The effect of donor graft type on survival after liver transplantation for hepatoblastoma in children.

BACKGROUND: Liver transplantation (LT) is the only potentially curative option for children with unresectable hepatoblastoma (HBL). Although post-transplant outcomes have improved in the contemporary era, the impact of donor graft type on survival remains unclear. METHODS: Using the United Network for Organ Sharing database (02/2002-06/2021), demographics, clinical characteristics, and patient and graft survival were analyzed in children (<18 years) who underwent LT for HBL according to donor graft type. The Kaplan-Meier method, log-rank tests, and Cox regression modeling were used to evaluate the effect of whole, partial, and split deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) on patient and graft survival. RESULTS: A total of 590 pediatric HBL LT recipients (344 whole graft DDLT; 62 partial graft DDLT; 139 split graft DDLT; 45 LDLT) were included. During 2012-2021 the proportion of LDLTs for HBL decreased to about 5% compared with about 11% during 2002-2011. No significant differences were identified by donor graft type in either patient survival (log-rank test, p = .45) or graft survival (log-rank test, p = .69). The results remained similar during the 2002-2011 era, while during the 2012-2021 era, split graft DDLT was associated with decreased graft loss risk versus whole graft DDLT (hazard ratio: 0.48, 95% confidence interval: 0.23-0.99, p = .046) without any other significant between-group differences. CONCLUSIONS: Utilizing non-whole liver grafts can increase access to LT in children with unresectable HBL while ensuring favorable outcomes. LDLT is underutilized in children with HBL in the United States, and efforts to explore LDLT options should be undertaken.

Fibrinolysis resistance after liver transplant as a predictor of early infection.

BACKGROUND: Infection is a leading cause of morbidity in liver transplant (LT). Considering that the fibrinolytic system is altered in sepsis, we investigated the relationship between fibrinolysis resistance (FR) and post-transplant infection. METHODS: Fibrinolysis was quantified using thrombelastography (TEG) with the addition of tPA to quantify FR. FR was defined as LY30 = 0% and stratified as transient if present on POD1 or POD5 (tFR), persistent (pFR) if present on both, or no FR (nFR) if absent. RESULTS: 180 LT recipients were prospectively enrolled. 52 (29%) recipients developed infection. 72 had tFR; 37 had pFR; and 71 had nFR. Recipients with pFR had significantly greater incidence of infections (51% vs. 26% tFR vs. 20% nFR, p = 0.002). pFR was independently associated with increased odds of post-transplant infection (adjusted OR 3.39, p = 0.009). CONCLUSIONS: Persistent fibrinolysis resistance is associated with increased risk of post-transplant infection.

Access to Left Ventricular Assist Device: Travel Time Does Not Tell The Whole Story.

BACKGROUND: Negative health effects of traveling longer distances for surgical services have been reported. Given the high complexity of multidisciplinary care required for management of Left Ventricular Assist Device (LVAD) implantation, only 4 of 18 centers in our state perform these operations. Given the limited access we hypothesized increased travel time would adversely affect postoperative outcomes and 30-d mortality. METHODS: A statewide Society of Thoracic Surgeons database was queried to identify patients undergoing Heartmate II/III and HVAD implantation, and 725 patients were identified. Travel time was calculated by zip code. Patients were stratified into regional and distant groups by the upper quartile of travel time (1-h). Preoperative variables and outcomes were compared between the groups. Multivariate analysis was performed to evaluate the impact of travel time in risk-adjusted models of 30-d mortality. RESULTS: Median patient travel time to their LVAD center in our state is 32 min (mean 53 ± 65 min, 46 ± 71 miles). Patients in the distant group (n = 191) had lower median incomes, higher self-pay status, higher rates of medical comorbid disease. Despite these differences there was no difference between the groups in ICU and/or hospital length of stay, readmission, postoperative complications, or 30-d mortality. Multivariate regression demonstrated insurance status, age, and prior surgery predicted 30-d mortality, but not travel time. CONCLUSIONS: Despite only four centers in the state performing LVAD implantation, travel time was strongly associated with preoperative risk, and socioeconomic status but not postoperative outcomes or 30-d mortality. Therefore, increasing access should focus on insurance, and patient characteristics not travel time.

