MicroRNA-1247 inhibits the viability and metastasis of osteosarcoma cells via targeting NRP1 and mediating Wnt/ß-catenin pathway.

OBJECTIVE: Osteosarcoma (OS) is a common malignant bone tumor that poses a serious threat to the health of adolescents or children. A large number of studies have proposed the role of microRNAs (miRNAs) in OS, except for miR-1247. Therefore, this research was designed to explore the molecular mechanism of miR-1247 in OS. PATIENTS AND METHODS: Quantitative Real Time-Polymerase Chain Reaction (qRT-PCR) or Western blot analysis was used to measure the expressions of miR-1247 and genes. The function of miR-1247 was investigated using Cell Counting Kit-8 (CCK-8) and transwell assays. The Dual-Luciferase reporter assay was used to explore the relationship between miR-1247 and neuropilin-1 (NRP1). RESULTS: MiR-1247 was downregulated in OS, which was related to the aggressive behavior of OS patients. Moreover, miR-1247 inhibited cell viability and metastasis in OS. At the same time, miR-1247 promoted apoptosis and inactivated the Wnt/ß-catenin pathway in OS. Furthermore, it was confirmed that NRP1 was a direct target of miR-1247. Upregulation of NRP1 attenuated the inhibitory effect of miR-1247 in OS. CONCLUSIONS: MiR-1247 played a suppressive role in OS by suppressing cell viability and metastasis.

Management of sudden profuse bleeding from varicose veins.

Varicose vein bleeding of the lower extremities is an unusual but pressing indication for treatment and can be lethal. This series reviews operative and injection treatment of such veins in patients with bleeding. During a 49-month period 14 patients (eight men and six women) with a mean age of 62.1 years (range, 23 to 93 years) were seen after venous bleeding related to varicosities of the lower extremity. They described between one and five episodes of bleeding (mean, 2.4), but only one patient required transfusion. The site of bleeding was the lower calf or foot in 11 and affected the thigh in three patients. One was in the third trimester of pregnancy. Nine patients had lesions involving clustered small 1 mm or less diameter varicose veins, whereas five had large diffuse varicose vein formation. None had evidence of coagulopathy, and the inciting episode was either unknown or related to minor trauma. Treatment of eight patients with small-diameter veins was instituted with 0.2% sodium tetradecyl injection with a 30-gauge needle, thrombosing veins within 5 cm of the bleeding focus. A total of 13 ml solution (1.0 to 27 ml) per patient was used during two or three treatment periods (mean, 2.5 treatment periods) spaced 2 weeks apart. Six patients were treated by means of standard vein-stripping techniques or local branch removal at the bleeding site. Effective thrombosis was achieved in all eight patients with small (less than 1 mm) varicose veins treated with sclerosis. In five patients who underwent surgery there was effective resolution of the hemorrhage. One patient with small-diameter varicose veins clustered about the ankle underwent operative treatment and had venous stasis ulceration requiring compression dressings for healing. In all 14 cases control of bleeding was obtained, with follow-up to 49 months (mean, 21.3 months); one had rebleeding from a site 32 cm remote from the original injected area 11 months after treatment. Bleeding from small-diameter varicose veins of the lower extremity can be controlled effectively by sclerosing techniques with sodium tetradecyl. Larger veins are managed with operative removal. Combining these techniques provides efficient management of often-elderly patients, many in an outpatient setting.

Patency of laser-assisted anastomoses in small vessels: one-year follow-up.

Laser-assisted arterial anastomoses can now be performed with satisfactory short-term patency. This study was undertaken to evaluate patency and aneurysm formation with a 1-year follow-up. A microscopically guided CO2 laser was used to anastomose 1.5 to 2.0 mm carotid arteries in 24 rabbits. Under X6 to X40 magnification, 60 to 70 mW were delivered with a spot size of approximately 0.32 mm. One carotid artery underwent laser anastomosis; the opposite served as a sutured control (10-0 nylon sutures). The 48 end-to-end anastomoses were evaluated for patency and aneurysm formation at 3, 6, and 12 months. Aneurysms were defined as a 1.5 times increase in diameter at the anastomotic site. The vessels underwent microscopic examination. All laser-assisted and sutured anastomoses were patent up to 1 year. At 3 months, one of eight sutured and one of eight laser anastomoses were aneurysmal; stenosis was noted in one laser anastomosis. At 6 months, one of eight laser and 0 of eight sutured anastomoses were aneurysmal. At 12 months, one of eight rabbits had died; of the remaining seven, three of seven laser and zero of seven sutured anastomoses were aneurysmal. In total, five of 23 (21.7%) aneurysms developed with the laser technique and one of 23 (4.3%) with the suture technique (p less than 0.05). Laser-assisted anastomoses are technically feasible, and patency at 1 year is equal to those performed with the suture technique. Aneurysm formation is a consistent problem that demands further investigation.

