Midterm outcomes of physician-modified endovascular stent grafts for the treatment of complex abdominal aortic aneurysms in Korea: a retrospective study.

Purpose: Physician-modified endovascular stent grafts (PMEG) are a good treatment option for complex abdominal aortic aneurysms (AAAs), especially in high-risk patients not amenable to open repair, and when commercial fenestrated devices are not available. We report our single-center experience with PMEG for the treatment of complex AAAs. Methods: We retrospectively reviewed patients who underwent PMEG repair for AAA from November 2016 to September 2020 at our institution. Demographic data, anatomic characteristics, perioperative and postoperative outcomes, major adverse events, and 30-day mortality were analyzed. Results: We identified 12 patients who underwent PMEG for complex AAA. The mean age was 74 years and the mean maximal AAA diameter was 58.1 mm. Indications for treatment included 4 impending or contained ruptures, 2 mycotic aneurysms, and 6 symptomatic cases. The technical success rate was 91.7%. Aneurysm sac regression was observed in 7 patients (58.3%), including 2 cases of complete regression. There was 1 aneurysm-related mortality at 3 months due to mycotic aneurysm. Also, there was 1 postoperative complication case of transient renal failure requiring temporary dialysis. At 1 year, there was 1 branch occlusion from the initial failed cannulation case and 2 type 1A endoleaks, and there was 1 case of open explantation. Conclusion: PMEG showed a low technical failure rate and acceptable midterm stent durability and sac stability, comparable to conventional endovascular aneurysm repair. Despite the small number of cases, there was a tendency for a high sac regression rate, although longer follow-up is needed.

Routine Ureteral Stenting in Kidney Transplant Reduces Postoperative Hydronephrosis and Percutaneous Ureteral Interventions: A Single-Center Experience.

OBJECTIVES: The effect of routine ureteral stenting on postoperative hydronephrosis and percutaneous ureteral intervention in kidney transplant remains unknown. This study aimed to evaluate the effects of routine ureteral stenting on hydronephrosis and percutaneous ureteral intervention and the cost benefit of ureteral stenting in kidney transplant. MATERIALS AND METHODS: We retrospectively analyzed patients who underwent kidney transplant at a tertiary institution between 2005 and 2021. We adopted a ureteral stentingprotocol in2017, anda comparisonwas performed with previous patients without stents. RESULTS: In total, 539 patients underwent kidney transplant(271 with stents [51.3%], 268 without stents [49.7%]). Hydronephrosis was detected in 16 cases (5.9%) and 30 cases (11.2%) of groups with and without stents,respectively (P = .041). Among patients with hydronephrosis, the number of patients who underwent percutaneous ureteral intervention was significantly lower in the stent group than in the nostent group (1 [6.25%] vs 10 [33.33%]; P= .014).Twenty patients (3.71%) experienced major urologic complications (19 [7.1%] in the no-stent group, and 1 [0.4%] in the stent group; P = .001). No significant differences between the groups were shown in the incidence of urinary tract infections within 3 months of transplant (24 [8.9%] vs 22 [8.2%]; P = .846). No differences were shown between the groups in ureterovesical anastomosis time (24.4 vs 24.03 min; P = .699) or 1-year graft survival (97% vs 97.8%; P = .803). The healthcare cost was significantly lower in the stent group than in the no-stent group by $1702.05 ($15000.89 vs $16702.95; P < .001). CONCLUSIONS: Routine ureteral stenting in kidney transplant significantly decreased the incidence of postoperative hydronephrosis and percutaneous ureteral intervention. Stenting did notlead to increased urinary tract infections and was cost-effective.

Technical Feasibility of Renal Artery Embolization on a Transplanted Kidney Due to Intractable Unilateral Hydronephrosis After En Bloc Kidney Transplantation: Case Report.

