Cleaning Up the Chimney: Early Renal Stent Graft Thrombosis Following Endovascular Treatment of a Juxtarenal Aortic Aneurysm With the Chimney Technique.

The endovascular management of juxtarenal aortic aneurysms with the chimney technique (ch-EVAR) has gained popularity in recent years. It provides an alternative to open repair, allowing treatment of challenging anatomies with devices readily available in any vascular suite. The primary drawback persists as the occurrence of type-Ia endoleak from gutters and renal stent thrombosis. We present two cases of early renal stent graft thrombosis following chimney endovascular aneurysm repair. The first patient was an 80-year-old man who underwent single ch-EVAR and came back on the fifth post-op day with renal stent graft thrombosis. He was re-operated for recanalization and additional stenting of his chimney graft. The patient recovered well with no complications. The second case involved a 72-year-old man with a juxtarenal aneurysm, treated with ch-EVAR on both renal arteries. Unfortunately, on the 10th post-op day, he was referred to our department due to lumbar pain and acute renal failure due to chimney graft thrombosis bilaterally. The left renal chimney graft was recanalized by endovascular means. On the contrary, despite efforts of the endovascular and open approach, the right chimney graft and the right renal artery remained occluded. While ch-EVAR is a viable and off-the-shelf solution for urgent and complex juxtarenal aortic aneurysms, it should be performed with awareness of the potential for graft thrombosis and persistent endoleaks. Despite these complications, the chimney technique can still be a viable treatment option. A better understanding of the indications and advancements in the devices used can lead to better long-term results.

Stress, Prevention, and Resilience among First Responders.

This Special Issue [...].

Serum Levels of Matrix Metalloproteinases in Patients Undergoing Endovascular Intervention for Peripheral Arterial Disease.

BACKGROUND: Matrix metalloproteinases (MMPs) play a significant role in the development and progression of atherosclerotic vascular disease. The purpose of this study was to measure and document the profile of plasma-circulating MMPs in patients with peripheral arterial disease (PAD) undergoing endovascular revascularization. METHODS: This was a single-center prospective observational study with 80 patients with PAD enrolled. They underwent percutaneous balloon angioplasty and/or angioplasty with stent. Exclusion criteria were acute limb ischemia, active inflammation, wet gangrene, liver disease, end-stage renal failure, and cancer. Patients that underwent open or hybrid (open and endovascular) approach were also excluded from the study. Venous blood samples were taken preoperatively, 24 hr, and 6 months postoperatively. The values of MMP-2, MMP-3, MMP-7, MMP-9, and their inhibitors (tissue inhibitor of metalloproteinases [TIMP]), TIMP-1 and TIMP-2 were measured. RESULTS: The mean age was 67.1 years, and 66 of them (82.5%) were male. During the clinical follow-up (mean 35.8% months), 12 patients died (16.4%), 15 (20.5%) of them had a major adverse limb event (MALE), and 14 (19.2%) of them had a major adverse cardiovascular event (MACE). There was a statistically significant rise in the values of MMP-2, MMP-3, and MMP-7 at 6 months postoperatively, when compared to the preoperative and 24 hr postoperative values. There was no correlation of MMP and TIMP values with mortality, MALE, and MACE events. CONCLUSIONS: The present single-center prospective study documented increased circulating levels of MMPs postoperatively in PAD patients undergoing endovascular treatment. Vascular trauma caused by angioplasty could trigger the expression of MMPs and TIMPs, but the absence of any association with clinical complications requires further investigation.

The Effect of Transfusion of Two Units of Fresh Frozen Plasma on the Perioperative Fibrinogen Levels and the Outcome of Patients Undergoing Elective Endovascular Repair for Abdominal Aortic Aneurysm.

