Profunda Femoris Pseudoaneurysm and Fatal Hemorrhage 2 Weeks After Modified Girdlestone Resection Arthroplasty: A Case Report.

CASE: A 62-year-old nonambulatory female patient presented with wound dehiscence and purulent bloody drainage 2 weeks after modified Girdlestone resection arthroplasty for subtrochanteric femur fracture. On developing an enlarging thigh hematoma and hemodynamic instability, the patient was taken to the vascular suite where a profunda femoris artery pseudoaneurysm was identified and ligated by the vascular surgery team. The proximal free edge of the resected femur was determined to be the likely cause of arterial injury. Two days later, the patient was taken by the orthopaedic surgery team for debridement and revision resection arthroplasty, but she ultimately decompensated and died. CONCLUSION: We believe this to be the first reported case of this serious complication of the Girdlestone procedure. We hope this case helps bring awareness to the complication and aids in early detection and prompt treatment of femoral artery complications.

A modified chain-based sponge dressing controls junctional hemorrhage in the tactical combat casualty care simulation of pigs.

BACKGROUND: Hemorrhage has always been the focus of battlefield and pre-hospitalization treatment. With the increasing fatality rates associated with junctional bleeding, treatment of bleeding at junctional sites has gradually gained attention in battlefield trauma emergency care. We designed a modified chain-based sponge dressing with a medical polyvinyl alcohol sponge that can be used to treat junctional hemorrhage and tested its hemostatic efficacy and biocompatibility. METHODS: Twenty adult Bama miniature pigs were randomly divided into the modified chain-based sponge dressing (MCSD) and standard gauze (SG) groups. The right femoral artery of the pigs was shot at after anesthesia. The Bama miniature pigs were moved to the safety zone immediately to assess the condition according to the MARCH strategy, which evaluates massive hemorrhaging, airway obstruction, respiratory status, circulatory status, head injury & hypothermia. Hemoglobin and coagulation status were checked during the experiment.Among the pigs in which the inguinal hemorrhagic model based on bullet penetrating wounds was successfully established, those in the MCSD group received a disinfected MCSD for hemostasis, while those in the SG group received standard gauze in an imbricate manner to pack the bullet exit and entrance wounds to stop bleeding until the wound was filled, followed by compression for 3 min at sufficient pressure. CT scanning, transmission electron microscopy, and HE staining were conducted after experiment. RESULTS: The MCSD group showed lower hemostasis time and blood loss than the gauze group. The MCSD group also showed a higher success rate of treatment,more stable vital signs and hemoglobin level. The CT scanning results showed tighter packing without large gaps in the MCSD group. The histopathological assessments and the transmission electron microscopy and HE staining findings indicated good biocompatibility of the polyvinyl alcohol sponge. CONCLUSION: The MCSD met the battlefield's requirements of speedy hemostasis and biosafety for junctional hemorrhage in Bama miniature pigs. Moreover, in comparison with the conventional approach for hemostasis, it showed more stable performance for deep wound hemostasis. These findings provide the theoretical and experimental basis for the application of MCSD in the treatment of hemorrhage in the battlefield in the future.

Estrategias para el abordaje en la enfermedad estenooclusiva de la arteria femoral común. El rol de la evidencia científica / Strategies for the management of steno-occlusive common femoral artery disease. The role of scientific evidence

La lesión estenótica u oclusiva confinada a la arteria femoral común (AFC) es bastante infrecuente. tradicionalmente, el tratamiento de referencia para esta entidad ha sido la endarterectomía femoral común (EFC). Este artículo tiene como objetivo realizar una revisión general de todas las estrategias terapéuticas actuales (cirugía abierta y abordajes endovasculares e híbridos) para el tratamiento de la lesión estenótica u oclusiva aislada de la AFC. Se realizó una búsqueda bibliográfica electrónica utilizando Pubmed y Google. Se analizaron las ventajas y las desventajas de cada técnica de revascularización y se informó de los resultados. La EFC demostró un alto éxito técnico y excelentes tasas de permeabilidad. Sin embargo, se asoció con una morbilidad local significativa, mayor duración de la estancia hospitalaria y mayores costos médicos en comparación con las terapias endovasculares. Los enfoques terapéuticos mínimamente invasivos mostraron resultados aceptables con complicaciones locales menores, pero tasas de permeabilidad más bajas en comparación con la cirugía abierta. Esta revisión sugiere la necesidad de más estudios comparativos aleatorios para evaluar el verdadero balance beneficio-riesgo de la EFC tradicional frente a las nuevas terapias mínimamente invasivas para tratar lesiones aisladas de la AFC.(AU)

