Comparing Post-operative Pain and Other Outcomes in Carotid Endarterectomy Versus Transcarotid Artery Revascularization.

BACKGROUND: Transcarotid artery revascularization (TCAR) is growing in popularity. Although major clinical end-points such as stroke rate and mortality are well-known, patient reported outcomes such as pain, and length of stay are among the purported benefits that are as yet untested. We sought to determine if there are differences in pain and other clinical outcomes when comparing carotid endarterectomy (CEA) and TCAR. METHODS: We performed a retrospective review of 326 patients undergoing TCAR (n = 50) or CEA (n = 276) from 2019-2023. Primary outcomes of interest were maximum pain numeric rating scales (NRS) reported in the post-anesthesia care unit (PACU) and on postoperative days (POD) zero and 1, and oral morphine milligram equivalents (OMMEs) received intraoperatively through POD1. Secondary outcomes included length of stay (LOS), complications, and 30-day emergency department (ED) returns/readmissions. RESULTS: Fifty TCAR and 150 CEA patients were included in the propensity score matched cohorts. TCAR patients reported lower pain-NRS in PACU (P < .001) and on POD0 (P = .002), but similar pain scores on POD1 (P = .112). Postoperatively, TCAR patients were less likely to receive opioids (52% vs 75.3%, P = .003) and received less OMME from PACU through POD1 (12.8 ± 16.2 vs 23.2 ± 27.2, P = .001). After adjusting for age, sex, BMI, prior chronic opioid use, and prior carotid surgery, TCAR patients were approximately 70% less likely to receive post-operative opioids. No significant differences in LOS, 30-day ED returns/readmissions, or complications were observed between groups. CONCLUSIONS: Compared with CEA, patients undergoing TCAR reported lower pain scores and consumed fewer narcotics overall. However, the absolute difference was modest, and pain scores were low in both cohorts. Differences in pain and post-operative narcotic use may be of less importance when deciding between TCAR and CEA. Total non-opioid protocols may be feasible in both approaches.

Plasma Fibrinogen Change as a Predictor of Major Bleeding During Catheter-Directed Thrombolysis.

BACKGROUND: Our primary objective was to determine the relationship between plasma fibrinogen levels (PFLs) and major bleeding complications during catheter-directed thrombolysis, including final, nadir, and change over time. Furthermore, we sought to evaluate additional predictors of bleeding outcomes, including duration of lysis and total dose of tissue plasminogen activator received. METHODS: In this multicenter retrospective cohort study, we reviewed all patients undergoing catheter-directed thrombolysis between January 2016 and August 2021. Patients undergoing thrombolysis for management of peripheral arterial or venous thromboses, as well as for submassive pulmonary embolism, were included. We examined the relationships between PFLs during catheter-directed lysis and the incidence of major bleeding-that is significant hemorrhage requiring transfusion, intracranial hemorrhage, or hemorrhage requiring adjunctive procedures. We also examined the duration of lysis and total lytic agent dose received to assess for association with major bleeding. RESULTS: A total of 438 patients underwent catheter-directed lysis from January 1, 2016 through August 21, 2021, with a major bleeding rate of 16%. Patients who experienced major bleeding were more likely to be older (P = 0.022), experience in-stent thrombosis (P = 0.041), or have thrombosis in a lower extremity vessel (P = 0.011). There was no association between the incidence of major bleeding and a nadir PFL of <150 mg/dL (P = 0.194). Those who experienced major bleeding complications had a significantly greater decrease in PFL from baseline to nadir. This was true for both absolute (P = 0.029) and relative (P = 0.034) PFL decrease. Only percent decrease remained a significant predictor when adjusting for age, thrombosis type, and thrombosis location (P = 0.041). The PFL changes that were the best predictors of major bleeding complications were an absolute decrease of 146 mg/dL, or a relative decrease of 47%, giving a sensitivity and specificity of 71% and 48%, respectively. If neither were true, the negative predictive value for major bleeding was 89% regardless of absolute PFL. CONCLUSIONS: In this large, multicenter cohort, there does not appear to be an association between absolute PFL and major bleeding during catheter-directed lysis. Specifically, the typical absolute threshold of < 150 mg/dL was not an independent predictor of major bleeding. There was an association between percent-change in plasma fibrinogen and major bleeding, which aligns with the underlying physiologic mechanism of fibrinogen degradation coagulopathy. Applying a so-called "50-150 Rule" to catheter-directed lysis may decrease bleeding complications. That is, continued lysis should be re-evaluated if PFL drops by ≥150 mg/dL or by ≥50% from baseline regardless of absolute PFL.