Abdominal aortic salmonellosis.

A recent example of Salmonella mycotic abdominal aortic aneurysm is presented together with a review of the 24 other cases in the literature. Emphasis is placed on common modes of presentation, diagnosis, and surgical management. A review of current theories of etiology is presented along with a new, more descriptive classification of mycotic aneurysms.

Use of the axillary artery in complex cerebral revascularization.

Two cases of complex common carotid and innominate artery disease managed by axillocarotid autogenous saphenous vein bypass are presented, including a detailed description of the operative technique. The results in each case were gratifying. Although the concept of extra-anatomic repair is not new, this modification in operative technique expands the surgeon's armamentarium. The ease and safety of exposure and anastomosis of the axillary artery combine to make it the preferable donor vessel for extra-anatomic cerebral revascularization in the poor-risk, elderly patient population.

Factor VIII-related antigen in occluded human arteries and grafts.

Direct immunofluorescence was used to determine the disposition of factor VIII-related antigen (VIIIR:Ag) in occluded arteries and grafts from patients undergoing reconstructive operation. The presence of VIIIR:Ag on the luminal surface of these vessels was equated with their endothelialization according to the work of others. In 12 of the 20 arteries examined, stain for VIIIR:Ag was absent or markedly reduced from the luminal surfaces, and in six more it was only present focally. The adventitial capillaries were brightly stained in most of these specimens. Both of two saphenous vein grafts and all of six Dacron grafts stained for VIIIR:Ag along their luminal surfaces and in the adventitial capillaries as brightly as normal arteries. However, all of eight Gore-tex grafts had little or no stain for VIIIR:Ag along their luminal surfaces, and the capillaries of the adventitia were not as plentiful as those in the normal arteries and Dacron grafts. With one exception, the Gore-tex grafts had become occluded less than 1 year after implantation, while the Dacron grafts had remained patent for 2 to 8 years. Thus many of the diseased arteries and the short-lived Gore-tex grafts were characterized by relative absence of VIIIR:Ag from their luminal surfaces, presumably reflecting the loss or absence of endothelialization.

Popliteal venous aneurysms.

Popliteal venous aneurysms are rarely reported but represent a potentially life-threatening condition requiring accurate diagnosis and surgical resection. Newer techniques including magnetic resonance imaging, computed tomography, and color flow duplex imaging offer new noninvasive methods to define popliteal fossa venous abnormalities. Excision of the aneurysm with venous reconstruction removes the embolic source and maintains prograde venous flow. A posterior surgical approach to the popliteal fossa is recommended to facilitate exposure. Early control of venous outflow is needed to avoid thromboembolism. This report describes the diagnosis and treatment of popliteal venous aneurysms in three patients with a review of the English-language literature.

Activated inflammatory cells are associated with plaque rupture in carotid artery stenosis.

BACKGROUND: Histologic studies of carotid plaques have demonstrated an association between symptomatic disease and plaque rupture. The purpose of this study was to characterize the cellular changes associated with plaque rupture. METHODS: Carotid plaques were obtained from 61 patients undergoing carotid endarterectomy for established indications. Plaques were fixed in formalin, embedded in paraffin, and stained with hematoxylineosin and Movat pentachrome stain to demonstrate plaque structure. Each plaque was examined with light microscopy and classified as containing evidence of plaque rupture (n = 29) or no plaque rupture (n = 32). By using immunohistochemical staining, the fibrous cap was examined for the presence of smooth muscle cells (alpha-actin), macrophages (KP-1), T lymphocytes (UCHL-1), and cell activation (HLA-DR). Data were analyzed with chi-squared analysis. RESULTS: With plaque rupture, macrophages and T lymphocytes were significantly more common than in specimens without evidence of rupture. Similarly, macrophages and T lymphocytes expressing HLA-DR were more often found in sections containing plaque rupture. Furthermore, vascular smooth muscle cells were more common with intact fibrous caps and were diminished with cap thinning. CONCLUSIONS: Rupture of the fibrous cap in carotid artery lesions is associated with increased numbers of macrophages and T lymphocytes, which are in an activated state. The activated inflammatory cells may release cytokines or metalloproteinases, which may be responsible for loss of the fibrous cap. Thus inflammation appears to play a role in the pathogenesis of the neurologic symptoms associated with carotid artery stenosis.