isolated atherosclerotic stenosis or occlusion of the common femoral artery (CFa) is rather uncommon. traditionally,the standard of care of this entity has been the common femoral artery endarterectomy (CFe).this manuscript provides a general review of all the current therapeutical strategies (open surgery, endovascularand hybrid approaches) used to treat isolated CFa stenoses or occlusions.an electronic bibliographic search was performed on the Pubmed and Google databases. advantages and dis-advantages of each revascularization technique were analyzed and the outcomes reported. Common femoralendarterectomy (CFe) showed high technical success and excellent patency rates. However, it was associated withsignificantly local morbidities, longer lengths of stay and higher medical costs compared with endovascular ther-apies. minimally invasive therapeutical approaches showed acceptable outcomes with minor local complicationsbut lower patency rates compared to open surgery.Further randomized comparative studies are needed to assess the true benefit-risk ratio of traditional CFe vs newminimally invasive therapies for CFa disease.(AU)

Testing and Evaluation of a Novel Hemostatic Matrix in a Swine Junctional Hemorrhage Model.

INTRODUCTION: In an ongoing effort to improve survival and reduce blood loss from hemorrhagic injuries on the battlefield, new hemostatic dressings continue to be developed. This study aimed to determine the efficacy of a novel silicon dioxide-based hemostatic matrix (HM) and compare it with the current military standard Quikclot Combat Gauze (QCG) utilizing a lethal femoral artery injury model. MATERIALS AND METHODS: The femoral arteries of 20 anesthetized swine were isolated, and an arteriotomy was performed. After a 45 s free bleed, the wound was treated with either HM or QCG (n = 10 per group). Following a 60-min observation period, ipsilateral leg manipulations and angiography were performed. Animal survival, hemostasis, blood loss, exothermic reaction, and femoral artery patency were analyzed. RESULTS: Despite a volumetric size discrepancy between the two products tested, the survival rate was similar between the two groups (80% HM, 90% QCG, n = 10, P = 0.588). Immediate hemostasis was obtained in 50% of HM animals and 40% of QCG animals. There was no difference in total blood loss recorded between the two groups (P = 0.472). Femoral artery patency rates following ipsilateral leg manipulations were similar between the two groups (50% HM, 33% QCG, P = 0.637), with no contrast extravasation in HM-treated wounds (0% HM, 33% QCG, P = 0.206). There was no significant difference in either pretreatment or posttreatment laboratory values, and there were no exothermic reactions in either group. CONCLUSIONS: The SiOxMed HM demonstrated comparable hemostatic efficacy to QCG. The tested form of HM may be appropriate for surgical or topical hemostasis applications, and with further product development, it could be used for battlefield trauma implementation.

Novel cross-linked polysaccharide-polyelectrolyte hemostatic foam improves survival compared to CombatGauze in swine femoral artery hemorrhage model.

