Radiology Environmental Impact: What Is Known and How Can We Improve?

The healthcare sector generates approximately 10% of the total carbon emissions in the United States. Radiology is thought to be a top contributor to the healthcare carbon footprint due to high energy-consuming devices and waste from interventional procedures. In this article, we provide a background on Radiology's environmental impact, describe why hospitals should add sustainability as a quality measure, and give a framework for radiologists to reduce the carbon footprint through quality improvement and collaboration.

Differences in Aortic Diameter Measurements with Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury.

BACKGROUND: Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) as computed tomography (CT) in injured patients may inaccurately determine the true aortic diameter. We hypothesize that CT and IVUS offer discordant measurements of aortic diameter in trauma patients and that each modality may result in different graft size estimates for TEVAR. METHODS: Patients treated by TEVAR for blunt aortic injury from June 2011 to 2016 were reviewed. Cases where IVUS was not used and those without complete CT and IVUS images were excluded. Three-dimensional reconstructions were used to derive centerline diameters of the aorta, proximal and distal to the injury. IVUS diameters were taken from the flow lumen, not including the aortic wall itself. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) with patients with discordant diameters (group 2). RESULTS: A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (±18), and 12 of the patients were men. The median time from injury to CT was 2.5 hr (0.9-8.5) and to TEVAR was 18 (3-48) hr. Stent graft diameter for implantation based on CT and IVUS imaging was the same in 5 cases (group 1). In 11 cases, the graft diameter for implantation based on IVUS was differently sized compared with that determined by CT (group 2). Ten diameters were 1 size larger, and 1 diameter was 1 size smaller by IVUS. There were no significant differences in the mean lowest systolic blood pressure (98 vs. 92, P = 0.53), median fluid resuscitation in the first 24 hr (4.9 vs. 5.0 L, P = 0.97), or median 24-hr transfusion requirements (130 vs. 1311 mL, P = 0.11) between the groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from the CT than from IVUS (9 vs. 2). CONCLUSIONS: The TEVAR has become the standard therapy for blunt aortic injury, despite a dearth of long-term outcome data. The preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. The implications of placing thoracic endografts and whether excessive oversizing results in long-term aortic dilation need to be the focus of long-term studies in these relatively young patients.

Hybrid Approach to Aneurysms of the Pancreaticoduodenal Artery Associated with Occlusion of the Celiac Axis.

Pancreaticoduodenal artery aneurysms are uncommon but often associated with occlusion or absence of the celiac axis. This anatomic alteration makes management decisions challenging. Presented here are 2 cases of incidentally identified aneurysms, treated with a hybrid approach.

Western Vascular Society guidelines for transfer of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: When a patient with ruptured abdominal aortic aneurysm (rAAA) presents at a facility ill-equipped to provide care, transfer may provide the best chance for survival. Large distances and long travel times provide challenging barriers to prompt and appropriate care in the western United States. METHODS: The Western Vascular Society (WVS) adopted a set of guidelines in considering transfer of a patient with an rAAA using published literature, membership survey and input, and existing recommendations. This article reports the guidelines and describes the process and rationale behind their development. RESULTS: Fifteen guidelines for transfer and care of rAAAs were endorsed by the WVS. CONCLUSIONS: When local care cannot be provided, transfer guidelines may standardize care for rAAAs and may be applicable across may practice settings.

Successful Reconstruction of Asymptomatic Bilateral External Carotid Artery Aneurysms.

True aneurysms of the external carotid artery (ECA) are extremely rare with an unknown incidence and natural history. We present the successful operative management of an asymptomatic 65-year-old man found to have bilateral internal carotid artery stenosis and bilateral ECA aneurysms. His bilateral carotid arteries were reconstructed with bifurcated interposition grafts in a staged fashion. The patient recovered without sequelae and continues to be asymptomatic 1 year after reconstruction. We present the operative management of this rare case.

Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database.