Liver Transplantation With Grafts From Super Obese Donors.

There are limited data on liver transplant (LT) outcomes with grafts from super obese donors. The present study aims to evaluate a unique cohort of recipients following LT using grafts from donors with body mass index (BMI) ≥50. METHODS: Patients receiving grafts from donors with BMI ≥50 and BMI <50 from 2010 to 2019 were identified. A 1:2 case-control match was conducted to compare outcomes between the groups. Survival was analyzed using the Kaplan-Meier curves. RESULTS: Six hundred sixty-five adult LTs were performed in the study period. Eighteen patients receiving a graft from a donor with BMI ≥50 were identified and matched to 36 patients receiving a graft from a donor with BMI <50. Grafts from male donors were significantly lower in the donor BMI ≥50 group when compared with the donor BMI <50 group (16.7% versus 66.7%, P = 0.001). Liver biopsy was performed in 77.8% of grafts in the donor BMI ≥50 group, whereas only in 38.8% of the grafts in the donor BMI <50 group (P = 0.007). Recipients in the donor BMI ≥50 group had a significantly higher diagnosis rate of hepatocellular carcinoma pretransplant versus the donor BMI <50 group (38.9% versus 8.3%, respectively; P = 0.006). Major complications within 30 d did not differ statistically between groups. Biliary complications within the first 30 d were equal among groups (16.7%). Subanalysis comparing the super obese donor group versus the nonobese donor group showed no differences in terms of postoperative complications, readmission rate, graft rejection, or major complications including the need for reoperation, retransplantation, or mortality. Graft and patient survival at 1-, 3-, and 5-y graft were similar between the donor BMI ≥50 group versus donor BMI <50 group (94%/89%/89% versus 88%/88%/88%, P = 0.89, and 94%/94%/94% versus 88%/88%/88%, P = 0.48, respectively). CONCLUSIONS: LT with carefully selected grafts from super obese donors can be safely performed with outcomes comparable with non-super obese donor livers. Therefore, these types of grafts could represent a safe means to expand the donor pool.

Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia.

The objective of this study is to describe utilization of revascularization and tissue resection in patients with chronic limb-threatening ischemia (CLTI) and determine whether the timing of resection impacts outcomes. Revascularizations for CLTI were queried (ACS-NSQIP 2011-2015). Outcomes included 30-day major adverse limb events (MALE), major adverse cardiac events (MACE), length of stay (LOS), operative time, 30-day readmissions, and wound infections. Groups included revascularization alone, revascularization/tissue resection during the same procedure (concurrent), or revascularization/delayed tissue resection (delayed). Resections were debridement or transmetatarsal amputations. Multivariate logistic regression determined risk-adjusted effects of tissue resection on outcomes. There was no difference in overall 30-day MACE or MALE between groups (P = .70 and P = .35, respectively). Length of stay (6.1 days revascularization alone vs 7.8 days concurrent vs 8.7 days delayed, P < .0001) was longer in patients who underwent any tissue resection. Highest 30-day readmission and operative time was the concurrent group (P = .02 and P < .0001, respectively). Wound infection was highest in the delayed group (1.4% revascularization alone vs 1.3% concurrent vs 6.2% delayed, P < .0001). After risk adjustment, timing of resection did not impact LOS for concurrent and delayed groups compared to revascularization alone (both P < .0001). Debridement and minor amputations can be done concurrently in patients undergoing revascularization for CLTI.

Sex-Based Differences Among Experimental Swine Abdominal Aortic aneurysms.