BACKGROUND: Uncontrolled hemorrhage is the leading cause of preventable death in combat and civilian trauma. Efficacious hemostatic agents in junctional hemorrhage can quell blood loss and improve survival. We hypothesized that a novel hemostatic foam of starch and chitosan would improve hemostasis, and thereby increase survival in a swine femoral artery hemorrhage model when compared with CombatGauze (CG). METHODS: A novel hemostatic foam of starch and chitosan was created and modified during the study period. Thirty pigs (four excluded) were assigned to treatment using either foam version 1 (FV1, n = 9) or 2 (FV2, n = 8), or (n = 9) in a standard swine femoral artery hemorrhage model. Animals were observed for 150 minutes. Outcomes assessed included hemostasis, survival, posttreatment blood loss, IV fluid volume, and hemodynamic and laboratory trends. RESULTS: Hemostasis prior to 150 minutes was similar with 44.4%, 77.8%, and 50% of swine treated with CG, FV1 and FV2, respectively (Kaplan-Meyer and log-rank test [KM-LR] p > 0.05). Survival to 150 minutes was improved in swine treated with FV1 (100%) compared with CG (55.6%) (KM-LR p = 0.02). Survival was similar between FV1 and FV2 (75%) (KM-LR p > 0.05), and between CG and FV2 (KM-LR p > 0.05). Using mixed model for longitudinal data, mean arterial pressure decreased significantly in CG- and FV2-treated swine, while there was no significant change in mean arterial pressure in FV1-treated swine. Trends in lactic acid, hematocrit, platelets, INR, and thrombelastography were more favorable for FV1 compared with CG. CONCLUSION: In this preclinical study of junctional hemorrhage, survival was improved in swine treated with version 1 of a novel chitosan/starch foam compared with CG. Trends in hemodynamics and laboratory data were also more favorable in the FV1-treated swine. This novel hemostatic foam may be an effective alternative to current hemostatic agents.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

The effectiveness of the manual pressure points technique for hemorrhage control-The 2022 THOR pre-conference meeting experience.

INTRODUCTION: Limb and junctional hemorrhage are leading causes of potentially preventable death among trauma casualties. Hemorrhage control for these regions could be achieved by direct or indirect pressure. The manual pressure points (MPP) involves applying manual pressure on the arterial supply to occlude distal blood flow without the need for specialized equipment. STUDY DESIGN AND METHODS: Prospective, non-randomized, human volunteer, controlled environment study involving 38 healthy military caregivers, with 26 participants attending a short instructional session. During a medical exercise, participants were requested to apply pressure on the supraclavicular and femoral points aiming to stop regional blood flow, measured by distal pulse palpation. The measures recorded included achievement of distal pulse cessation, success in achieving cessation for a full minute, and subjects' pain scores reported after each attempt. RESULTS: All participants succeeded in achieving distal pulse cessation for both the supraclavicular and femoral points for a full minute. The median time to initial success was 3.0 (interquartile range 2.0-5.0) seconds in the supraclavicular point and 4.5 (interquartile range 3.0-6.0) seconds in the femoral point. Pain scores ranging between 0 and 3 were reported by most subjects during supraclavicular (68.4%) and femoral occlusion (84.2%). CONCLUSION: The MPP technique was highly effective in occluding distal palpable pulses in healthy volunteers when applied to the supraclavicular and femoral arteries. Brief instruction on the technique can potentially improve the chances of achieving hemorrhage control within 5 s. Further research is required to determine efficacy among different populations and providers with varying experience levels.

A novel sodium polyacrylate-based stasis dressing to treat lethal hemorrhage in a penetrating trauma swine model.

BACKGROUND: Control of massive hemorrhage from penetrating wound sites is difficult in both combat and civilian settings. A new hemostatic dressing, sodium polyacrylate (PAAs)-based bag (PB), based on PAAs is designed for the first aid of massive penetrating hemorrhage. This study aimed to investigate the efficacy of PB in a penetrating trauma model in swine. METHODS: A complex groin penetrating injury was produced in swine by completely excising the femoral vessels and surrounding muscles. After 15-second free bleeding, 18 healthy Guizhou female swine were administered PB (n = 6), CELOX-A (n = 6; Medtrade Products, Crewe, United Kingdom), or standard gauze (n = 6) for hemostatic intervention, followed by 3-minute compression if the bleeding persisted, with subsequent observation continuing for 1 hour. The primary outcomes included initial hemostasis, the incidence of applying manual pressure, and application time. RESULTS: Sodium polyacrylate could rapidly absorb the liquid to expand, crosslink with a large number of red blood cells, induce cellular morphological alteration, and promote blood coagulation. Sodium polyacrylate-based bag and CELOX-A initiated and sustained hemostasis for 60 minutes, whereas 0% of the standard gauze achieved initial hemostasis. Maximum number of manual compressions were applied in standard gauze (6 of 6 [100%]), followed by CELOX-A (5 of 6 [80%]), while no manual pressure was required in the case of PB (0 of 6 [0%]). Application time for PB (19.0 ± 4.6 seconds) was significantly less than CELOX-A (169.0 ± 73.5 seconds) and standard gauze (187.8 ± 1.7 seconds). CONCLUSION: We prepared a type of superabsorbent PAAs and made an original hemostatic dressing, PB. It can rapidly achieve durable hemostasis in the groin-penetrating trauma hemorrhage swine model without any external compression. The packet form makes PB easy to deploy and remove from wounds. Therefore, PB could be a promising hemostatic candidate for controlling penetrating hemorrhage.