INTRODUCTION: En bloc kidney transplantation (EBKT) is a technique used to transplant pediatric kidneys to adult recipients, but can lead to certain complications seldom found in single-kidney transplantation. We report a case of renal artery embolization after EBKT due to intractable unilateral hydronephrosis and highlight the technical details and challenges of the procedure. CASE: An 18-year-old female with MELAS syndrome underwent EBKT from a 10-month-old male baby. Two months later, the patient developed unilateral hydronephrosis and recurrent urinary tract infections, which was intractable to conventional therapy. Therefore, we underwent embolization of the problematic transplanted left kidney. Owing to the complicated anatomy and multiple angulations, multiple microcatheters, wires and support catheters were needed to select the renal arteries. Repeated procedures were required due to remnant flow from small branches and accessory renal arteries that were not easily visualized by conventional angiography, which were eventually detected by adjunctive use of 3-dimensional rotational angiography. CONCLUSIONS: Selective renal artery embolization after EBKT is challenging due to the short renal artery length and multiple angulations, yet it can still be performed safely and effectively by use of meticulous catheter-wire interactions and adjunctive intraoperative imaging techniques to delineate the precise anatomy of the target arteries. CLINICAL IMPACT: Selective renal artery embolization, which is less invasive than nephrectomy, can be considered if the culprit kidney must inevitably be sacrificed in en bloc kidney transplantation.

Capmatinib suppresses LPS-induced interaction between HUVECs and THP-1 monocytes through suppression of inflammatory responses.

BACKGROUND: Capmatinib (CAP) is a drug that has been used to treat non-small cell lung cancer (NSCLC) in adults. Presently, its novel effects on skeletal muscle insulin signaling, inflammation, and lipogenesis in adipocytes have been uncovered with a perspective of drug repositioning. However, the impact of CAP on LPS-mediated interaction between human umbilical vein endothelial cells (HUVECs) and THP-1 monocytes has yet to be investigated. METHODS: HUVECs and THP-1 monocytes were treated with LPS and CAP. The protein expression levels were determined using Western blotting. Target protein knockdown was conducted using small interfering (si) RNA transfection. Interactions between HUVECs and THP-1 cells were assayed using green fluorescent dye. RESULTS: This study found that CAP treatment ameliorated cell adhesion between THP-1 monocytes and HUVECs and the expression of adhesive molecules, such as intracellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin. Moreover, phosphorylation of inflammatory markers, such as NFκB and IκB as well as TNFα and monocyte chemoattractant protein-1 (MCP-1) released from HUVECs and THP-1 monocytes, was prevented by CAP treatment. Treatment with CAP augmented PPARδ and IL-10 expression. siRNA-associated suppression of PPARδ and IL-10 abolished the effects of CAP on cell interaction between HUVECs and THP-1 cells and inflammatory responses. Further, PPARδ siRNA mitigated CAP-mediated induction of IL-10 expression. CONCLUSION: These findings imply that CAP improves inflamed endothelial-monocyte adhesion via a PPARδ/IL-10-dependent pathway. The current study provides in vitro evidence for a therapeutic approach for treating atherosclerosis.

Preliminary outcomes of the LifeStream balloon-expandable stentgraft in Zenith Iliac branch device to preserve pelvic circulation: A Korean multicenter study.

BACKGROUND: To evaluate early outcomes of aortoiliac or isolated iliac artery aneurysm repair using the Zenith® Bifurcated Iliac Side (ZBIS) stent graft combined with the LifeStream™ Balloon Expandable Vascular Covered Stent as a bridging stentgraft. METHODS: Between August 2018 and February 2020, 38 patients (37 male, mean age 72.7 years) received 46 LifeStream stents in conjunction with 38 ZBIS stent grafts to bridge hypogastric arteries for aneurysm repair in six university hospitals in Korea. The primary outcomes were technical success rate and procedure-related complications. Secondary outcomes were bridging stent graft patency and re-intervention. RESULTS: All procedures were performed as elective standard endovascular aortic aneurysm repair (EVAR) and unilateral iliac branch device (IBD). Mean follow-up was 13.1 months, and patient overall survival rate was 96.7%. Technical success rate was 76.3% (n = 29). Causes of failure included seven total endoleaks; six type Ic and one type IIIc from the IBD junction, one unintentional IIA coverage, and one failure to deploy the IIA stent graft. Procedure-related complications occurred in two patients: one LifeStream migration and one ZBIS stent graft migration. Overall patency rates for the LifeStream and ZBIS stents were 97.4% and 97.2%, respectively. CONCLUSION: This multicenter preliminary experience with the LifeStream™ Balloon Expandable Vascular Covered Stent in IBD demonstrated good patency; however, an unexpectedly high rate of type Ic endoleaks was observed. Combined use of the LifeStream stent with the ZBIS stent graft is safe and feasible to preserve pelvic circulation with good patency and a low rate of device-related reintervention.