BACKGROUND: Female sex protects against abdominal aortic aneurysms (AAAs); however, the mechanisms behind these sex-based differences remain unknown. The purpose of this study was to explore the role of sex and sex hormones in AAA formation among swine. MATERIALS AND METHODS: Using a previous validated model, infrarenal AAA were surgically created in uncastrated male (n = 8), female (n = 5), and castrated male (n = 4) swine. Aortic dilation was measured on postoperative day 28 during the terminal procedure and compared to initial aortic diameter measured during the index procedure. Tissue was analyzed for immunohistochemistry, cytokine array, gelatin zymography, serum 17ß-estradiol, and testosterone assay. RESULTS: Uncastrated males had significantly larger maximal aortic dilation compared to castrated males (113.5% ± 11.4% versus 38.1% ± 4.5%, P = 0.0012). Females had significantly higher mean aortic dilation compared to castrated males (96.2% ± 7.5% versus 38.1% ± 4.5%, P = 0.0004). Aortic diameters between females and uncastrated males were not significantly different on day 28. Female swine had significantly higher concentrations of 17ß-estradiol compared with uncastrated males (1590 ± 873.3 ng/mL versus 95.2 ± 2.3 ng/mL, P = 0.047), with no significant difference between females and castrated males. Uncastrated male AAA demonstrated significantly more elastin degradation compared with female and castrated males (P = 0.01 and <0 .01, respectively). No differences existed for T-cells or smooth muscle cells between groups. Multiple proinflammatory cytokines were elevated within uncastrated male aortic walls compared to females and castrated males. CONCLUSIONS: Sex hormones, specifically 17ß-estradiol and testosterone, influence experimental swine AAA formation as demonstrated by increased aneurysm size, collagen turnover, and elastolysis in uncastrated males in processes reflective of human disease.

Expanding the donor pool for liver transplantation with marginal donors.

The current supply of acceptable donor livers is not sufficient to meet the demands of listed patients awaiting transplantation resulting in thousands of deaths each year. Increased utilization of marginal livers may help alleviate this supply/demand mismatch by expanding the donor liver pool. The current status of liver transplantation using marginal donor grafts and efforts to optimize usage are discussed with attention to elderly donors, steatotic livers, donors after circulatory death, and split liver grafts.

Female Mice Exhibit Abdominal Aortic Aneurysm Protection in an Established Rupture Model.

BACKGROUND: Male gender is a well-established risk factor for abdominal aortic aneurysm (AAA), whereas estrogen is hypothesized to play a protective role. Although rupture rates are higher in women, these reasons remain unknown. In the present study, we sought to determine if female mice are protected from AAA rupture. MATERIALS AND METHODS: Apolipoprotein E-deficient male and female mice (aged 7 wk; n = 25 per group) were infused with angiotensin II (AngII; 2000 ng/kg/min) plus ß-aminopropionitrile (BAPN) in the drinking water for 28 d to test the effects of gender on AAA rupture. Separately, a second group of male apolipoprotein E-deficient mice underwent AngII infusion + BAPN while being fed high-fat phytoestrogen free or a high-fat phytoestrogen diet to assess effects of phytoestrogens on rupture. In a third group, female mice either underwent oophorectomy or sham operation 4 wk before infusion of AngII and BAPN to further test the effects of female hormones on AA rupture. Surviving mice abdominal aorta were collected for histology, cytokine array, and gelatin zymography on postoperative day 28. RESULTS: Female mice had decreased AAA rupture rates (16% versus 46%; P = 0.029). Female mice expressed fewer elastin breaks (P = 0.0079) and decreased smooth muscle cell degradation (P = 0.0057). Multiple cytokines were also decreased in the female group. Gelatin zymography demonstrated significantly decreased pro-matrix metalloproteinase 2 in female mice (P = 0.001). Male mice fed a high dose phytoestrogen diet failed to decrease AAA rupture. Female mice undergoing oophorectomy did not have accelerated aortic rupture. CONCLUSIONS: These data are the first to attempt to tease out hormonal effects on AAA rupture and the possible role of gender in rupture.

