Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis.

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Endovascular treatment of popliteal artery aneurysms has comparable long-term outcomes to open repair with shorter lengths of stay.

OBJECTIVE: During the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. Although open surgical repair (OR) has remained the reference standard for treatment, endovascular repair (ER) has become an attractive alternative for select patient populations. The objective of the present study was to compare the outcomes of OR vs ER of PAAs at a single institution. METHODS: We performed a retrospective review of the medical records for all patients who had undergone repair for PAAs from 1998 to 2017. The baseline patient, anatomic, and operative characteristics and outcomes were compared between the OR and ER cohorts. Intervention and treatment were at the discretion of the surgeon. RESULTS: From 1998 to 2017, 64 patients had undergone repair of 73 PAAs at our tertiary care center. Of the 69 patients (73 PAAs), 29 (33 PAAs) had undergone OR and 35 (40 PAAs) had undergone ER. When comparing the two cohorts, no statistically significant differences were found in the demographic characteristics such as age, gender, or number of runoff vessels. Significantly more patients in the ER group (n = 21; 53%) than in the OR group (n = 7; 21%) had had hyperlipidemia (P = .008) and a previous carotid intervention (6% vs 0%; P = .029). Overall, the presence of symptoms was similar between the two groups. However, the OR group had a significantly higher number of patients who had presented with acute ischemia (P = .01). The length of stay was significantly shorter for the ER cohort (mean, 1.8 days; range, 1-11 days) than for the OR group (mean, 5.4 days; range, 2-13 days; P < .0001). No significant difference was found in the primary or secondary patency rates between the two groups. In the ER group, good runoff (two or more vessels) was a positive predictor for primary patency at 1 year (odds ratio, 3.36; 95% confidence interval, 1.0-11.25). However, it was not in the OR group. Postoperative single and/or dual antiplatelet therapy did not affect primary patency in either cohort. CONCLUSIONS: The results of our study have demonstrated that ER of PAAs is a safe and durable option with patency rates comparable to those with OR and a decreased length of stay, with good runoff a positive predictor for primary patency in the ER cohort.

Natural History, Clinical Significance, and the Role of Vascular Referral in the Management of Penetrating Ulcers of the Abdominal Aorta.

BACKGROUND: Penetrating ulcers of the abdominal aorta (PUAA) are an increasingly common finding on abdominal imaging studies; however, their significance and natural history are not well described. This study's objective was to analyze the demographics, presentation, and outcomes of patients with a radiographic diagnosis of PUAA. MATERIALS AND METHODS: Patients at our tertiary referral center were identified for inclusion based on a search for the term "penetrating ulcer" in abdominal computed tomography and magnetic resonance imaging reports between January 2014 and December 2017. Patients' electronic medical records were retrospectively reviewed to determine baseline medical characteristics, imaging indication, and subsequent clinical course, interventions, and outcomes. Aortic diameters and ulcer depths were measured by a single observer on initial and follow-up imaging to assess for association with concomitant aortic pathology, evolving aortic disease, and ulcer progression, defined as increase in depth of ≥ 1 mm. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC), and a threshold P-value of <0.05 was set for significance. RESULTS: Ninety-two patients with PUAA were identified; 57 (62%) were male. The mean age at diagnosis was 79.3 years, and comorbidities included hypertension (74%), hyperlipidemia (65%), and malignancy (34%). The most common indication for imaging was chest, back, or abdominal pain (19%). On initial imaging, the mean ulcer depth was 1 cm (range from 0.2 cm to 3.4 cm). Concomitant abdominal aortic dilation ≥ 3 cm was found in 34 (37%) patients. Thirty-six (39%) patients had a vascular surgery consultation immediately after radiographic diagnosis. Follow-up axial imaging was performed on 27 (29%) untreated patients. The overall sample's mean ulcer depth remained essentially unchanged from initial measurement (P = 0.99); however, 14 (52%) patients with follow-up imaging were found to have increased overall aortic diameter. Of the total 92 patients, 9 (10%) underwent an endovascular abdominal aortic intervention during the review period: 2 for symptomatic PUAA and the remainder for progression of concomitant aneurysmal disease. All-cause mortality was 5% during the mean follow-up period of 21.9 months (range 0 to 72.5 months). Of the patients lost to follow-up, 61% did not receive vascular referral after initial diagnosis. CONCLUSIONS: PUAA are typically incidental findings identified in elderly, comorbid patients undergoing imaging for an unrelated indication. Although isolated findings of asymptomatic PUAA rarely require surgical intervention, these patients we argue would benefit from vascular surgery referral for long-term follow-up and interval imaging to assess for disease progression and concomitant aortic degeneration, which may necessitate repair. In addition, we observed that most of those patients lost to follow-up did not receive vascular consultation, suggesting that lack of involvement of vascular specialists at the time of diagnosis is a missed opportunity to secure appropriate follow-up and management.

Repair of Isolated Innominate Artery Pathology with a Modified Endovascular Graft.

Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology.

Lapatinib, a dual EGFR and HER2 kinase inhibitor, selectively inhibits HER2-amplified human gastric cancer cells and is synergistic with trastuzumab in vitro and in vivo.

PURPOSE: HER2 amplification occurs in 18% to 27% of gastric and gastroesophageal junction cancers. Lapatinib, a potent ATP-competitive inhibitor simultaneously inhibits both EGFR and HER2. To explore the role of HER family biology in upper gastrointestinal cancers, we evaluated the effect of lapatinib, erlotinib, and trastuzumab in a panel of molecularly characterized human upper gastrointestinal cancer cell lines and xenografts. EXPERIMENTAL DESIGN: EGFR and HER2 protein expression were determined in a panel of 14 human upper gastrointestinal cancer cell lines and HER2 status was assessed by fluorescent in situ hybridization. Dose-response curves were generated to determine sensitivity to lapatinib, erlotinib, and trastuzumab. In HER2-amplified cells, the combination of trastuzumab and lapatinib was evaluated using the median effects principal. The efficacy of lapatinib, trastuzumab, or the combination was examined in HER2-amplified xenograft models. RESULTS: Lapatinib had concentration-dependent antiproliferative activity across the panel with the greatest effects in HER2-amplified cells. There was no association between EGFR protein expression and sensitivity to any of the HER-targeted agents. Cell cycle analysis revealed that lapatinib induced G(1) arrest in sensitive lines and phosphorylated AKT and phosphorylated ERK were decreased in response to lapatinib as well. The combination of lapatinib and trastuzumab was highly synergistic in inhibiting cell growth with a combination index of <1. The combination also induced greater decreases in AKT and ERK activation, G(0)-G(1) cell cycle arrest, and increased rates of apoptosis. In vivo studies showed that the combination of lapatinib and trastuzumab had greater antitumor efficacy than either drug alone. CONCLUSION: Together, these data suggest that lapatinib has activity in HER2-amplified upper gastrointestinal cancer and supports the ongoing clinical investigation of lapatinib in patients with HER2-amplified disease.