OBJECTIVES: Female gender has been shown to negatively affect the outcomes of surgical bypass for peripheral arterial disease (PAD). We examined gender-related disparities in outcomes of endovascular PAD procedures in a large population-based study. METHODS: We used discharge data from California hospitals to identify patients who had PAD interventions during 2005 to 2009. Logistic regression was used for 12-month reintervention, and Cox proportional hazard regression was used for amputation-free survival comparisons. RESULTS: A total of 25 635 patients had endovascular procedures (11 389 [44.4%] women). Women were more likely than men (34.5% vs 30.1%, P < .0001) to have critical limb ischemia (CLI). Twelve-month reintervention rate in women was similar to men. Amputation-free survival was better among women than men (hazard ratio 0.84, 95% confidence interval [CI] 0.76-0.93, P = .0006). CONCLUSION: Despite presenting more frequently with CLI, women had better amputation-free survival than men following endovascular procedures. Future research should determine whether findings favor one type of PAD treatment modality over another for women.

Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease.

OBJECTIVE: Although smoking cessation is recommended for all patients with peripheral artery disease, there are little data regarding the prevalence of smoking among patients at the time of angiography or the effect of smoking cessation on clinical outcomes. METHODS: Consecutive patients with claudication or critical limb ischemia who underwent peripheral angiography from 2006 to 2013 were included in an observational cohort analysis. Smoking status was assessed at the time of angiography and during follow-up clinic visits. Kaplan-Meier analysis was used to assess the relationship between smoking cessation, mortality, and amputation-free survival. RESULTS: Among 739 patients (423 men and 316 women; mean age, 60 ± 12 years), 204 (28%) remained active smokers at the time of lower extremity angiography. At the time of angiography, the mean number of cigarettes smoked per day was 16 ± 10, and the mean pack-years was 40 ± 25. During the course of the subsequent year, 61 patients (30%) successfully quit smoking and maintained continued abstinence. Baseline medication use between groups did not differ significantly. The mean ankle-brachial index was also similar for quitters vs nonquitters (0.53 ± 24 vs 0.49 ± 0.22; P = .3). During follow-up to 5 years, patients who quit smoking had significantly lower all-cause mortality (14% vs 31%; hazard ratio, 0.40; 95% confidence interval, 0.18-0.90) and improved amputation-free survival (81% vs 60%; hazard ratio, 0.43, 95% confidence interval, 0.22-0.86) compared with patients who continued smoking, with most of the difference driven by reduced mortality among patients who quit smoking. The findings remained significant on multivariable analysis. CONCLUSIONS: Approximately one-third of active smokers with peripheral artery disease successfully quit smoking ≤ 1 year after lower extremity angiography. Patients who quit smoking have lower mortality and improved amputation-free survival compared with patients who continue smoking.

Endovascular therapy is effective treatment for focal stenoses in failing infrapopliteal vein grafts.

BACKGROUND: To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. METHODS: We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance. RESULTS: Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. CONCLUSIONS: In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.

Octogenarians develop infrapopliteal arterial occlusive disease in the absence of traditional risk factors.