Use of a temporary shunt for renal transplant protection during aortic aneurysm repair.

Broader indications for renal transplantation and improved allograft survival suggest that aortic aneurysms will be encountered more commonly in kidney transplant recipients. This report describes the use of a temporary heparin-bonded shunt placed from the proximal abdominal aorta to the femoral artery for perfusion of a renal allograft during simultaneous repair of an aortic aneurysm and correction of transplant renal artery stenosis. Renal function was satisfactorily maintained intraoperatively and has continued to be excellent during 2 1/2 years of follow-up. Methods of renal transplant protection during aortic reconstruction are reviewed, and principles of temporary shunting for allograft protection are proposed.

Hemodynamic assessment of venous problems.

Objective assessment of venous function based on venous refilling time recorded by photoplethysmography (PPG) was done in 89 patients with postphlebitic syndrome (47), primary varicose veins (29), and after an episode of acute deep vein thrombosis (13). Limbs with symptomatic postphlebitic changes had a shortened venous refilling time of 15.6 +/- 11 seconds (normal greater than 20 seconds). When venographic findings (ascending and descending) in 47 patients with postphlebitic syndrome were analyzed, it was noted that femoral valve incompetence demonstrated by descending venography was a common finding (81%), even in asymptomatic limbs (85%). Venous refilling time bore no relationship to the degree of femoral venous valve reflux. However, if there were associated diseased deep veins with incompetent perforating veins, the venous refilling time was much shorter (14 +/- 4 seconds) than in limbs without calf perforating veins (27 +/- 11.9 seconds, P less than 0.05). A tourniquet was used to impede saphenous flow, and changes in refilling time were recorded in 34 limbs with varicosities of the long saphenous vein. Refilling time normalized after tourniquet application in 31 limbs (14.43 +/- 4.34 to 30.64 +/- 11.9 seconds), and all patients underwent vein stripping. Postoperative recording confirmed the improvement in venous refilling time (29.52 +/- 27.8 seconds, P less than 0.05). Thirteen patients with acute deep vein thrombosis had serial PPG tests during a follow-up period of 27 months (mean 15.8 months). Seven had initial abnormal PPG results and persistently abnormal readings, and all developed postphlebitic changes. Venous refilling time is an useful test to determine the hemodynamic significance of femoral venous valve incompetence and to assess the effect of vein stripping on varicose veins. In acute deep vein thrombosis, follow-up study may help to identify patients at risk for development of postphlebitic changes.

Correlation of immune and nutritional status with wound complications in patients undergoing vascular operations.

The acquired failure of host immunocompetence that may result from significant protein and caloric malnutrition has been associated with an increased incidence of septic complications in patients undergoing operation. Wound infection in patients undergoing vascular surgical procedures may lead to exposure or contamination of a vascular graft, with the subsequent risk of hemorrhage, limb loss, or death. The present study was undertaken to correlate the immune and nutritional status of patients undergoing vascular surgical procedures with the development of significant wound complications. Seventy-nine patients undergoing a variety of vascular operations were subjected to comprehensive nutritional assessment, including anthropometric measurements (height, weight, midarm circumference, triceps skin fold), serologic testing (albumin, transferrin, lymphocyte count, serum zinc), cutaneous assessment of delayed hypersensitivity (anergy battery), and neutrophil functional analysis. After operation the patients were observed for the development of delayed wound healing or wound infection. Statistical analysis of measured variables was performed to identify immune and nutritional markers with prognostic value. Patients with serum albumin levels above 3 gm/dl were much more likely to have uncomplicated wound healing (P less than 0.001). Similarly, patients with serum transferrin levels above 150 mg/dl had significantly fewer wound problems (P less than 0.01). Only 29% of patients with cutaneous anergy had normal wound healing, while 56% of those with intact cutaneous reactivity healed primarily; this difference, however, was not statistically significant. Diabetics in this series were more likely to develop wound problems (P less than 0.05). Anthropometric measurements provided no predictive information regarding the likelihood of uncomplicated healing. Similarly, measurement of total lymphocyte count and serum zinc yielded no significant prognostic information. The urgent nature of many vascular surgical procedures may preclude preoperative immune and nutritional assessment; however, the outcome of these procedures may ultimately depend upon intact host defense. The contribution of protein and caloric malnutrition to immunocompromise can be easily assessed in these patients. The detection and subsequent reversal of immunoincompetence through the use of enteral or parenteral alimentation should provide a significant reduction in operative morbidity and mortality.

Intimal hyperplasia and neointima: An ultrastructural analysis of thrombosed grafts in humans.