Hybrid Approach for Treatment of a Symptomatic Giant Splenic Artery Aneurysm.

A 56-year-old female presented with a symptomatic giant fusiform mid-splenic artery aneurysm (7.3 x 6.4 cm). The patient underwent hybrid management of the aneurysm with endovascular embolization of the aneurysm and inflow splenic artery followed by laparoscopic splenectomy with control and division of the outflow vessels. The patient had an uneventful post-operative course. This case demonstrates the safety and efficacy of an innovative, hybrid management of a giant splenic artery aneurysm with endovascular embolization and laparoscopic splenectomy that spares the pancreatic tail.

Impact of inferior vena cava thrombus extension on thrombolysis for acute iliofemoral thrombosis.

BACKGROUND: Inferior vena cava (IVC) thrombosis may occur in patients with iliofemoral deep venous thrombosis (DVT), and its impact on thrombolysis outcomes is poorly defined. This study compared outcomes of patients undergoing thrombolysis for acute iliofemoral DVT with and without IVC involvement. METHODS: Patients who underwent thrombolysis for iliofemoral DVT between May 2007 and March 2014 were identified from a prospectively maintained database and divided into two groups: those with IVC involvement and those without. End points were technical and clinical success (≥50% lysis or freedom from 30-day DVT recurrence), long-term DVT recurrence, and post-thrombotic syndrome (PTS; Villalta score ≥5). Multivariate regression models were used to determine predictors of anatomic and clinical failures. RESULTS: There were 102 patients (127 limbs) treated with various combinations of catheter-directed or pharmacomechanical thrombolysis. In 46 patients, thrombus extended into the IVC (54.3% extended up to the renal veins; 87% had ≥50% luminal reduction; 50% occurred in association with an indwelling thrombosed IVC filter). The caval group had fewer women and more previous DVTs but otherwise was similar to the noncaval group. Pharmacomechanical thrombolysis was used more frequently in the caval thrombus group (97.8% vs 82.1%; P = .011), and iliac vein stenting was used more often in the noncaval group (41.3% vs 62.5%; P = .033). Clinical success was similar between the two groups (88.7% for caval vs 89.3% for noncaval; P = .921). All failures in the caval group occurred in patients with an indwelling thrombosed IVC filter. Primary patency at 2 years for the caval and noncaval groups was 76.7% and 78.0%, respectively (P = .787). Valve reflux and PTS at 2 years were higher in the noncaval group (50.8% and 34.3% vs 23.3% and 11.5% in the caval group; P = .013 and P = .035). On multivariate analysis, incomplete lysis was predictive of recurrence (hazard ratio [HR], 22.7; P < .001) and PTS (HR, 5.59; P = .010), whereas caval involvement (HR, 0.22; P = .005) was protective from PTS. CONCLUSIONS: IVC thrombosis does not have an impact on the technical success of thrombolysis in patients with iliofemoral DVT; the presence of a thrombosed IVC filter, though, may make failure more likely. Caval thrombosis may not affect primary patency but is associated with a lower incidence of PTS after successful lysis.

Contemporary outcomes of civilian lower extremity arterial trauma.

OBJECTIVE: Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation. METHODS: The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. RESULTS: We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. CONCLUSIONS: Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.

Endovascular management of symptomatic gastrointestinal complications associated with retrievable inferior vena cava filters.