BACKGROUND: With increasing longevity, a growing proportion of patients who present with lower extremity peripheral arterial disease (LE-PAD) are ≥80 years old. While smoking and diabetes mellitus (DM) have traditionally been the main risk factors associated with PAD, we noted a pattern of severe infrapopliteal PAD in patients ≥80 years old in the absence of these traditional risk factors. As recognition of patterns of disease affects decisions regarding diagnostic and therapeutic approach, we sought to confirm this observation. METHODS: A single-center retrospective review was performed on all patients who underwent lower extremity arteriography between March 2007 and September 2009. Arteriograms were scored in a blinded fashion. Any infrapopliteal PAD was defined as one or more infrapopliteal arteries with either >50% stenosis or total occlusion. Severe infrapopliteal PAD was defined as 2 or more infrapopliteal arteries with >50% stenosis or total occlusion. Fisher's exact test and 2-sample t-test or Wilcoxon rank-sum test were used for analysis. RESULTS: Two hundred ninety-seven patients comprised the study population. Eighty-two percent (= 145/176) of those ≤70 years old versus 96% (= 46/48) of those ≥80 years old had any infrapopliteal PAD (P = 0.02). Thirty percent of patients ≥80 years old with infrapopliteal PAD had no history of DM or smoking, while only 5% of younger patients had infrapopliteal PAD in the absence of DM or smoking (P < 0.0001). A similar pattern was seen for severe infrapopliteal PAD. Tissue loss was an indication for lower extremity arteriography in 45% of those ≤70 years of age versus 65% of those ≥80 (P = 0.022). CONCLUSIONS: A significant proportion of patients ≥80 years of age with PAD develop arterial disease in the infrapopliteal pattern in the absence of the traditional risk factors of smoking and DM. Our data also showed that this pattern of disease is significantly associated with tissue loss and critical limb ischemia, particularly in patients ≥80 years of age. Primary care providers need to be educated to suspect ischemic etiology for foot pain and ulcers in elderly patients not otherwise thought to have risk factors associated with PAD. Vascular specialists need to anticipate this pattern of disease when planning interventions. As smoking becomes less prevalent and as the population ages, octogenarians with severe infrapopliteal arterial occlusive disease will become a larger proportion of the patients treated by vascular specialists.

Nitinol self-expanding stents vs. balloon angioplasty for very long femoropopliteal lesions.

PURPOSE: To compare the patency rates and clinical outcomes of balloon angioplasty vs. nitinol stent placement for patients with short (≤150 mm) as compared to long (>150 mm) femoropopliteal (FP) occlusive lesions. METHODS: Between 2006 and 2011, 254 patients (134 men; mean age 68 years) underwent FP angioplasty. The majority of patients (64%) were treated for critical limb ischemia. One hundred thirty-nine (55%) patients had short FP lesions ≤150 mm, while 115 patients had long FP lesions >150 mm. The mean lesion length was 78±43 mm in the short FP lesion group and 254±58 mm in the long FP lesion group. Duplex ultrasound follow-up with a peak systolic velocity ratio ≥2.0 was used to define restenosis. RESULTS: The overall procedure success rate was 98%. One hundred forty-eight (58%) patients underwent stent placement. The mean number of stents deployed for treatment of short FP lesions was 1.0±0.4 vs. 2.0±0.7 for long FP lesions (p<0.001). The primary patency rate of short FP lesions treated with balloon angioplasty vs. stenting was 66% vs. 63% at 1 year (p=0.7). For long FP lesions, the 1-year primary patency rates of balloon angioplasty vs. stenting were 34% vs. 49% (p=0.006). Balloon angioplasty of long FP lesions was also associated with significantly lower assisted primary and secondary patency compared to stenting (p<0.05 for all comparisons). Sustained clinical improvement was >90% at 30 days but declined to 62% to 75% at 1 year. CONCLUSION: Balloon angioplasty and stent placement result in similar patency rates and clinical outcomes for shorter to medium-length FP lesions. In comparison, stent placement in long FP lesions is associated with superior outcomes to balloon angioplasty, even when multiple stents are required. Procedure success and clinical improvement can be achieved in the majority of patients, but rates of restenosis remain high.

Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia.

BACKGROUND: Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. METHODS: All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. RESULTS: A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P < .001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P = .02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). CONCLUSIONS: Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.

The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States.