The use of polytetrafluoroethylene graft for damaged renal artery in ABO-incompatible living donor kidney transplantation: a case report.

Short donor renal vessels during donor nephrectomy represent a technical challenge. The allograft of vessels from deceased donors can be an option for reconstruction; however, cryopreserved vessels are not routinely prepared for living donor kidney transplantation (LDKT). We report a reconstruction of the damaged short renal artery (RA) in LDKT using a polytetrafluoroethylene (PTFE) graft. A 45-year-old male patient underwent ABO-incompatible LDKT from his wife. After donor nephrectomy, we detected a hematoma surrounding the proximal RA of the allograft. The injured segment of the RA was transected, and the short RA was connected to the right external artery of the recipient; however, the blood flow was interrupted by the graft location. Once the arterial anastomosis was removed, the graft was flushed with cold saline, and a PTFE graft was used for the reconstruction of the short RA. Immediate blood flow to the renal graft was excellent without sign of parenchymal infarction until fascial closure. Renal graft Doppler on postoperative day 7 and 3 months showed good blood flow. In this patient, the use of PTFE graft presented no additional morbidity to the kidney transplantation, and no postoperative complications related to its use were noted.

A multicenter randomized controlled trial of cyanoacrylate closure and surgical stripping for incompetent great saphenous veins.

OBJECTIVE: The treatment of varicose veins has shifted from conventional surgical stripping (SS) to minimally invasive endovenous modalities. Cyanoacrylate closure (CAC) with the VenaSeal system (Medtronic, Dublin, Ireland) has increased in popularity owing to its nonthermal and nontumescent technique. The purpose of the present study was to compare the clinical outcomes of CAC and SS for the treatment of incompetent great saphenous veins. METHODS: An open-label, multicenter, prospective, randomized controlled trial was conducted. The subjects were randomized to either the CAC or SS procedure. The primary endpoint of the present study was to evaluate complete closure of the target vein at 3 months. Target vein occlusion was assessed on the third day and 1, 3, 6, and 12 months postoperatively using duplex ultrasound. The pain and ecchymosis grades were also assessed. Additionally, the clinical outcomes, such as the venous clinical severity score and Aberdeen Varicose Vein Questionnaire score, were assessed. RESULTS: Three-month follow-up data were obtained for all 126 enrolled and randomized subjects (63 with CAC and 63 with SS). At 3 months, complete target vein closure was observed in both groups. The postoperative pain score was significantly better in the CAC group than in the SS group (0.3 ± 0.6 in the CAC group and 1.1 ± 1.5 in the SS group; P < .001). In addition, the mean ecchymosis grade was 0.3 ± 0.5 in the CAC group and 1.1 ± 1.1 in the SS group (P < .001). The venous clinical severity score and quality of life had improved equally in both groups. The adverse events after both procedures were mostly minor complications (9 events in CAC group and 20 events in SS group). Major complications occurred in one patient who had undergone the SS procedure. CONCLUSIONS: The CAC and SS procedures were both associated with complete occlusion of the target vein at 3 months. The postoperative pain and ecchymosis grades were significantly lower in the CAC group. Other differences between the two groups included the frequency and nature of the complications. The results showed that CAC has high success with few complications.

Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries.