Porcine Model of Infrarenal Abdominal Aortic Aneurysm.

Large animal models to study abdominal aortic aneurysms are sparse. The purpose of this model is to create reproducible, clinically significant infrarenal abdominal aortic aneurysms (AAA) in swine. To achieve this, we use a combination of balloon angioplasty, elastase and collagenase, and a lysyl oxidase inhibitor, called ß-aminopropionitrile (BAPN), to create clinically significant infrarenal aortic aneurysms, analogous to human disease. Noncastrated male swine are fed BAPN for 7 days prior to surgery to achieve a steady state in the blood. A midline laparotomy is performed and the infrarenal aorta is circumferentially dissected. An initial measurement is recorded prior to aneurysm induction with a combination of balloon angioplasty, elastase (500 units)/collagenase (8000 units) perfusion, and topical elastase application. Swine are fed BAPN daily until terminal procedure on either postoperative day 7, 14, or 28, at which time the aneurysm is measured, and tissue procured. BAPN + surgery pigs are compared to pigs that underwent surgery alone. Swine treated with BAPN and surgery had a mean aortic dilation of 89.9% ± 47.4% at day 7, 105.4% ± 58.1% at day 14, and 113.5% ± 30.2% at day 28. Pigs treated with surgery alone had significantly smaller aneurysms compared to BAPN + surgery animals at day 28 (p < 0.0003). The BAPN + surgery group had macroscopic and immunohistochemical evidence of end stage aneurysmal disease. Clinically significant infrarenal AAA can be induced using balloon angioplasty, elastase/collagenase perfusion and topical application, supplemented with oral BAPN. This model creates large, clinically significant AAA with hallmarks of human disease. This has important implications for the elucidation of AAA pathogenesis and testing of novel therapies and devices for the treatment of AAA. Limitations of the model include variation in BAPN ingested by swine, quality of elastase perfusion, and cost of BAPN.

Clinical Characteristics and Longitudinal Outcomes of Primary Mycotic Aortic Aneurysms.

Medical therapy for mycotic aortic aneurysms (MAA) is almost universally fatal, while surgical and endovascular repair carry high morbidity and mortality. The purpose of this study was to compare outcomes between patients receiving treatment for MAA. Records were obtained and patients with MAA were stratified by intervention: endovascular repair, open surgery, and medical therapy. Primary outcomes were aneurysm-related mortality and survival. Risk-adjusted associations with mortality were assessed using time-to-event analysis. Thirty-eight patients were identified (median age, 67). Twenty-one underwent endovascular repair,10 had open surgery and 7 received medical therapy alone. Overall mortality was 47% (n = 18), with 94% aneurysm related. Median survival was significantly longer in the endovascular group (747.0 [161-1249]) vs open surgery and medical therapy (507.5 [34-806] and 66 [13-146] days, respectively; P = .02). The endovascular group had significantly fewer perioperative complications (43% vs 80%, P < .01). However, 4 endovascular patients experienced reinfection versus no open surgery patients. Mortality risk factors included medical therapy (hazard ratio [HR]: 5.3, P < .01) and aneurysm size (HR: 1.4 per 1-cm increase in diameter, P = .03). Endovascular repair of MAA was associated with the best long-term survival and lowest perioperative complication rate, although it is associated with greater reinfection. These tradeoffs should be considered when selecting which procedure is best for a patient.

Preoperative beta blockade is associated with increased rates of 30-day major adverse cardiac events in critical limb ischemia patients undergoing infrainguinal revascularization.