Emergency approach to the femoral artery.

PURPOSE: The purpose of this study was to evaluate the applicability and potentially associated harms of emergency access to the femoral artery and vein in a sample of physicians working together in the emergency department of a level I trauma center. In addition, to investigate whether there are differences between participants in terms of different levels of training. METHODS: A sample of 36 orthopedic trauma and anesthesiology assistant doctors, specialists, and senior physician was recruited from the emergency room management at a level I trauma center in Graz, Austria. Emergency approach to the femoral vessels was performed on 33 fresh cadavers. Attention was paid to time, successful clamping of the vessels, self-assessment and learning curve. RESULTS: The approach was performed correctly in 97.2% (35/36) of all cases. 97.2% of all participants (35/36) were confident to perform the emergency access. They were proven right, since especially the resident and senior subgroups achieved satisfactory results concerning the correct performance of the approach to the femoral vessels as well as correct identification of the femoral artery and vein. CONCLUSION: In conclusion, we evaluated the emergency access to the femoral artery (FA) and femoral vein (FV) as an easily teachable procedure including high success rates (correct performance in 97.2%).

A patient with femoral artery pseudoaneurysm treated with ultrasound-guided injection of an exogenous lyophilized human fibrin sealant.

A femoral artery pseudoaneurysm (FAP) is a serious complication of arterial injury. It can cause compression of the surrounding nerves and tissues, rupture and bleeding of the aneurysm, and formation and dislodgement of thrombi, and can lead to distal limb embolism, tissue necrosis, and infection. Computed tomography angiography and ultrasonography are the preferred techniques for diagnosis of FAP. This report describes the successful treatment of an FAP using an ultrasound-guided percutaneous intracavitary injection of a lyophilized human fibrin sealant. This treatment was safe, associated with minimal pain and complications, and clinically effective.

Exsanguination from ruptured femoral artery pseudoaneurysm - A fatal complication of groin heroin injection.

Intravenous drug users (IDUs) eventually encounter a common problem- a need to turn to a new vessel to inject drugs. Whether it is because no other spot is available due to scarring or convenience, the groin is the preferred spot for some. Chronic puncture of femoral vessels can lead to a rare but significant complication- femoral artery pseudoaneurysm (FAP). Its fatal consequence- rupture and bleeding is well recognized, but the forensic literature on this subject is limited. We present eight cases of exsanguination due to the ruptured FAP in IDUs who share most or all the following characteristics: long-term heroin use and/or pronounced drug use stigmata, chronic groin injection-related lesions, absence of significant precipitating pseudoaneurysm trauma, and no or minimal concentrations of heroin metabolites in blood. The FAP presentation varied greatly, from palpable fist-sized mass or slight elevation under the skin defect to infundibular arterio-cutaneous fistula that ruptured through the skin induration. In some, surrounding skin or soft tissue showed signs of inflammation but without suppuration. The most prominent FAP characteristic was smooth-surface cavitation on cross-sections. We performed microscopic evaluation in two cases and verified disruption of the artery wall (i.e., pseudoaneurysm) with elements of acute and chronic inflammation and fibrosis; foci of fibrinoid necrosis were noticed on the arterial wall. All subjects were pale, with faint hypostasis and organ anemia, consistent with reported massive hemorrhage. Because such sudden, unwitnessed, and suspicious deaths may raise the question of injury infliction, proper autopsy evaluation is crucial, for which we propose guidelines.

Myeloid PHD2 deficiency accelerates neointima formation via Hif-1α.