BACKGROUND: Aortic infections, even with treatment, have a high mortality and risk of recurrent infection and limb loss. Cryopreserved aortoiliac allograft (CAA) has been proposed for aortic reconstruction to improve outcomes in this high-risk population. METHODS: A multicenter study using a standardized database was performed at 14 of the 20 highest volume institutions that used CAA for aortic reconstruction in the setting of infection or those at high risk for prosthetic graft infection. RESULTS: Two hundred twenty patients (mean age, 65; male:female, 1.6/1) were treated since 2002 for culture positive aortic graft infection (60%), culture negative aortic graft infection (16%), enteric fistula/erosion (15%), infected pseudoaneurysm adjacent to the aortic graft (4%), and other (4%). Intraop cultures indicated infection in 66%. Distal anastomosis was to the femoral artery and iliac. Mean hospital length of stay was 24 days, and 30-day mortality was 9%. Complications occurred in 24% and included persistent sepsis (n = 17), CAA thrombosis (n = 9), CAA rupture (n = 8), recurrent CAA/aortic infection (n = 8), CAA pseudoaneurysm (n = 6), recurrence of aortoenteric fistula (n = 4), and compartment syndrome (n = 1). Patients with full graft excision had significantly better outcomes. Ten (5%) patients required allograft explant. Mean follow-up was 30 ± 3 months. Freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. Primary graft patency was 97% at 5 years, and patient survival was 75% at 1 year and 51% at 5 years. CONCLUSIONS: This largest study of CAA indicates that CAA allows aortic reconstruction in the setting of infection or those at high risk for infection with lower early and long-term morbidity and mortality than other previously reported treatment options. Repair with CAA is associated with low rates of aneurysm formation, recurrent infection, aortic blowout, and limb loss. We believe that CAA should be considered a first line treatment of aortic infections.

Association between statin medications and mortality, major adverse cardiovascular event, and amputation-free survival in patients with critical limb ischemia.

OBJECTIVES: The aim of this study was to determine the associations between statin use and major adverse cardiovascular and cerebrovascular events (MACCE) and amputation-free survival in critical limb ischemia (CLI) patients. BACKGROUND: CLI is an advanced form of peripheral arterial disease associated with nonhealing arterial ulcers and high rates of MACCE and major amputation. Although statin medications are recommended for secondary prevention in peripheral arterial disease, their effectiveness in CLI is uncertain. METHODS: We reviewed 380 CLI patients who underwent diagnostic angiography or therapeutic endovascular intervention from 2006 through 2012. Propensity scores and inverse probability of treatment weighting were used to adjust for baseline differences between patients taking and not taking statins. RESULTS: Statins were prescribed for 246 (65%) patients. The mean serum low-density lipoprotein (LDL) level was lower in patients prescribed statins (75 ± 28 mg/dl vs. 96 ± 40 mg/dl, p < 0.001). Patients prescribed statins had more baseline comorbidities including diabetes, coronary artery disease, and hypertension, as well as more extensive lower extremity disease (all p values <0.05). After propensity weighting, statin therapy was associated with lower 1-year rates of MACCE (stroke, myocardial infarction, or death; hazard ratio [HR]: 0.53; 95% confidence interval [CI]: 0.28 to 0.99), mortality (HR: 0.49, 95% CI: 0.24 to 0.97), and major amputation or death (HR: 0.53, 95% CI: 0.35 to 0.98). Statin use was also associated with improved lesion patency among patients undergoing infrapopliteal angioplasty. Patients with LDL levels >130 mg/dl had increased HRs of MACCE and mortality compared with patients with lower levels of LDL. CONCLUSIONS: Statins are associated with lower rates of mortality and MACCE and increased amputation-free survival in CLI patients.

Angiographic characteristics of femoropopliteal in-stent restenosis: association with long-term outcomes after endovascular intervention.