OBJECTIVE: With the increase in retrievable inferior vena cava (IVC) filter use, a higher than expected reported rate of pericaval tine penetration is observed. Symptomatic gastrointestinal (GI) complications associated with retrievable IVC filters have been documented; however, their management remains controversial. We describe a series of GI complications of retrievable IVC filters, detailing the spectrum of presenting symptoms and multiple treatment options, including the safety of endovascular retrieval. METHODS: A retrospective chart review was performed to describe the presentation, diagnosis, and treatment of patients with symptomatic GI complications associated with retrievable IVC filters from 2008 to 2014. RESULTS: Nine patients had symptomatic GI complications associated with a retrievable IVC filter (two G2 Recovery [Bard Peripheral Vascular, Tempe, Ariz], seven Celect [Cook Medical, Bloomington, Ind]; six women; age range, 17-81 years). All patients had small bowel perforation on computed tomography scan, four confirmed by esophagogastroduodenoscopy. Concomitant aortic and vertebral penetration occurred in seven and five patients, respectively. Patients presented with various abdominal complaints; one patient presented in acute sepsis. Two patients underwent laparotomy without complications. The remaining seven patients had attempted endovascular retrieval, six of which were successful. One patient's IVC filter was unable to be retrieved, and he was managed medically. Of the six patients who had successful endovascular retrieval, all had resolution of their symptoms with no complications, except for transient sepsis in a single patient who was not receiving periprocedural antibiotics. A follow-up computed tomography scan was performed 48 to 72 hours after endovascular retrieval and ruled out duodenal leak in all patients. Long-term follow-up demonstrated continued resolution of GI symptoms without further episodes of deep venous thrombosis or pulmonary embolism. CONCLUSIONS: GI complications of retrievable IVC filters are manifested with a wide spectrum of symptoms and frequent concomitant aortic and vertebral penetration. Endovascular retrieval can be safely used as a first-line therapy even in the setting of small bowel and aortic penetration.

Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions.

OBJECTIVE: Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. METHODS: Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. RESULTS: Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45-87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. CONCLUSIONS: Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.

CT-guided injection of N-butyl cyanoacrylate glue for treatment of chylous leak after aorto-mesenteric bypass.

Lymphangiography and thoracic duct embolization are well-described techniques for the diagnosis and treatment of thoracic lymphatic leaks refractory to conservative treatment. However, thoracic duct embolization is not an option in patients with abdominal chylous leaks. The present report describes a 68-year-old man who underwent an aortomesenteric bypass complicated by a high-output postoperative chylothorax (>2,000 ml/day) and chylous ascites (>7,000 ml/paracentesis). Ultrasound-guided intranodal lymphangiography demonstrated a retroperitoneal lymphatic leak tracking along the vascular graft into the peritoneal cavity. Computed tomography-guided lymphatic duct occlusion with N-butyl cyanoacrylate glue was performed, resulting in successful treatment of both chylothorax and chylous ascites.

Anatomic and functional outcomes of pharmacomechanical and catheter-directed thrombolysis of iliofemoral deep venous thrombosis.

OBJECTIVE: Pharmacomechanical thrombolysis (PMT) and catheter-directed thrombolysis (CDT) are commonly used for the treatment of iliofemoral deep venous thrombosis (DVT). The purpose of this study was to examine the short- and long-term venous patency and venous valvular function as well as clinical outcomes of patients treated for iliofemoral DVT by PMT and CDT. METHODS: A retrospective review of all patients with symptomatic DVT treated between 2006 and 2011 with PMT or CDT was performed. All patients were treated by local tissue plasminogen activator delivered with PMT or CDT. Patients were divided into two groups on the basis of initial treatment modality: patients treated by PMT alone (group 1), and those who underwent PMT and CDT or CDT alone (group 2). Group comorbidities, initial presenting symptoms, and Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification scores were compared. Postprocedural duplex ultrasound was used to assess valve function and treated vein patency rates. At all visits, Villalta and CEAP scores were recorded and compared. Group demographic and procedural results were analyzed by Fisher exact test for dichotomous variables and Kruskal-Wallis equality-of-populations rank test for the ordinal and continuous data. Kaplan-Meier survival estimates were used to assess preserved valve function as well as primary and secondary patency rates. RESULTS: There were 79 patients with 102 limbs treated for extensive iliofemoral DVT (median age, 51.5 years; range, 16.6-83.8 years). There were 18 patients in group 1 and 61 patients in group 2 (PMT + CDT [n = 54] or CDT alone [n = 7]). There were no differences in demographics or comorbidities between groups aside from malignant disease, which was more common in group 1 (35.3% vs 11.5%; P = .03). A total of 102 limbs were analyzed, 24 in group 1 and 78 in group 2. Patients in group 1 had a shorter symptom duration compared with group 2 (7 days vs 16 days; P = .011). The median number of procedures in group 1 was lower than in group 2 (P < .001). At last clinical follow-up, there was no significant difference between the Villalta and CEAP scores or the rate of clinical improvement in symptoms between groups. By Kaplan-Meier analysis, there was no difference in primary patency, secondary patency, and treated valve function at 48 months. CONCLUSIONS: This study suggests that PMT as a stand-alone therapy is as effective as CDT with or without PMT in preserving valve function and preventing postthrombotic syndrome. Long-term physiologic and functional outcomes are comparable between the modalities, with preserved venous valve function in the majority of patients.