OBJECTIVE: The association between beta blockers and cardiovascular or limb-related outcomes after revascularization for critical limb ischemia (CLI) remains unclear. The objective of this study was to assess the impact of preoperative beta blockade on 30-day major adverse cardiac events (MACEs) and major adverse limb events (MALEs) in patients undergoing infrainguinal revascularization for CLI. We hypothesized that rates of MALEs and MACEs will be higher in patients not receiving preoperative beta blockade. METHODS: The National Surgical Quality Improvement Program vascular targeted file for 2011 to 2014 identified patients receiving beta blockade and undergoing infrainguinal endovascular intervention and open bypass for CLI. Primary outcomes including 30-day MACE (stroke, myocardial infarction [MI], or death) and MALE (untreated loss of patency, reintervention, or amputation) were compared between patients taking and not taking preoperative beta blockers. Multivariate logistic regression identified independent predictors of MACEs and MALEs. RESULTS: A total of 11,785 revascularizations were performed for CLI during the study period (7408 bypasses vs 4377 endovascular interventions). Preoperative beta blockers were used by 7365 patients, including 4541 (61.7%) in the open bypass cohort and 2824 (64.5%) in the endovascular group (P < .01). MACEs and MI were significantly higher in patients with preoperative beta blockers (MACEs, 5.8% vs 3.4% [P < .0001]; MI, 3.1% vs 1.8% [P < .0001]). After controlling for cardiac risk factors, beta blockers independently predicted MACEs (odds ratio [OR], 1.27; P = .03) and MI (OR, 1.36; P = .03) but not stroke (OR, 1.17; P = .58) or 30-day mortality (OR, 1.22; P = .19). Beta-blocker use did not have an effect on MALEs (OR, 0.99; P = .88). CONCLUSIONS: In patients with CLI, preoperative beta blockade was an independent predictor of 30-day MI and MACEs after controlling for other cardiovascular risk factors. Beta blockers did not have an impact on short-term limb-related outcomes. The association between beta blockade and revascularization for CLI deserves further investigation.

Increased warm ischemia time during vessel harvest decreases the primary patency of cryopreserved conduits in patients undergoing lower extremity bypass.

OBJECTIVE: Autologous vein is the preferred conduit for lower extremity bypass. However, it is often unavailable because of prior harvest or inadequate for bypass owing to insufficient caliber. Cryopreserved cadaveric vessels can be used as conduits for lower extremity revascularization when autogenous vein is not available and the use of prosthetic grafts is not appropriate. Many studies have shown that donor characteristics influence clinical outcomes in solid organ transplantation, but little is known regarding their impact in vascular surgery. The purpose of this study was to examine the effects donor variables have on patients undergoing lower extremity bypass with cryopreserved vessels. METHODS: The tissue processing organization was queried for donor blood type, warm ischemia times (WITs), and serial numbers of cryopreserved vessels implanted at a single center from 2010 to 2016. The serial numbers were then matched with their respective patients using the institutional Clinical Data Repository and patient data were obtained from the Clinical Data Repository and chart review. Primary outcomes were primary patency of the bypass conduits and limb salvage. Time to loss of patency was evaluated using Kaplan-Meier methods and a Cox proportional hazards model determined risk-adjusted predictors of patency and limb salvage. RESULTS: Sixty patients underwent lower extremity bypass with 65 cryopreserved vessels (23 superficial femoral arteries, 41 saphenous veins, 1 femoral vein). Thirty-eight procedures were reoperations. There were 21 inflow, 44 outflow, and 44 infrainguinal procedures. Preexisting comorbidities did not differ significantly between those who lost patency and those who did not. The mean WIT among the entire cohort was 892.3 ± 389.1 minutes (range, 158.0-1434.0 minutes). The median follow-up was 394 days. Kaplan-Meier analysis demonstrated an overall 1-year primary patency rate of 51%. Primary patency at 1 year was 67% and 41% for inflow and outflow procedures, respectively, and did not differ significantly between the two groups (P = .15). Donor-to-recipient ABO incompatibility was not associated with loss of primary patency. The 1-year amputation-free survival was 74%. Primary patency significantly decreased with each hourly increase in WIT on risk-adjusted analysis (hazard ratio, 1.1; P = .02). CONCLUSIONS: Higher cryopreserved vessel WIT was associated with increased risk-adjusted loss of primary patency in this cohort. At 1 year, the overall primary patency was 51% and amputation-free survival was 74%. Vascular surgeons should be aware that WIT may affect outcomes for lower extremity bypass.