The key players of the hypoxic response are the hypoxia-inducible factors (Hif), whose α-subunits are tightly regulated by Prolyl-4-hydroxylases (PHD), predominantly by PHD2. Monocytes/Macrophages are involved in atherosclerosis but also restenosis and were found at hypoxic and sites of the lesion. Little is known about the role of the myeloid PHD2 in atherosclerosis and neointima formation. The study aimed to investigate the consequences of a myeloid deficiency of PHD2 in the process of neointima formation using an arterial denudation model. LysM-cre mice were crossed with PHD2fl/fl, PHD2fl/fl/Hif1αfl/fl and PHD2fl/fl/Hif2αfl/fl to get myeloid specific knockout of PHD2 and the Hif-α subunits. Denudation of the femoral artery was performed and animals were fed a western type diet afterwards with analysis of neointima formation 5 and 35 days after denudation. Increased neointima formation in myeloid PHD2 knockouts was observed, which was blunted by double-knockout of PHD2 and Hif1α whereas double knockout of PHD2 and Hif-2α showed comparable lesions to the PHD2 knockouts. Macrophage infiltration was comparable to the neointima formation, suggesting a more inflammatory reaction, and was accompanied by increased intimal VEGF-A expression. Collagen-content inversely correlated to the extent of neointima formation suggesting a destabilization of the plaque. This effect might be triggered by macrophage polarization. Therefore, in vitro results showed a distinct expression pattern in differentially polarized macrophages with high expression of Hif-1α, VEGF and MMP-1 in proinflammatory M1 macrophages. In conclusion, the results show that myeloid Hif-1α is involved in neointima hyperplasia. Our in vivo and in vitro data reveal a central role for this transcription factor in driving plaque-vascularization accompanied by matrix-degradation leading to plaque destabilization.

Ruptured femoral artery pseudoaneurysm in drug abuser mimicking homicidal inguinal stab wound.

A 47-year-old woman with a long-term history of intravenous heroin use was found dead lying on the couch in a pool of blood with the wound in her right groin, 15 × 4 mm in diameter. The autopsy revealed the thickened superficial right femoral artery wall and the tract communication between the artery lumen and the skin surface, with pseudoaneurysm formation, confirmed by microscopic examination. Toxicological findings were negative for heroin and its metabolites. The cause of death was fatal blood loss from ruptured chronic femoral pseudoaneurysm. Persons with a long-term history of intravenous drug use experience injection-related problems: prominent vein scarring, lumps, and swelling. The risk of injecting the groin is substantially greater than in typical areas such as the cubital fossa. The proximity of the femoral vein to the femoral artery and nerve poses the risk of accidental trauma to these sites. Accidental groin arterial injections can cause a tear in the arterial wall, on which a pseudoaneurysm can develop. A false or pseudoaneurysm is a breach in the vascular wall leading to an extravascular hematoma that freely communicates with the intravascular space. In the presented case, the autopsy findings pointed out that the fatal blood loss from femoral pseudoaneurysm rupture occurred probably after trivial trauma (shortly after sexual intercourse) or even spontaneously, and not immediately or shortly after arterial drug injection.

Pseudoaneurisma de artéria femoral comum em paciente covid19: relato de caso / Pseudoaneurysm of the common femoral artery in a covid-19 patient: case report / Pseudoaneurisma de la arteria femoral común en un paciente con covid-19: estudio de caso

Introdução: O pseudoaneurisma pode ser definido como um hematoma pulsátil resultante de uma laceração de uma artéria em que há extravasamento de sangue contido pelos tecidos circunvizinhos. Dessa forma, cria-se uma comunicação entre a artéria e uma cavidade, que receberá fluxo sistólico. As principais etiologias incluem traumas, pós procedimento, pós cirurgia vascular e infecções. Objetivo: Relatar o caso de uma paciente com pseudoaneurisma de artéria femoral, durante quadro de COVID-19. Método: Relato de caso baseado na análise de prontuário médico, exames de imagem e revisão da literatura. Relato de caso: Apresentamos uma paciente do sexo feminino, com 79 anos, com diagnóstico de pseudoaneurisma em Artéria Femoral Comum após realização de cateterismo arterial e durante quadro de COVID-19. No pós operatório, paciente evoluiu com deiscência e necrose da ferida operatória. Conclusão: A escolha cirúrgica foi eficaz e relativamente segura. Uso de aparato cirúrgico específico para a paciente positiva para COVID-19 foi necessário. A evolução complicada da ferida operatória possui associação ao crescimento de bactérias multirresistentes devido à internação e ao estado geral grave pós COVID-19.(AU)