Inferior vena cava filter placement during thrombolysis for acute iliofemoral deep venous thrombosis.

OBJECTIVE: The objectives of this study were to evaluate the need for inferior vena cava (IVC) filters and to identify anatomic and patient-specific risk factors associated with embolization in patients undergoing thrombolysis for acute iliofemoral deep venous thrombosis (DVT). METHODS: Consecutive patients who underwent catheter-directed thrombolysis or pharmacomechanical thrombolysis (PMT) for iliofemoral DVT from May 2007 to March 2012 were identified from a prospectively maintained database. Patients were categorized in two groups, depending on the status of IVC filtration during the lysis procedures: patients with an IVC filter protection (group A) and patients without an IVC filter protection (group B). The primary outcome was perioperative clinically significant pulmonary embolism (PE) or intraprocedural IVC filter clot capture. RESULTS: Eighty patients (mean age, 50 ± 16 years; 39 women) with symptoms averaging 12 ± 10 days were treated. A perioperative IVC filter was placed in 32 patients, and nine patients had an indwelling patent filter (group A, n = 41). Twenty patients received no filter, and 19 patients had an indwelling thrombosed filter (group B, n = 39). There were no clinically significant PE in either group. In group A, nine patients (22%) had documented embolic clot within the filter nest. The clot volume was deemed clinically significant in only two patients (5%). Factors related to embolization included female gender (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.038-32.797; P = .032) and preoperative clinical PE (OR, 5.6; 95% CI, 1.043-30.081; P = .054). A trend for increased embolization was seen with a higher average number of DVT risk factors (1.44 vs 1; P = .065) and when PMT was used as a single treatment (OR, 4.32; 95% CI, 0.851-21.929; P = .087). CONCLUSIONS: IVC filters during thrombolysis should be used selectively in patients with preoperative clinical PE, in women and potentially in patients with multiple risk factors for DVT, or when stand-alone PMT is planned.

Inflow thrombosis does not adversely affect thrombolysis outcomes of symptomatic iliofemoral deep vein thrombosis.

OBJECTIVE: The presence of popliteal or tibial vein clot is thought to adversely affect thrombolysis for iliofemoral deep vein thrombosis (DVT). We examined the effect of inflow thrombosis on functional and anatomic outcomes. METHODS: Data for 44 patients treated for symptomatic iliofemoral DVT between 2006 and 2009 were retrospectively reviewed. All patients were treated by pharmacomechanical thrombectomy with local lytic therapy. Catheter-directed lysis and vena cava filters were used sparingly. Univariate and multivariate logistic regression analyses were used. The independent variable used in the logistic regression model was symptom relief. RESULTS: Forty-four patients (mean age, 52.1 ± 15.8 years) presented with symptoms averaging 13.4 ± 9.9 days in duration. Twenty (45.4%) had symptoms for >14 days. Seventeen patients were treated in one session, but 27 patients required lytic infusion for residual thrombus. Iliac stenting was required in 49% of limbs. Successful lysis (>50%) was achieved in 91% of patients, and symptom resolution or improvement in 91%. All patients became ambulatory, with no or minimal limitation. No major systemic bleeding complications occurred. Freedom from DVT recurrence and reintervention was 84% at 24 months by life-table analysis. Preoperative ultrasound imaging showed 89% had popliteal and tibial clots. A thrombosed popliteal vein was accessed for treatment and was corroborated by venographic findings. One patient required simultaneous tibial lysis. At a mean follow up of 8.7 ± 6.3 months, 41 patients (93%) had no symptom recurrence, 82% had preserved valve function and no reflux on duplex imaging, with a mean CEAP class of 1.4 and Villalta score of 3.3. Inflow thrombus had no adverse effect on symptom relief, treatment duration, patency, CEAP class, or valve reflux. Interestingly, 90% of patients with initial popliteal thrombus had a patent popliteal vein on postlysis ultrasound imaging, and the presence of tibial thrombus on presentation was predictive of symptom relief with thrombolysis (odds ratio, 13.03; 95% confidence interval, 1.02-165.58; P = .048). CONCLUSIONS: Inflow thrombosis is common and does not preclude successful thrombolysis of iliofemoral DVT. Valve function is preserved on midterm follow-up, with maintained CEAP class and symptom relief.