BACKGROUND: We aimed to investigate whether the transfusion of 2 units of fresh frozen plasma (FFP) immediately post aneurysm exclusion has any effect on the perioperative fibrinogen levels and the outcome of patients undergoing elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: Consecutive infrarenal AAA patients undergoing elective EVAR with the bifurcated Endurant-II stent-graft (Medtronic) were recruited from 2 vascular units. The first unit has a routine policy of administering 2 units of FFP immediately upon aneurysm exclusion (FFP group), whereas the second unit has no such policy (control group). Serum fibrinogen levels were measured on admission and 24 hr post-EVAR and the perioperative change in fibrinogen (Δfib) was calculated (24-hr postoperative minus preoperative fibrinogen). The 2 groups were compared with regards to the perioperative fibrinogen levels (preoperative, 24-hr postoperative, and Δfib) and the outcome (endoleaks, reinterventions, major adverse cardiovascular events, death) during follow up. RESULTS: A total of 70 patients (41 in the FFP group, 29 controls) were examined. There were 68 men, the mean age was 70 ± 7 years and the maximum AAA diameter was 63.3 ± 13.8 mm. During the follow up (34 ± 19 months), a total of 6 endoleaks were recorded (2 type Ia, 2 type Ib and 1 type II). Mean preoperative fibrinogen, 24-hr postoperative fibrinogen and Δfib was 391.1 ± 92.8 mg/dL, 367.7 ± 97.8 mg/dL and -23.5 ± 51.02 mg/dL, respectively. There was a trend for the fibrinogen to fall 24 hr postprocedure, but this was not statistically significant (P = 0.07). There was a weak negative association between Δfib and endoleaks (P = 0.007, r = -0.29). Compared to controls, the FFP group had a higher 24-hr postoperative fibrinogen (401.8 ± 112.9 mg/dL vs. 319.3 ± 34.9 mg/dL, P < 0.0001) and a lower Δfib (-3.00 ± 56.01 mg/dL vs. -52.48 ± 21.15 mg/dL, P < 0.0001). No significant difference was observed between the 2 groups with regards to endoleaks, reinterventions, major adverse cardiovascular events, or deaths. CONCLUSIONS: Transfusion of 2 units of FFP postaneurysm exclusion prevents a significant drop in plasma fibrinogen 24 hr post-EVAR, but the impact on clinical outcome has yet to be defined.

Organizational Solutions to the Moral Risks of Policing.

In addition to the physical and emotional challenges faced by law enforcement professionals, the job confronts officers with numerous moral risks. The moral risks include moral distress, moral injury, ethical exhaustion, compassion fatigue, and practices that lead to lapses in ethical decision-making. The paper focuses on what police agencies can do to better address the moral risks of policing. These moral risks are central to officer wellness and, thus, a crucial component of officers' operational readiness. Strategies are presented that will improve prevention efforts, including recruiting and hiring, training, supervision, and promotional practices. Additionally, the paper offers recommendations for effective approaches to intervention with officers who have displayed the effects of these moral risks. Finally, the paper highlights the kind of law enforcement leaders who are best able to implement strategies designed to prevent negative outcomes associated with the moral risks of policing.

Routine Stent Flushing with Heparinized Saline during Distal Filter-Protected Carotid Artery Stenting: A Technical Modification to Reduce Delayed Embolization.

INTRODUCTION: Delayed embolization after filter-protected carotid artery stenting (CAS) may occur because of the protrusion and release of loose atherosclerotic plaque fragments through the stent cells. METHODS AND RESULTS: We describe a technical modification to the standard filter-protected CAS by introducing an extra step, that of washing away the luminal stent surface debris with heparinized saline while the filter is still in place. Aided by the guiding catheter, flushing heparinized saline under manual pressure against the stent will force all loose fragments distally in the internal carotid artery to be captured by the overlying filter. CONCLUSIONS: Stent washout with heparinized saline before filter retrieval during filter-protected CAS may potentially increase debris capture and reduce delayed embolization.

Inevitable Loss and Prolonged Grief in Police Work: An Unexplored Topic.

The present manuscript presents foundational constructs related to death and loss (i.e., grief, bereavement, prolonged grief) providing empirical findings from recent research on the impact of death and loss on police officers' health, behavior, and overall functioning. Police officers are routinely exposed to death. In many instances, officers' contact with decedents includes, among others, victims of accidents, catastrophes, or violent crimes and witnessing the intense emotional suffering of relatives of the deceased. Additionally, it is not uncommon for officers to experience the loss of fellow officers from on-duty deaths and permanent, career-ending injuries. Simultaneously, like everyone, police officers have to cope with deaths of loved ones in their personal lives. The result is that officers' health and well-being are likely compromised because of the systematic exposure to on- and off-duty deaths. In this perspective paper, death and loss in law enforcement are explored in an attempt to raise awareness and increase attention to this area of police work. In addition, the authors list a number of prophylactic intervention strategies that would support officers cope with the impact of loss and death and promote their own resilience.