A Comparison of Outcomes After Lower Extremity Bypass and Repeat Endovascular Intervention Following Failed Previous Endovascular Intervention for Critical Limb Ischemia.

The optimal approach for repeat revascularization after failed endovascular intervention for critical limb ischemia (CLI) is unclear. This study compared major adverse limb events (MALEs) and major adverse cardiac events (MACEs) between lower extremity bypass (LEB) and repeat endovascular intervention (REI) in patients with prior failed ipsilateral endovascular intervention. American College of Surgeons National Surgical Quality Improvement Program database identified patients undergoing LEB and endovascular intervention for CLI from 2011 to 2014. We compared REI to LEB with single-segment saphenous vein (LEB-SV) and LEB alternative conduit (LEB-alt). Primary outcomes were 30-day MALE and MACE. Multivariate analysis identified independent predictors of MALE and MACE. A total of 1567 revascularizations were performed after failed ipsilateral endovascular intervention (REI: 683 [43.5%], LEB-SV: 570 [36.4%], LEB-alt: 314 [20.0%]). There were 994 and 573 suprageniculate and infrageniculate revascularizations, respectively. Major adverse cardiac events were significantly lower after REI compared to LEB (REI: 15 [2.2%], LEB-SV: 33 [5.8%], LEB-alt: 21 [6.7%], P < .001). Major adverse limb event were not different between groups ( P = .99). In patients with CLI presenting after failed endovascular intervention, REI is associated with lower MACE without an increased risk of MALE compared to LEB. When the anatomy is amenable, REI should be considered a less morbid first option.

A novel swine model of abdominal aortic aneurysm.

OBJECTIVE: Few large-animal models exist for the study of aortic aneurysms. ß-Aminopropionitrile (BAPN) is a compound known to cause aortic aneurysms by inhibiting lysyl oxidase, a collagen cross-linking enzyme. It is hypothesized that BAPN plus aneurysm induction surgery would result in significant aneurysm formation in swine with biologic properties similar to human disease. METHODS: Initial experiments were performed in uncastrated male swine not treated with BAPN (surgery alone). Subsequently, uncastrated male swine were fed BAPN (0.15 g/kg) for 7 days before undergoing surgery; the infrarenal aorta was circumferentially dissected and measured, balloon dilated, and perfused with elastase (500 units) and type I collagenase (8000 units), with extraluminal elastase application. In the BAPN groups, daily BAPN feedings continued until swine harvest at postoperative days 7, 14, and 28. RESULTS: Swine undergoing surgery alone (n = 12) had significantly less dilation at 28 days compared with BAPN + surgery swine (51.9% ± 29.2% [0%-100%] vs 113.5% ± 30.2% [52.9%-146.2%]; P < .0003). Mean aortic dilation in animals undergoing treatment with surgery and BAPN was 86.9% ± 47.4% (range, 55.6%-157.1%), 105.4% ± 58.1% (50%-133.3%), and 113.5% ± 30.2% (52.9%-146.2%) at 7, 14, and 28 days, respectively. In the BAPN + surgery group, significant elastolysis was present at all time points, whereas aortic wall collagen content was not significantly different. Smooth muscle cells were significantly depleted at 14 and 28 days, and M1 macrophages were increased at 14 and 28 days (P < .05, all). Matrix metalloproteinase 2 was elevated at 7 days (P < .05). Multiple proinflammatory cytokines were elevated within the aortic wall of BAPN + surgery swine. CONCLUSIONS: BAPN plus surgery resulted in significantly larger aortic aneurysms than surgery alone and was critical to aneurysm formation in this novel swine model. Hallmarks of human disease, such as elastin fragmentation, smooth muscle cell depletion, macrophage infiltration, matrix metalloproteinase activation, and proinflammatory cytokine expression, were observed in BAPN-treated swine. This model better parallels many of the characteristics of human AAAs and may be suitable for prehuman drug trials.