The distal anastomoses of thrombosed saphenous vein (11), bovine (4), Dacron (7), and polytetrafluoroethylene (PTFE) (27) grafts removed en bloc during reoperation or amputation were studied with light microscopy, scanning electron microscopy, and transmission electron microscopy. Analysis of the ultrastructures of the distal anastomostic regions was done to characterize morphogenesis of intimal hyperplasia and neointimal proliferation. Complete reendothelialization occurred in all vein grafts. In bovine heterografts, there were isolated areas of endothelia. Thrombosed PTFE grafts were lined with gelatinous, proteinaceous material with no consistent organized cellular pattern. In contrast, laminated fibrous tissue produced by fibroblasts lined the Dacron grafts. Intimal hyperplasia was found in 6 of 11 vein grafts and in all prosthetic grafts examined. Regardless of the type of graft used, intimal hyperplasia was found predominantly at the heel of the graft and on the floor of the artery. Beneath the endothelia, collagenous ground substance and myofibroblasts mixed with smooth muscle cells were seen, characterized by pyknotic nuclei, reduced cytoplasm/nuclei ratio, and loss of cytoplasmic organelles. Endothelialization occurred exclusively in vein grafts. Prosthetic grafts lacked endothelia, with the neointima consisting of fibroblasts and fibrous matrix. In intimal hyperplasia, two forms of smooth muscle cell pathomorphogenesis were recognized. Formation of myofibroblasts induced medial fibroplasia, whereas degeneration of muscle cells progressed to medial necrosis. Smooth muscle cells seem to play a role not previously recognized in the pathogenesis of graft failure.

Sequential femoral-tibial bypass for severe limb ischemia.

Sequential femoral-popliteal-tibial bypass has been recommended for surgical treatment of severe lower limb ischemia in patients with complex multisegmental arterial occlusion. To evaluate this alternative technique critically, sequential grafting was performed in 40 limbs with severe ischemia manifest by rest pain (20), nonhealing ulceration (eight), or gangrene (12). Measurement of segmental Doppler arterial pressure revealed a significant increase in ankle brachial index from 0.29 +/- 0.15 before operation to 0.93 +/- 0.12 after operation, confirming the hemodynamic improvement among these patients. In the early postoperative period occlusion of the distal graft segment was recognized in 12 patients by a characteristic reduction of the ankle/brachial index (0.50 +/- 0.14), while the low thigh pressures remained unchanged. Recurrent severe ischemia was prevented in most by persistent patency of the proximal graft segment. Overall, significant hemodynamic improvement was achieved in 29 of 38 limbs, a limb salvage rate (76%) comparable to that reported for femoral-distal bypass or femoral-popliteal bypass to an isolated popliteal segment. Early graft failure in this series resulted in major amputation in eight of 16 limbs, a significantly lower rate than for these other techniques. Sequential bypass grafting is a useful alternative method for limb salvage. The preservation of the proximal graft patency after distal segmental occlusion may be an important characteristic of this type of reconstruction.

A systematic approach to severe hand ischemia.

Because severely symptomatic hand ischemia is not common and because there are a wide variety of clinical conditions which can cause arterial insufficiency of the upper extremity, a retrospective study has been done to determine the efficacy of various diagnostic manipulations used in managing 65 patients with severe hand ischemia at the Northwestern University McGaw Medical Center, Traumatic, thermal, and iatrogenic causes of hand ischemia were diagnosed by simple history taking, as was advanced uremic arteritis. Doppler ultrasound and digital arterial pressure recording were confirmative, rather than diagnostic. These aided in defining precise degrees of ischemia and identifying proximal arterial occlusions. Invasive total extremity angiography clarified atherosclerotic, atheroembolic, and other chronic occlusive lesions while serum electrophoresis and immunoelectrophoresis defined the polyclonal and monoclonal gammopathies. When digital necrosis was present, organic arterial occlusions usually were found. These responded best to direct arterial reconstruction down to the mid-palm level. Transpleural, transthoracic sympathectomy was useful as an adjuvant or as definitive treatment for distal digital arterial occlusions. Selective vasodilator therapy was used as dictated by the cause of ischemia and its eventual outcome.

Forefoot perfusion pressure and minor amputation for gangrene.

In many cases of digital gangrene, limited amputation to preserve the majority of the foot is possible. In the absence of invasive infection, forefoot perfusion pressure is the single most important factor in determining outcome of minor amputation. At ankle pressures of less than 35 mm. Hg, salvage of the foot appears to be futile. The presence or absence of diabetes mellitus has no noticeable effect on the result of amputation. Ankle systolic pressure measurement cannot supplant but should supplement clinical judgement in selecting surgical treatment for gangrene.