Introduction: The pseudoaneurysm can be defined as a pulsatile hematoma resulting from a laceration of an artery in which there is extravasation of blood contained by the surrounding tissues. This creates a communication between the artery and a cavity, which will receive systolic flow. The main etiologies include trauma, post-procedure, post-vascular surgery and infections. Objective: To report the case of a patient with pseudoaneurysm of the femoral artery, during COVID-19. Materials and Methods: Case report based on medical record analysis, imaging tests and literature review. Case report: We present a female patient, aged 79, diagnosed with pseudoaneurysm in Common Femoral Artery after arterial catheterization and during COVID-19. In the postoperative period, the patient evolved with dehiscence and necrosis of the operative wound. Conclusion: The surgical choice was effective and relatively safe. Use of specific surgical apparatus for the patient positive for COVID-19 was necessary. The complicated evolution of the surgical wound is associated with the growth of multidrug-resistant bacteria due to hospitalization and severe general condition after COVID-19.(AU)

Introducción: El pseudoaneurisma se puede definir como un hematoma pulsátil resultante de la laceración de una arteria en la que hay extravasación de sangre contenida por los tejidos circundantes. De esta forma, se crea una comunicación entre la arteria y una cavidad, que recibirá el flujo sistólico. Las principales etiologías incluyen trauma, post-procedimiento, post-cirugía vascular e infecciones. Objetivo: Reportar el caso de un paciente con pseudoaneurisma de la arteria femoral durante la COVID-19. Método: Reporte de caso basado en análisis de historias clínicas, pruebas de imagen y revisión de la literatura. Caso clínico: Presentamos una paciente de 79 años diagnosticada de pseudoaneurisma en la arteria femoral común tras cateterismo arterial y durante la COVID-19. En el postoperatorio la paciente evolucionó con dehiscencia y necrosis de la herida quirúrgica. Conclusión: La elección quirúrgica fue efectiva y relativamente segura. Fue necesario el uso de aparato quirúrgico específico para el paciente COVID-19 positivo. La complicada evolución de la herida quirúrgica se asocia al crecimiento de bacterias multirresistentes por la hospitalización y el grave estado general tras la COVID-19.(AU)

Pseudoaneurisma e fístula arteriovenosa da artéria femoral profunda após rotura completa do músculo vasto medial: tratamento endovascular / Pseudoaneurysm and arteriovenous fistula of the deep femoral artery after complete rupture of the vastus medialis muscle: endovascular treatment

Resumo A artéria femoral profunda, devido às suas características anatômicas, se encontra protegida da maioria dos traumatismos vasculares. Relatamos um caso de pseudoaneurisma de ramo perfurante da artéria femoral profunda, associado à fístula arteriovenosa, secundário a rotura completa do músculo vasto medial em paciente jogador de futebol. A ressonância magnética demonstrou lesão muscular associada a pseudoaneurisma, e a angiotomografia confirmou a presença de pseudoaneurisma associado a fístula arteriovenosa de ramo da artéria femoral profunda. Foi realizado tratamento endovascular da fístula através da embolização com micromolas fibradas e drenagem cirúrgica do hematoma muscular. O paciente evoluiu bem, sem queixas clínicas no 30º dia de pós-operatório e também após 1 ano.

Abstract Due to its anatomical characteristics, the deep femoral artery is protected from most vascular injuries. We report a case of a soccer player with pseudoaneurysm of a perforating branch of the deep femoral artery, associated with an arteriovenous fistula and secondary to complete rupture of the vastus medialis muscle. Magnetic resonance imaging showed muscle damage associated with a pseudoaneurysm and angiotomography confirmed the presence of a pseudoaneurysm associated with a deep arteriovenous fistula of a branch of the deep femoral artery. Endovascular treatment of the fistula was performed by embolization with fibrous microcoils and surgical drainage of the muscle hematoma. The patient recovered well, was free from clinical complaints on the 30th postoperative day and also after 1 year.