Resolvin D1 decreases abdominal aortic aneurysm formation by inhibiting NETosis in a mouse model.

OBJECTIVE: Resolvins have been shown to attenuate inflammation, whereas NETosis, the process of neutrophils releasing neutrophil extracellular traps (NETs), produces increased inflammation. It is hypothesized that treatment of animals with resolvin D1 (RvD1) would reduce abdominal aortic aneurysm (AAA) formation by inhibiting NETosis. METHODS: Wild-type 8- to 12-week-old C57BL/6 male mice (n = 47) and apolipoprotein E-deficient (ApoE-/-) mice (n = 20) were used in two models to demonstrate the effects of RvD1 on AAA growth. In the topical elastase AAA model, wild-type mice were divided into three groups: a deactivated elastase control group, in which sham surgery was performed using deactivated elastase and mice were intravenously injected with phosphate-buffered saline (PBS) once a day until harvest; an elastase group, in which active elastase was used to induce AAA and mice were injected with PBS daily until harvest; and an RvD1-treated group, in which AAA was induced and mice were injected with RvD1 daily until harvest. In the angiotensin II (Ang II)-induced AAA model, ApoE-/- mice were fed a high-fat diet and implanted with osmotic infusion pumps containing Ang II (1000 ng/kg/min). The Ang II model was divided into two groups: an Ang II control group, in which Ang II was delivered and mice were injected with PBS daily until harvest; and an RvD1-treated group, in which Ang II was delivered and mice were injected with RvD1 daily until harvest. On postoperative day 3, day 14, or day 28, aortic and blood samples were collected for Western blot, histology, cytokine array, enzyme-linked immunosorbent assay, and gelatin zymography after aortic diameter measurement. RESULTS: The day 14 RvD1-treated group demonstrated 42% reduced AAA diameter compared with the elastase group (P < .001). On postoperative day 3, the RvD1-treated group showed decreased levels of NETosis markers citrullinated histone H3 (P = .04) and neutrophil elastase (P = .002) compared with the elastase group. Among important cytokines involved in AAA formation, interleukin (IL) 1ß was downregulated (P = .02) whereas IL-10, a protective cytokine, was upregulated (P = .01) in the RvD1-treated group. Active matrix metalloproteinase 2 also decreased in the RvD1-treated group (P = .03). The RvD1-treated group in the Ang II AAA model, a second model, demonstrated reduced AAA diameter compared with the Ang II control group on day 28 (P < .046). The RvD1-treated group showed decreased levels of citrullinated histone H3 on day 3 (P = .002). Cytokines interferon γ, IL-1ß, C-X-C motif chemokine ligand 10, monocyte chemotactic protein 1, and regulated on activation, normal T cell expressed and secreted (RANTES) were all decreased on day 28 (P < .05). CONCLUSIONS: RvD1-mediated inhibition of NETosis may represent a future medical treatment for the attenuation of AAA growth.

Tamsulosin attenuates abdominal aortic aneurysm growth.