The Role of Moral Injury in PTSD Among Law Enforcement Officers: A Brief Report.

Exposure to critical incidents and hence potentially traumatic events is endemic in law enforcement. The study of law enforcement officers' experience of moral injury and their exposure to potentially morally injurious incidents, and research on moral injury's relationship with different forms of traumatization (e.g. compassion fatigue, post-traumatic stress disorder) are in their infancy. The present study aims to build on prior research and explores the role of moral injury in predicting post-traumatic stress disorder (PTSD) and its clusters thereof. To this end, a sample of law enforcement officers (N = 370) from the National Police of Finland was recruited to participate in the current study. Results showed that moral injury significantly predicted PTSD as well as its diagnostic clusters (i.e., avoidance, hyperarousal, re-experiencing). The aforementioned role of moral injury to significantly predict PTSD and its clusters were unequivocal even when compassion fatigue was incorporated into the path model. Clinical, research, and law enforcement practice implications are discussed.

Endovascular Treatment of a Chronically Thrombosed Abdominal Aortic Aneurysm: Technical Considerations.

BACKGROUND: Chronic thrombosis of an abdominal aortic aneurysm (AAA) is a rare entity and the ideal management is debatable. METHODS AND RESULTS: A 74-year-old man presented with an enlarging chronically thrombosed AAA and incapacitating bilateral claudication, worse on the left side. We opted for an endovascular approach. Under local anesthesia and via a left axillary and left femoral cutdown, an aorto-uni-iliac stent graft (Endurant, Medtronic) was implanted down the left common iliac artery. A femorofemoral crossover bypass was not necessary because the right leg circulation was considered adequate on completion of the endovascular procedure. He had an uneventful recovery. His left leg symptoms were completely resolved and he was able to walk with only moderate right leg claudication after 300-400m. CONCLUSIONS: Endovascular treatment of a chronically thrombosed AAA can be performed under local anesthesia and is a safe alternative to open surgery in high-risk patients. The long-term results need further investigation.

The Importance of WE in POWER: Integrating Police Wellness and Ethics.

In this article, the authors introduce the POWER perspective of police wellness and ethics. POWER stands for Police Officer Wellness, Ethics, and Resilience. The perspective represents the view that wellness and ethics cannot be discussed separately; they are inextricably connected to each other. Initiatives to address one should always, simultaneously, include the other. Although there is a need for wellness and ethics to be addressed on an organizational level, the present article emphasizes the importance of POWER for individual police officers. The authors make the argument that officers need to expand the way in which they conceptualize their own wellness to include efforts to maintain ethical decision-making. Specifically, officers will remain psychologically healthier when they take active steps to stay steadfastly committed to their ethical principles. Likewise, officers who utilize a comprehensive wellness program, including strategies to boost resilience, will be far less likely to experience lapses in ethical decision-making. Further recommendations for action and implication of this matter in law enforcement are presented and discussed.

New Directions in Police Academy Training: A Call to Action.

The complexities of modern policing require law enforcement agencies to expand how officers are trained to do their jobs. It is not sufficient for training to focus solely on the law or on perishable skills; such as arrest and control; defensive tactics; driving; and firearms. The present manuscript addresses the critical importance of infusing academy training with the psychological skills essential for officers to meet the contemporary challenges of police work. The authors suggest that the skills (i.e., cognitive; emotional; social; and moral) discussed in this paper may improve officers' wellness as well as promote relationships between police officers and community members. Specific methods of incorporating these skills in academy training are offered.

Retroperitoneal Liposarcoma Masquerading as an Impending Rupture of Inflammatory Abdominal Aortic Aneurysm.

BACKGROUND: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. CONCLUSIONS: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.

Endovascular Management of a Distally Migrated Bifurcated Endograft with a New Bifurcated Endograft.

A 75-year-old man presented with abdominal and lumbar pain 6 years after previous endovascular repair of an abdominal aortic aneurysm. At the time of the initial operation, the aneurysm measured 6.0 cm in maximum diameter and a bifurcated Anaconda (Vascutek) endograft had been implanted. This time, computed tomography showed a distally migrated endograft which had been folded within the sac and the aneurysm measured 8.4 cm in maximum diameter. We opted to treat this by endovascular means deploying a new bifurcated endograft with suprarenal fixation within the old one. We consider the different management options and discuss the associated technical difficulties.