OBJECTIVES: The purpose of this study was to identify the relationship between angiographic patterns of restenosis and outcomes after endovascular treatment of femoro-popliteal in-stent restenosis (FP-ISR). BACKGROUND: ISR is a frequent clinical problem after femoro-popliteal stenting. METHODS: This was a single center study of all endovascular interventions for FP-ISR from 2006 to 2012. Class I ISR was defined as focal lesions ≤50 mm; Class II ISR as lesions > 50 mm; and Class III ISR as stent chronic total occlusion. Recurrent ISR was defined as peak systolic velocity ratio > 2.4 by duplex ultrasound. RESULTS: Among 75 cases of FP-ISR, 28 (37%) were Class I, 22 (29%) were Class II, and 25 (33%) were Class III. The mean lesion length was 26 mm for Class I, 135 mm for Class II, and 178 mm for Class III ISR. Patients with Class III ISR more frequently had ISR extending into both the superficial femoral and popliteal artery (48% vs. 18%, P = 0.005). Balloon angioplasty was used most frequently to treat Class I ISR, while adjunctive atherectomy and/or stenting was used for almost all cases of Class III ISR. During 2-year follow-up, rates of repeat restenosis were 39% for Class I, 67% for Class II, and 72% for Class III ISR (P = 0.04). Rates of stent occlusion were 8% for Class I, 11% for Class II, and 52% for Class III ISR (P = 0.009). Class III ISR was associated with significantly increased risk of recurrent ISR (HR 2.4, 95% CI 1.1-5.6) and recurrent occlusion (HR 5.8, 95% CI 1.8-19.0) compared to other types of ISR. CONCLUSION: Angiographic patterns of FP-ISR are important determinants of subsequent outcomes. Repeat restenosis and occlusion remain common despite currently available technologies.

Mid-term outcomes following endovascular re-intervention for iliac artery in-stent restenosis.

OBJECTIVES: We sought to evaluate the procedural characteristics and clinical outcomes of endovascular repair for iliac artery (IA) in-stent restenosis (ISR). BACKGROUND: An increasing percentage of patients with complex IA occlusive disease are treated with an endovascular approach, but the outcomes of IA-ISR have not been well described. METHODS: We analyzed all endovascular procedures for treatment of IA-ISR performed at our institution between July 2006-December 2010. The primary outcome was primary patency, defined as <50% stenosis as assessed by clinical examination and duplex ultrasonography (DUS). RESULTS: Forty-one lesions in 24 patients who underwent repeated endovascular intervention for treatment of IA-ISR. Most lesions were unilateral and involved the common IA (66%). The mean length of ISR was 30.1 ± 14.1 mm with type I (focal) and II (diffuse) ISR occurring with the greatest frequency (34% and 39%, respectively). All patients underwent balloon angioplasty; adjunctive stenting zwas performed in 27 (66%) of the lesions. Type II ISR lesions more frequently required stenting (13/16 lesions, P = 0.02 compared with other patterns of ISR). Procedural success was 100% with a mean gain of 0.13 in the ankle-brachial index (P = 0.001). The 6- and 12-month primary patency rates were 96% and 82%, respectively. The 12-month primary-assisted patency rate was 90% with clinically driven target lesion revascularization (TLR) in three patients. CONCLUSIONS: Endovascular treatment of IA-ISR using an approach of balloon angioplasty followed by selective stenting is associated with high-patency rates and low rates of TLR at 1 year.

Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization.