PURPOSE: Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology. MATERIALS AND METHODS: Patients diagnosed with symptomatic SID-CA and SIDSMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed. RESULTS: Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period. CONCLUSION: Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SIDCA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

CASS (CyanoAcrylate closure versus Surgical Stripping for incompetent saphenous veins) study: a randomized controlled trial comparing clinical outcomes after cyanoacrylate closure and surgical stripping for the treatment of incompetent saphenous veins.

BACKGROUND: Several modalities are used for the treatment of varicose veins. Open surgical treatment with ligation and stripping of the saphenous vein has been the standard of care for many years. Endovenous thermal ablation has been shown to be a safe and effective alternative with high, long-term, target-vein closure rates. Despite this, there is the possibility of thermal injury to surrounding structures. The recently introduced cyanoacrylate closure is also considered to be a good alternative and the risk of injury to surrounding structures is minimal. The purpose of this study is to demonstrate the non-inferiority of cyanoacrylate closure with the VenaSeal™ closure system compared to surgical stripping in terms of clinical outcomes for the treatment of incompetent great saphenous veins. METHODS/DESIGN: This is an open-label, multicenter, prospective, randomized controlled trial evaluating the non-inferior clinical outcomes of cyanoacrylate closure compared to surgical stripping for the treatment of incompetent saphenous veins. After baseline measurements, participants will be randomly allocated into either the cyanoacrylate closure group or the surgical-stripping group. The primary endpoint of the study is the complete closure rate of the target vein in the cyanoacrylate closure group, and the absence of venous reflux or residual venous tissue after surgical stripping in the surgical-stripping group. These endpoints will be measured by Doppler ultrasound performed by qualified vascular technologists or investigators at 3 months after treatment. Secondary outcomes include perioperative pain, postoperative ecchymosis, clinical assessment (including general and disease-specific quality of life evaluations), complete closure rate, and absence of venous reflux or residual venous tissue at the 12- and 24-month follow-ups, as well as all adverse event rates during the 24-month follow-up period. DISCUSSION: This multicenter randomized controlled trial is designed to show non-inferiority in terms of complete closure rate of cyanoacrylate compared to surgical stripping for the treatment of incompetent saphenous veins. TRIAL REGISTRATION: Clinical Research Information Service (CRIS), ID: KCT0003203. Registered on 20 September 2018.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm.

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-yearold man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Clinical outcomes of the first 300 cases of kidney transplantation: a single-center retrospective cohort study.

Background: Kidney transplantation (KT) is regarded as the most effective treatment for end-stage renal disease. The annual number of KT cases in South Korea has increased rapidly as more centers are implementing a transplantation program. The objective of this study was to determine clinical outcomes of the first 300 consecutive cases of KT in a single center. Methods: Clinical data of 300 cases of KT at Seoul National University Bundang Hospital from January 2004 to March 2018 were obtained from a prospectively collected database and retrospectively reviewed. Results: The mean age of patients was 47.7±12.9 years, and 59% of patients were male. There were 225 living donors and 75 deceased donors. A total of 42 cases were from ABO-incompatible donors. During a mean follow-up of 68.6±43.5 months, 38 patients (12.7%) experienced rejection. The most common cause was acute T-cell mediated rejection (9.0%). Eighteen patients experienced graft loss. One-year and 5-year death-censored graft survival rates were 99% and 96.6%, respectively. One-year and 5-year patient survival rates were 98.3% and 96.6%, respectively. Multivariate analysis revealed that graft weight-to-recipient weight ratio and rejection were significant factors affecting graft survival. Conclusions: This single-center review demonstrates clinical outcomes comparable to other major centers. Such good outcomes were obtained by good patient selection, dedicated transplant physicians, and adequate use of immunosuppressive therapy.

Mid- to Long-Term Outcomes in Management of Spontaneous Isolated Coeliac Artery Dissection (SICAD).

OBJECTIVE: Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment. METHODS: Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed. RESULTS: The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period. CONCLUSION: Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.

Successful Treatment of Life-Threatening Small Bowel Bleeding With Thalidomide After Living Donor Kidney Transplantation: A Case Report.