Pseudoaneurisma de la arteria femoral derecha posterior a cateterismo cardíaco / Right femoral artery pseudoaneurysm following cardiac catheterization

El pseudoaneurisma se puede definir como un hematoma pulsátil repermeabilizado y encapsulado, en comunicación con la luz de un vaso dañado. Los pseudoaneurismas de las extremidades son los más frecuentes; entre ellos se destacan los iatrogénicos de la arteria femoral. Su incidencia es del 2 por ciento-8 por ciento cuando se realizan angioplastia/stent coronarios y del 0,2 por ciento-0,5 por ciento cuando únicamente se hace angiografía diagnóstica. Se presenta un paciente con diagnóstico de pseudoaneurisma femoral derecho posterior a un cateterismo cardíaco, con el objetivo de demostrar la importancia del diagnóstico temprano de las pseudaeurismas para el tratamiento quirúrgico oportuno y evitar complicaciones posteriores. Al mes del procedimiento, el paciente comenzó con aumento de volumen en la región inguinal derecha y a la auscultación se apreció un soplo a ese nivel. Se le realizó exérisis del pseudoaneurisma y reparación quirúrgica de la arteria femoral. En las consultas de evaluación posoperatoria se mostró una evolución clínica y radiológica satisfactoria. El diagnóstico rápido de estas entidades vasculares evita que se presenten complicaciones posteriores y aseguran una evolución rápida y satisfactoria de los pacientes que la padecen(AU)

Pseudoaneurysm can be defined as a repermeabilized and encapsulated pulsatile hematoma, in communication with the light of a damaged vessel. Pseudoaneurysms of the limbs are the most frequent; among them are the iatrogenic of the femoral artery. Its incidence is 2 percent -8 percent when coronary angioplasty/stent is performed and 0.2 percent-0.5 percent when only diagnostic angiography is performed. A patient with a diagnosis of right femoral pseudoaneurysm after cardiac catheterization is presented, with the aim of demonstrating the importance of early diagnosis of pseudoaneurysms for timely surgical treatment and avoiding subsequent complications. A month after the procedure, the patient began with an increase in volume in the right inguinal region and auscultation showed a murmur at that level. Pseudoaneurysm exeresis and surgical repair of the femoral artery were performed. In the postoperative evaluation consultations, a satisfactory clinical and radiological evolution was shown. The rapid diagnosis of these vascular entities prevents subsequent complications from occurring and ensures a rapid and satisfactory evolution of patients who suffer from it(AU)

Nonbone Marrow CD34+ Cells Are Crucial for Endothelial Repair of Injured Artery.

[Figure: see text].

Predictive Factors of Severe Dissection after Balloon Angioplasty for Femoropopliteal Artery Disease.

BACKGROUND: Arterial dissection is one of the mechanisms of balloon angioplasty. Although some degree of dissection is unavoidable, severe dissection that impedes blood flow decreases patency and increases the need for additional procedures. To improve the results of angioplasty, it is necessary to understand the factors related to severe dissection and make efforts to reduce its occurrence. This study aimed to elucidate the predictive and protective factors associated with severe dissection in femoropopliteal balloon angioplasty. METHODS: This was a retrospective, single-center, nonrandomized study. A total of 409 limbs were studied in 334 patients with symptomatic femoropopliteal lesions treated between 2010 and 2019. Dissections after initial balloon angioplasty were classified according to the Kobayashi dissection classification (grade A: no dissection; B: mild dissection <1/3 of the lumen; C: severe dissection, ≥1/3 of the lumen) into the nonsevere dissection group (grades A and B), and severe dissection group (grade C). We compared clinical, procedural and lesion-related characteristics between the 2 groups. Factors with statistical significance in univariate analyses were entered into a multivariate logistic regression model to identify independent predictive factors of severe dissection. RESULTS: Severe dissection occurred in 237 limbs and nonsevere dissection in 172 limbs. In univariate analyses, the predictive factors of severe dissection were TransAtlantic Inter-Society Consensus II C/D grades (P < 0.001), lesion length ≥15cm (P < 0.001), chronic total occlusion (P = 0.004), and degree of stenosis ≥70% (P < 0.001). Protective factors for severe dissection were end-stage renal disease (P = 0.008), severe calcification >50% (P < 0.001), and the use of a scoring balloon (P = 0.001). In multivariate analysis, factors associated with severe dissection were lesion length ≥15cm (OR, 2.259; 95% CI: 1.417-4-3.601), occlusion or degree of stenosis ≥70% (OR, 1.931; 95% CI: 1.255-2.971), severe calcification (OR, 0.520; 95% CI: 0.338-0.800), and the use of a scoring balloon (OR, 0.467; 95% CI: 0.263-0.830). CONCLUSIONS: Lesion length ≥15cm and occlusion or stenosis ≥70% were identified as independent predictive factors of severe dissection in femoropopliteal artery balloon angioplasty. Conversely, severe calcification and the use of a scoring balloon appeared to be protective factors against severe dissection.