Comparison of modern open infrarenal and pararenal abdominal aortic aneurysm repair on early outcomes and renal dysfunction at one year.

OBJECTIVE: This study was conducted to review contemporary results of elective open infrarenal abdominal aortic aneurysm (IAAA) and pararenal abdominal aortic aneurysm (PAAA) repairs and determine predictors of death and acute and 1-year renal dysfunction (RD). METHODS: A retrospective review identified 432 consecutive patients undergoing open IAAA (233 patients) or PAAA (184 patients) repair between January 2000 and December 2007. Demographic, preoperative, intraoperative, and postoperative variables were collected. RD was defined as an increase in creatinine of ≥ 0.5 mg/dL from baseline. Multiple logistic regression models were used to identify predictors of mortality and RD. RESULTS: Mortality rates were similar between the groups (3.9% IAAA and 6.0% PAAA). Preoperative coronary artery disease (CAD), postoperative myocardial infarction, or pulmonary complications were all strong predictors of operative mortality in patients undergoing repair of PAAAs and IAAAs. However, neither PAAA nor baseline renal insufficiency was an independent predictor of death. Postoperative RD occurred in 32% of patients after PAAA repairs compared with 13% of patients after IAAA repairs (P < .001). The presence of PAAA, baseline hypertension, and hyperlipidemia all correlated positively with postoperative RD, while a trend was noted with baseline renal insufficiency (P = .09). At the 1-year follow-up, 5.1% of patients in the PAAA group had RD compared with none in the IAAA group. Similarly, the serum creatinine level was significantly higher in the PAAA group (1.4 mg/dL vs 1.2 mg/dL, PAAA and IAAA, respectively; P = .02) at 1 year. However, there were no instances of new-onset hemodialysis dependence at 1 year. Mean follow-up was 2.2 years overall. CONCLUSION: Open PAAA repair can be performed without a significant increase in mortality compared to open IAAA repair. Although the incidence of renal function deterioration after open PAAA repairs remains higher than with open IAAA repairs, the overall incidence remains low at 1-year follow-up.

Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations.

BACKGROUND: Gallstones appear more frequently in patients with cirrhosis and open cholecystectomy in this patient population is associated with higher morbidity and mortality. The aim of the present study was to evaluate experience with laparoscopic cholecystectomy in patients with cirrhosis and to provide recommendations for management. METHODS: Retrospective review of laparoscopic cholecystectomy in patients with cirrhosis from March 1999 to May 2008 was performed. Peri-operative characteristics and subgroup analysis were performed in patients with Child-Pugh's classes A, B and C cirrhosis. RESULTS: A total of 68 patients were reviewed in this study. In all, 69% of the patients were Child's class A. The most common indication for cholecystectomy was chronic/symptomatic cholelithiasis (68%). Compared with patients with Child's class B and C, laparoscopic cholecystectomy in patients with Child's class A was associated with significantly decreased operative time (P= 0.01), blood loss (P= 0.001), conversion to open cholecystectomy (P= 0.001) and length of hospital stay (P= 0.001). CONCLUSIONS: Laparoscopic cholecystectomy in patients with cirrhosis is feasible with no mortality and low morbidity, especially in patients with Child's class A cirrhosis.

Late collapse of a thoracic endoprosthesis.

Thoracic stent graft collapse is a rare complication of thoracic endovascular aortic repair that is mostly asymptomatic and occurs ≤ 3 months of the procedure. We describe the case of a 36-year-old man who presented with symptomatic endograft collapse 38 months after an initial thoracic endovascular aortic repair that was performed for traumatic aortic transection. He had sudden and complete loss of bilateral lower extremity motor and sensory functions (spinal cord ischemia) and anal sphincter tone. The patient was successfully treated with redo thoracic endovascular aortic repair, followed by open conversion and device explantation.

Bradyarrhythmias during rheolytic pharmacomechanical thrombectomy for deep vein thrombosis.