BACKGROUND: Tamsulosin, an α1A-adrenergic receptor inhibitor, is prescribed to treat benign prostatic hyperplasia in men >60 years of age, the same demographic most susceptible to abdominal aortic aneurysm. The goal of this study was to investigate the effect of tamsulosin on abdominal aortic aneurysm pathogenesis. METHODS: Abdominal aortic aneurysms were induced in WT C57BL/6 male mice (n = 9-18/group), using an established topical elastase abdominal aortic aneurysm model. Osmotic pumps were implanted in mice 5 days before operation to create the model, administering either low dose (0.125 µg/day tamsulosin), high dose (0.250µg/day tamsulosin), or vehicle treatments with and without topical application of elastase. Blood pressures were measured preoperatively and on postoperative days 0, 3, 7, and 14. On postoperative day 14, aortic diameter was measured before harvest. Sample aortas were prepared for histology and cytokine analysis. RESULTS: Measurements of systolic blood pressure did not differ between groups. Mice treated with the low dose of tamsulosin and with the high dose of tamsulosin showed decreased aortic diameter compared with vehicle-treated control (93% ± 24 versus 94% ± 30 versus 132% ± 24, respectively; P = .0003, P = .0003). Cytokine analysis demonstrated downregulation of pro-inflammatory cytokines in both treatment groups compared with the control (P < .05). Histology exhibited preservation of elastin in both low- and high-dose tamsulosin-treated groups (P = .0041 and P = .0018, respectively). CONCLUSION: Tamsulosin attenuates abdominal aortic aneurysm formation with increased preservation of elastin and decreased production of pro-inflammatory cytokines. Further studies are necessary to elucidate the mechanism by which tamsulosin attenuates abdominal aortic aneurysm pathogenesis.

Recurrent Aortic Dissection in a Patient With an Actin Mutation Treated With a Laser-Fenestrated Aortic Arch Stent-Graft.

A 58-year-old African American female, who had previously undergone a valve-sparing aortic root replacement for a type A dissection, represented 2 months later with a new focal dissection and aneurysm with intramural hematoma just distal to the origin of the left subclavian artery. Since no landing zone distal to the subclavian artery existed, the patient underwent thoracic endovascular aortic repair with laser fenestration-aided stent-graft placement in the left subclavian artery. The patient recovered without complication, and 52 months later, she is doing well with normal renal function and ambulatory status.

A novel reproducible model of aortic aneurysm rupture.

INTRODUCTION: Given the unknown biologic antecedents before aortic aneurysm rupture, the purpose of this study was to establish a reproducible model of aortic aneurysm rupture. METHODS: We fed 7-week-old apolipoprotein E deficient mice a high-fat diet for 4 weeks and osmotic infusion pumps containing Angiotensin II were implanted. Angiotensin II was delivered continuously for 4 weeks at either 1,000 ng/kg/min (n = 25) or 2,000 ng/kg/min (n = 29). A third group (n = 14) were given Angiotensin II at 2,000 ng/kg/min and 0.2% ß-aminopropionitrile dissolved in drinking water. Surviving mice were killed 28 days after pump placement, aortic diameters were measured, and molecular analyses were performed. RESULTS: Survival at 28 days was significantly different among groups with 80% survival in the 1,000 ng/kg/min group, 52% in the 2,000 ng/kg/min group, and only 14% in the Angiotensin II/ß-aminopropionitrile group (P = .0001). Concordantly, rupture rates were statistically different among groups (8% versus 38% versus 79%, P < .0001). Rates of abdominal aortic aneurysm were 48%, 55%, and 93%, respectively, with statistically higher rates in the Angiotensin II/ß-aminopropionitrile group compared with both the 1,000 ng and 2,000 ng Angiotensin II groups (P = .006 and P = .0165, respectively). Rates of thoracic aortic aneurysm formation were 12%, 52%, and 79% in the 3 groups with a statistically higher rate in the Angiotensin II/ß-aminopropionitrile group compared with 1,000 ng group (P < .0001). CONCLUSIONS: A reproducible model of aortic aneurysm rupture was developed with a high incidence of abdominal and thoracic aortic aneurysm. This model should enable further studies investigating the pathogenesis of aortic rupture, as well as allow for targeted strategies to prevent human aortic aneurysm rupture.

Ileal J-Pouch Volvulus Following Total Proctocolectomy for Ulcerative Colitis.

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) allows restoration of continence in select patients with ulcerative colitis but is associated with significant morbidity. Well-known complications following IPAA include pouchitis, anastomotic leak, and small bowel obstruction. Obstruction secondary to ileal pouch volvulus is exceedingly rare. We report a case of ileal pouch volvulus, which occurred secondary to internal hernia. Radiographic and endoscopic identification of volvulus allowed for early operative management and pouch salvage.