Celastrol ameliorates vascular neointimal hyperplasia through Wnt5a-involved autophagy.

Neointimal hyperplasia caused by the excessive proliferation of vascular smooth muscle cells (VSMCs) is the pathological basis of restenosis. However, there are few effective strategies to prevent restenosis. Celastrol, a pentacyclic triterpene, has been recently documented to be beneficial to certain cardiovascular diseases. Based on its significant effect on autophagy, we proposed that celastrol could attenuate restenosis through enhancing autophagy of VSMCs. In the present study, we found that celastrol effectively inhibited the intimal hyperplasia and hyperproliferation of VSMCs by inducing autophagy. It was revealed that autophagy promoted by celastrol could induce the lysosomal degradation of c-MYC, which might be a possible mechanism contributing to the reduction of VSMCs proliferation. The Wnt5a/PKC/mTOR signaling pathway was found to be an underlying mechanism for celastrol to induce autophagy and inhibit the VSMCs proliferation. These observations indicate that celastrol may be a novel drug with a great potential to prevent restenosis.

Salt-Inducible Kinase 3 Promotes Vascular Smooth Muscle Cell Proliferation and Arterial Restenosis by Regulating AKT and PKA-CREB Signaling.

Objective: Arterial restenosis is the pathological narrowing of arteries after endovascular procedures, and it is an adverse event that causes patients to experience recurrent occlusive symptoms. Following angioplasty, vascular smooth muscle cells (SMCs) change their phenotype, migrate, and proliferate, resulting in neointima formation, a hallmark of arterial restenosis. SIKs (salt-inducible kinases) are a subfamily of the AMP-activated protein kinase family that play a critical role in metabolic diseases including hepatic lipogenesis and glucose metabolism. Their role in vascular pathological remodeling, however, has not been explored. In this study, we aimed to understand the role and regulation of SIK3 in vascular SMC migration, proliferation, and neointima formation. Approach and Results: We observed that SIK3 expression was low in contractile aortic SMCs but high in proliferating SMCs. It was also highly induced by growth medium in vitro and in neointimal lesions in vivo. Inactivation of SIKs significantly attenuated vascular SMC proliferation and up-regulated p21CIP1 and p27KIP1. SIK inhibition also suppressed SMC migration and modulated actin polymerization. Importantly, we found that inhibition of SIKs reduced neointima formation and vascular inflammation in a femoral artery wire injury model. In mechanistic studies, we demonstrated that inactivation of SIKs mainly suppressed SMC proliferation by down-regulating AKT (protein kinase B) and PKA (protein kinase A)-CREB (cAMP response element-binding protein) signaling. CRTC3 (CREB-regulated transcriptional coactivator 3) signaling likely contributed to SIK inactivation-mediated antiproliferative effects. Conclusions: These findings suggest that SIK3 may play a critical role in regulating SMC proliferation, migration, and arterial restenosis. This study provides insights into SIK inhibition as a potential therapeutic strategy for treating restenosis in patients with peripheral arterial disease.