up period of 101 months, primary outcome incidence was significantly higher in the ipsilateral group than the contralateral group (73% vs 40%, P = 0.03), although the incidences of any-cause mortality (P = 0.28) and cardiac mortality (P > 0.99) were similar between the groups. Secondary outcome incidence did not differ significantly between the 2 groups (55% vs 30%, P = 0.36). Kaplan-Meier survival analysis revealed similar primary and secondary VA patency rates in both groups. On subgroup analysis, patients with upper arm VA had similar primary and secondary patency to those with forearm VA. CONCLUSIONS: Despite some notable limitations of the study, the retrospective study design and small sample size, we found that the any-cause mortality incidence and VA patency did not differ between the 2 groups, but primary outcome incidence was significantly higher among patients with ipsilateral CIED and VA.