PURPOSE: To explore possible mechanisms of bradycardia occurring during rheolytic pharmacomechanical thrombectomy (PMT) for deep venous thrombosis (DVT) and to propose a treatment algorithm for this phenomenon. METHODS: Intraoperative anesthesia records, operative notes, and hospital records of 57 patients treated with the AngioJet rheolytic thrombectomy device for DVT over a 3-year period were retrospectively reviewed. Of the 57 patients, 7 (12.3%) patients (5 women; mean age 67 years, range 23-78) experienced bradyarrhythmias: 2 had a brief period of asystole and 5 patients experienced sinus bradycardia, 4 of which had >1 episode. All patients were in normal sinus rhythm (NSR) preoperatively, and only 2 had underlying coronary disease. RESULTS: The AngioJet device was located in the infrarenal inferior vena cava in over half of the patients and in other peripheral venous beds in the others when the bradyarrhythmias occurred. Five of 7 patients reverted to NSR with cessation of the device alone, while 2 required a dose of atropine in addition. External pacing was not required, and all patients did well postoperatively. Since sinus bradycardia resolved immediately upon cessation of the device in all cases, the theory that adenosine (a product of hemolysis affecting conduction) plays an important role is called into question. Stretch receptor activation in the right heart from cyclical high-pressure gradients generated by the device may play a more important role mechanistically. CONCLUSION: The occurrence of bradyarrhythmias during peripheral venous use of the AngioJet device is poorly described in the literature. Routine pre-treatment with various agents is not recommended during use of the device in peripheral venous beds as the incidence of bradyarrhythmias appears to be very low, with no defined mechanism of onset.

Recurrent laryngeal nerve injury following uncomplicated carotid angioplasty and stenting.

PURPOSE: To describe a unique instance of cranial nerve injury related to uncomplicated carotid artery stenting (CAS). CASE REPORT: A 74-year-old woman with a history of expressive aphasia and right upper/lower extremity weakness underwent staged CAS procedures under local anesthesia and conscious sedation. After routine predilation with a 4-mm balloon, a tapered 7 x 10 x 30-mm Acculink stent was placed and dilated with a 5-mm balloon. At 1 month after the second procedure, the carotid stents were patent bilaterally, but the patient reported voice fatigue and hoarseness along with dysphagia to liquids that started 2 days after her second procedure. Brain scans ruled out stroke. Direct laryngoscopy showed left vocal cord paralysis and a mobile right vocal cord; computed tomography revealed adduction of the left vocal cord consistent with a left recurrent laryngeal nerve injury. Radiography did not show any evidence of stent fracture. Electromyography was suggestive of right recurrent laryngeal nerve paralysis and only mild abnormalities on the left. A repeat laryngoscopy performed 4 months after the initial evaluation revealed persistent left vocal fold paralysis and no abnormalities on the right. The patient was referred for voice therapy; at 18 months, the stents were patent, and her vocal symptoms had significantly improved. CONCLUSION: While minimally invasive endovascular techniques evolve for management of vascular disease, the anatomical structures at risk during open procedures may be injured with endovascular approaches as well.

Preactivation of NKT cells with alpha-GalCer protects against hepatic ischemia-reperfusion injury in mouse by a mechanism involving IL-13 and adenosine A2A receptor.

Hepatic preconditioning has emerged as a promising strategy of activating natural pathways to augment tolerance to liver ischemia-reperfusion (IR) injury. Liver-resident natural killer T (NKT) cells play an important role in modulating the local immune and inflammatory responses. This work was aimed to investigate whether preactivation of NKT cells could provide a beneficial "preconditioning" effect to ameliorate the subsequent hepatic IR injury. To selectively activate NKT cells, C57BL/6 mice were treated intraperitoneally with the glycolipid antigen alpha-galactosylceramide (alpha-GalCer) 1 h prior to hepatic ischemia. Significantly reduced liver IR injury was observed in mice pretreated with alpha- GalCer, and this protective effect was specifically abrogated by a CD1d blocking antibody. Serum TNF-alpha, IFN-gamma, and IL-13 levels were markedly increased shortly after alpha-GalCer injection. Pretreatment with a neutralizing antibody against TNF-alpha or IFN-gamma did not influence the protective effect of alpha-GalCer preconditioning, whereas preadministration of an IL-13 neutralizing antibody completely abolished the effect. Treatment with alpha-GalCer also led to an increased expression of adenosine A2A receptor (A2AR) in the liver, and blockade of A2AR by SH58261 diminished alpha-GalCer pretreatment-mediated attenuation of liver IR injury. In contrast, administration of the selective A2AR agonist CGS21680 reversed the counteracting effect of the IL-13 neutralizing antibody on alpha-GalCer preconditioning. Additionally, alpha-GalCer pretreatment was associated with a decreased neutrophil accumulation in the ischemic liver. These findings provide the first evidence that hepatic preconditioning by preactivation of NKT cells with alpha-GalCer protects the liver from IR injury via an IL-13 and adenosine A2AR-dependent mechanism.