Association Between Perioperative Fibrinogen Levels and the Midterm Outcome in Patients Undergoing Elective Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: We investigated the potential association between perioperative fibrinogen levels and outcome in patients undergoing elective endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS: Consecutive patients with an intact AAA undergoing elective EVAR with a specific bifurcated endograft (Endurant, Medtronic) were recruited between December 2012 and October 2016. Preoperative and 24-hr postoperative fibrinogen levels were recorded, and potential associations with outcome were tested. Primary outcome measures included endoleaks, lower limb ischemic complications, including endograft limb occlusion, and aneurysm-related reinterventions. RESULTS: Ninety-four patients (91 male, mean age 71.8 ± 8.0 years) with an intact AAA were enrolled in the study. The technical success was 98% (2 failures: 1 type Ia endoleak on completion angiography, 1 lower limb ischemia immediately postoperatively requiring femoral endarterectomy). There was 1 death during the first 30 days due to myocardial infarction (1%). Another patient died 15 months after the procedure from cardiac causes. During the existing follow-up (mean 14.8 ± 14.3 months), 14 patients (15%) developed an endoleak (4, type Ia endoleak and 10, type II endoleak), 6 patients (6.3%) had lower limb ischemia/endograft limb occlusion, and 10 patients (10.6%) required reintervention. Compared with the preoperative values, no significant change occurred with regard to the fibrinogen levels 24 hr after procedure (mean preoperative fibrinogen 360 ± 101 mg/dl vs 24-hr postoperative fibrinogen 349 ± 105 mg/dl, P = 0.1). Neither preoperative nor 24-hr postoperative fibrinogen levels were significantly associated with the development of endoleaks, lower limb ischemia, or reinterventions. However, the difference in fibrinogen levels (baseline to 24 hr after procedure) was significantly higher in patients with endoleaks (median -65 mg/dl vs. 15 mg/dl, P = 0.04). CONCLUSIONS: Perioperative fibrinogen levels may play a role in predicting midterm outcomes in patients undergoing elective EVAR and appears to be associated, directly or indirectly, with the development of endoleaks. Further studies are needed to investigate these findings and explore future therapeutic implications.

Arterial Stiffness in a Toddler with Neurofibromatosis Type 1 and Refractory Hypertension.

Arterial hypertension is a common finding in patients with neurofibromatosis (NF) type 1. Renovascular hypertension due to renal artery stenosis or midaortic syndrome could be the underlying cause. We report the case of a 4-year-old girl with NF type 1 and midaortic syndrome whose changes in blood pressure and pulse wave velocity suggested the evolution of vasculopathy, diagnosis of renovascular hypertension, and provided insights of response to treatment. Hypertension persisted after percutaneous transluminal angioplasty in the abdominal aorta, requiring escalation of antihypertensive treatment, while arterial stiffness demonstrated a mild decrease. Regular assessment of blood pressure using ambulatory blood pressure monitoring and noninvasive assessment of arterial stiffness may enhance the medical care of patients with NF type 1.

Changes in circulating markers of coagulation and fibrinolysis after EVAR.

INTRODUCTION: The presence of an abdominal aortic aneurysm (AAA) is associated with increased thrombin formation, fibrin turnover and fibrinolysis. EVIDENCE ACQUISITION: The aim of this study was to review the relevant literature and summarize the evidence regarding the impact of endovascular repair on the circulating markers of coagulation and fibrinolysis postprocedure. EVIDENCE SYNTHESIS: The main findings are that the increased thrombin activation, and formation, as well as fibrinolysis, in patients with AAA is exacerbated after endovascular repair in the short-term and the mid-term, implying that this may be a period associated with an increased likelihood for adverse cardiovascular events. It is estimated that this prothrombotic state is normalized within a year of the endovascular procedure. Furthermore, elevated levels of specific markers of fibrinolysis are associated with the presence of an endoleak during the follow-up imaging and the clinical implications of these findings merit investigation. CONCLUSIONS: Further and larger studies are needed to explore the impact of these changes in coagulation and fibrinolysis on the outcome of endovascular repair in patients with AAA.