OBJECTIVE: Currently, there are no well-established duplex ultrasound (DUS) criteria for the evaluation of the mesenteric arteries after stenting for occlusive disease. Previous studies suggested DUS velocity criteria in the native superior mesenteric artery (SMA) overestimate stenosis in stented arteries, but most studies have not evaluated DUS imaging after SMA stenting longitudinally. This study was undertaken to determine the accuracy of DUS after mesenteric artery revascularization and, in particular, to evaluate the utility of DUS imaging for the detection of in-stent stenosis (ISS) of the SMA. METHODS: A retrospective record review was performed for all patients who underwent SMA stenting for chronic mesenteric ischemia at a single institution from January 2004 to May 2011. RESULTS: Mesenteric artery occlusive disease resulted in 24 patients undergoing mesenteric stenting of the SMA alone (n = 20) or the SMA and celiac artery simultaneously (n = 3). The mean ± standard deviation peak systolic velocity (PSV) in 13 prestent DUS images of the SMA was 464 ± 130 cm/s. Prestenting angiography revealed an average SMA stenosis of 79% ± 14%. After stenting, completion angiography in each case revealed <20% residual stenosis. No significant correlation was identified between SMA PSV and angiographic stenosis before and after stenting (P > .05). Follow-up SMA DUS imaging showed an average PSV of 335 ± 138 cm/s at 0.9 ± 1.5 months, 360 ± 143 cm/s at 4.8 ±2.6 months, and 389 ± 95 cm/s at 14.4 ± 5.1 months. A significant difference existed between the prestent and the first poststent mean SMA PSV (P < .05), but no significant difference existed between each poststenting interval. Eight reinterventions for SMA ISS were performed, with a mean elevated in-stent SMA PSV of 505 ± 74 vs 341 ± 145 cm/s in patients who did not undergo reintervention. Angiography before the eight reinterventions demonstrated an average SMA ISS of 53% ± 25%. In-stent SMA PSV decreased from 505 ± 74 to 398 ± 108 cm/s after the reintervention (P < .05). CONCLUSIONS: Consistent with other reports, our data demonstrate the PSV in successfully stented SMAs remains higher than the PSV threshold of 275 cm/s used for the diagnosis of high-grade native SMA stenosis. In addition, in-stent SMA PSVs did not significantly change over DUS surveillance for patients who did not undergo reintervention. Thus, obtaining a baseline DUS early after mesenteric stenting should be considered to compare future surveillance DUS. An increase above this baseline or an in-stent SMA PSV approaching 500 cm/s should be considered suspicious for ISS, but larger prospective studies will be required to validate these preliminary findings.

Y chromosome gene expression in the blood of male patients with ischemic stroke compared with male controls.

BACKGROUND: Sex is suggested to be an important determinant of ischemic stroke risk factors, etiology, and outcome. However, the basis for this remains unclear. The Y chromosome is unique in males. Genes expressed in males on the Y chromosome that are associated with stroke may be important genetic contributors to the unique features of males with ischemic stroke, which would be helpful for explaining sex differences observed between men and women. OBJECTIVE: We compared Y chromosome gene expression in males with ischemic stroke and male controls. METHODS: Blood samples were obtained from 40 male patients ≤3, 5, and 24 hours after ischemic stroke and from 41 male controls (July 2003-April 2007). RNA was isolated from blood and was processed using Affymetrix Human U133 Plus 2.0 expression arrays (Affymetrix Inc., Santa Clara, California). Y chromosome genes differentially expressed between male patients with stroke and male control subjects were identified using an ANCOVA adjusted for age and batch. A P < 0.05 and a fold change >1.2 were considered significant. RESULTS: Seven genes on the Y chromosome were differentially expressed in males with ischemic stroke compared with controls. Five of these genes (VAMP7, CSF2RA, SPRY3, DHRSX, and PLCXD1) are located on pseudoautosomal regions of the human Y chromosome. The other 2 genes (EIF1AY and DDX3Y) are located on the nonrecombining region of the human Y chromosome. The identified genes were associated with immunology, RNA metabolism, vesicle fusion, and angiogenesis. CONCLUSIONS: Specific genes on the Y chromosome are differentially expressed in blood after ischemic stroke. These genes provide insight into potential molecular contributors to sex differences in ischemic stroke.

Direct insertion of Amplatzer plugs to control lumbar arteries during open repair of type II endoleaks.

Type II endoleak after endovascular repair of an infrarenal aortic aneurysm (EVAR) may be difficult to diagnose and treat in the best of circumstances. Management is more difficult in the patient with significant renal insufficiency. We report an 81-year-old man with stage IV chronic kidney disease and a rapidly expanding, asymmetric aortic aneurysm sac, 31 months after EVAR. A type II lumbar endoleak was diagnosed by duplex ultrasound imaging and managed successfully with open aortic exposure and direct insertion of Amplatzer plugs into two bleeding lumbar arteries due to complex anatomic factors.