Technical challenges and utility of anterior exposure for thoracic spine pathology.

BACKGROUND: Thoracic surgeons are frequently called upon to provide exposure to the anterior cervicothoracic, thoracic, and proximal lumbar spine. We reviewed our surgical experience and the perioperative outcomes of these spinal approaches. Relevant technical and anatomic considerations of each procedure are highlighted. METHODS: A total of 213 patients (116 female, 97 male) undergoing anterior thoracic spinal exposures over an 11-year period at a single institution were analyzed. Primary endpoints include morbidity, mortality, and perioperative outcomes. RESULTS: Mean age was 53.7 years. Surgical approaches were determined based on the location and length of spinal involvement, and included cervicothoracic (5), thoracotomy (117), and thoracoabdominal (91) techniques. Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08). Procedures for infection were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001) and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy. CONCLUSIONS: The increased use of anterior approaches to spinal pathology necessitates greater involvement by thoracic surgeons. Familiarity with the anatomic and technical features of the anterior spinal exposure is required by thoracic surgeons to optimize surgical outcomes.

Noninvasive radiofrequency ablation of cancer targeted by gold nanoparticles.

INTRODUCTION: Current radiofrequency ablation (RFA) techniques require invasive needle placement and are limited by accuracy of targeting. The purpose of this study was to test a novel non invasive radiowave machine that uses RF energy to thermally destroy tissue. Gold nanoparticles were designed and produced to facilitate tissue heating by the radiowaves. METHODS: A solid state radiowave machine consisting of a power generator and transmitting/receiving couplers which transmit radiowaves at 13.56 MHz was used. Gold nanoparticles were produced by citrate reduction and exposed to the RF field either in solutions testing or after incubation with HepG2 cells. A rat hepatoma model using JM-1 cells and Fisher rats was employed using direct injection of nanoparticles into the tumor to focus the radiowaves for select heating. Temperatures were measured using a fiber-optic thermometer for real-time data. RESULTS: Solutions containing gold nanoparticles heated in a time- and power-dependent manner. HepG2 liver cancer cells cultured in the presence of gold nanoparticles achieved adequate heating to cause cell death upon exposure to the RF field with no cytotoxicity attributable to the gold nanoparticles themselves. In vivo rat exposures at 35 W using direct gold nanoparticle injections resulted in significant temperature increases and thermal injury at subcutaneous injection sites as compared to vehicle (water) injected controls. DISCUSSION: These data show that non invasive radiowave thermal ablation of cancer cells is feasible when facilitated by gold nanoparticles. Future studies will focus on tumor selective targeting of nanoparticles for in vivo tumor destruction.

Arginase blockade protects against hepatic damage in warm ischemia-reperfusion.

BACKGROUND: Liver ischemia reperfusion (I/R) injury is associated with profound arginine depletion due to arginase release from injured hepatocytes. Nitric oxide (NO), shown to have protective effects in I/R, is produced by nitric oxide synthase (NOS) from the substrate arginine. The purpose of this study was to determine if nor-NOHA, a novel arginase inhibitor, would be able to increase circulating arginine levels and decrease hepatic damage following warm I/R. METHODS: C57BL/6 mice underwent partial liver warm I/R and were treated intraperitoneally with either nor-NOHA (100mg/kg) or saline. Serum and tissue samples were collected to measure liver enzyme levels, amino acids, and inflammatory mediators. The agent nor-NOHA (100mg/kg) was administered 15 min before ischemia and immediately after reperfusion. Serum amino acid analysis was performed using HPLC. RESULTS: Arginase activity after hepatic I/R peaked at 3-6h after reperfusion and resulted in a 10-fold drop in circulating arginine levels. Treatment with nor-NOHA inhibited arginase activity and reversed the arginine depletion after I/R while simultaneously increasing serum nitric oxide. In addition, circulating citrulline, a product of NOS activity, was increased in nor-NOHA-treated animals compared to controls. Inhibition of arginase also resulted in protection from hepatic I/R-induced damage in association with markedly lower hepatic TNF, IL-6, and inducible NOS mRNA levels compared to controls. CONCLUSION: Arginase blockade represents a potentially novel strategy to combat liver injury under conditions of arginine deficiency. This protection may be mediated through the arginine-NO pathway.