Gastrointestinal bleeding after kidney transplantation is a complication that can occur from immunosuppressant use. We present a case of refractory small bowel bleeding treated successfully with thalidomide after multiple failed attempts of conventional treatment. A 65-year-old male patient with diabetic nephropathy underwent living donor kidney transplantation. The surgery was uneventful, however, he developed immunosuppressant-induced melena with unstable vital signs 11 days later. There were a total of 4 bleeding episodes until the 90th postoperative day, and he received a total of 290 units of red blood cell transfusion during this period. Endoscopic clipping, transarterial embolization, and 2 surgical interventions failed to stop the bleeding. A trial of thalidomide 100 mg per day finally stopped the bleeding and the patient was discharged on the 110th postoperative day with a functioning renal graft. This case shows that thalidomide can be a safe option to treat immunosuppressant-induced refractory gastrointestinal bleeding in the setting of kidney transplantation. Additionally, this is the first case that reports the survival of a renal graft after more than 3000 mL of transfusion.

Kynurenic acid attenuates pro-inflammatory reactions in lipopolysaccharide-stimulated endothelial cells through the PPARδ/HO-1-dependent pathway.

Kynurenic acid (KA) regulates energy homeostasis and alleviates inflammation in adipose tissue but how KA affects the atherosclerotic response in HUVECs remains unclear. We evaluated the effects of KA on lipopolysaccharide (LPS)-induced inflammation and apoptosis in HUVECs. KA enhanced peroxisome proliferator-activated receptor delta (PPARδ) expression in HUVECs and THP-1 cells and suppressed LPS-induced atherosclerotic responses through PPARδ-mediated signaling. Moreover, KA treatment mitigated LPS-induced phosphorylation of nuclear factor kappa B and pro-inflammatory cytokine release in HUVECs and THP-1 cells, and down-regulated adhesion molecules in HUVECs and adhesion of THP-1 cells to HUVECs following LPS treatment. KA treatment decreased LPS-induced inflammation and apoptosis, and also promoted heme oxygenase (HO)-1 expression, which suppresses inflammation in HUVECs. Suppression of PPARδ or HO-1 expression markedly mitigated the effects of KA on atherosclerotic responses in HUVECs. Thus, KA attenuates LPS-induced atherosclerotic responses by suppressing inflammation via the PPARδ/HO-1-dependent pathway.

Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases.

PURPOSE: Pseudoaneurysms after percutaneous vascular access are common and potentially fatal if left untreated. The aim of this study was to determine the incidence and risk factors associated with access site pseudoaneurysms after endovascular intervention for peripheral arterial disease (PAD) under a routine postintervention ultrasound (US) surveillance protocol. METHODS: A total of 254 PAD interventions were performed in a single center between January 2015 and November 2016, and puncture site duplex US surveillance was routinely performed within 48 hours of the procedure. Clinical, procedural and follow-up US data were analyzed. RESULTS: The overall incidence of pseudoaneurysm was 2.75% (6 cases in the femoral artery and 1 in the brachial artery). There was no difference between retrograde and antegrade approach, but there was a higher rate of pseudoaneurysm formation after manual compression compared to arterial closure device (ACD) use (4.3% vs. 0.87%). Manual compression was more commonly used for antegrade punctures (79.0%) and ACD for retrograde punctures (67.7%). Calcification was more frequently found in antegrade approach cases (46.8% vs. 16.9% for retrograde cases) and manual compression was preferred in its presence. All pseudoaneurysms were treated successfully at the time of diagnosis by US-guided compression repair and there were no cases of rupture. CONCLUSION: Pseudoaneurysm rates after therapeutic endovascular intervention for PAD were comparable to other cardiologic or interventional radiologic procedures despite the higher possibility of having a diseased access vessel. Routine US surveillance of access sites allowed for early diagnosis and noninvasive treatment of pseudoaneurysms, preventing potentially fatal complications.

Implementation of a resident night float system in a surgery department in Korea for 6 months: electronic medical record-based big data analysis and medical staff survey.

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.