Ankle pressure changes in distal bypass grafts during knee flexion.

Systolic ankle blood pressure was measured with the limb extended and then acutely flexed in four study groups. These included 11 normal individuals, 11 patients with below-knee autologous saphenous vein bypass grafts, 11 patients with polytetrafluoroethylene (PTFE) prosthetic below-knee bypass grafts, and 11 patients with femoropopliteal arterial occclusion who had not undergone bypass grafting. This study shows that normal limbs, limbs with saphenous vein bypass grafts, arteriosclerotic limbs, and those with PTFE bypass grafts all tolerate acute knee flexion without significant decrease in distal blood pressure.

Assessment of donor limb hemodynamics in femorofemoral bypass for claudication.

During a 5-year period (1975 to 1980), 44 patients underwent femorofemoral bypass for unilateral disabling claudication caused by iliac atheroocclusive disease. All patients had complete Doppler arterial examination performed pre- and postoperatively, including segmental thigh and ankle pressure and calculation of an ankle/brachial (A/B) index for each limb. In 37 patients, standard treadmill exercise testing was performed before and after femorofemoral grafting. Hemodynamic improvement in the symptomatic limb was evidenced by an increase in resting A/B index from a mean of 0.54 +/- 0.14 before to 0.76 +/- 0.22 after operation (P less than 0.001). Exercise tests which were abnormal in all 37 recipient limbs preoperatively were improved. Six of the seven unimproved recipient limbs had associated femoropopliteal occlusion. Donor limb mean resting ankle/brachial index fell from 0.93 +/- 0.22 before to 0.83 +/- 0.22 after surgery (P less than 0.05). However, in 13 of 23 donor limbs, exercise response which had been normal before surgery became abnormal. Additionally, in 14 patients with abnormal donor limb exercise response before grafting, seven limbs had a significantly worsening of the exercise response postoperatively. These findings were not related to the patency of the superficial femoral artery in the donor limb. Deterioration in donor limb hemodynamics noted in 20 (45%) of the 44 patients in this series suggests that strict patient selection criteria should be maintained. Unlike in healthy subjects, an arteriographically patent atherosclerosis iliac artery may not support flow requirements of bilateral lower limb exercise.

Correlation of foot arterial anatomy with early tibial bypass patency.

The detailed arterial anatomy of the foot in severe limb ischemia is not well known. This study was undertaken to define foot arterial anatomy and correlate these findings with the early results (6 months) of femoral-distal bypass. After completion of the bypass, operative arteriography was performed by direct injection of contrast media into the graft. A lateral view of the distal limb and foot was obtained. Foot vessel anatomy was classified into primary and secondary pedal arches, analogous to the superficial and deep volar arches of the hand. For peroneal bypass, special attention was paid to perforating branches and their communications with these two pedal arches. A total of 56 distal bypass operations was analyzed. Femoral--anterior tibial bypass was performed in 26 cases. When either a primary or a secondary pedal arch was intact, early graft patency (6 months) was achieved in 20 of 21 patients. When neither pathway was present, graft failure occurred in four of five cases. Similarly, of 10 femoral--posterior tibial grafts, seven remained patent with at least one pedal arch intact, whereas six of seven grafts failed when neither arch was patent. Bypass to the peroneal artery was successful in eight of nine limbs when a patent primary or secondary arch was reconstituted via either the anterior or posterior perforating branches. None of four peroneal grafts remained patent when both arches were occluded. As a whole, in 40 limbs with either a patent primary or secondary pedal arch, early graft success was achieved in 35 limbs (87.5%). In contrast, in 16 limbs with no patent arch, only two (12.5%) were successfully reconstructed (P less than 0.001). Analysis of the results of femoral-distal bypass based on a single plantar arch as the sole determining anatomic factor in graft patency is not adequate. The secondary pedal arch and communicating branches of the peroneal artery are also of surgical significance. Operative arteriography can define runoff in the foot, and this information has prognostic significance. It may allow rational judgment regarding reintervention in patients with failed grafts.

Lymphatic disruption in varicose vein surgery.

In order to investigate the possibility of lymphatic disruption occurring during varicose vein surgery, lymphangiography performed by a modification of the Kinmonth technique was done in seven patients before and after standard surgical ablation of primary varicose veins. All seven patients demonstrated marked disruption of lymphatics. Extravasation of lymphangiogram contrast medium at the calf level and at the thigh level precluded demonstration of the groin lymphatics. It is concluded that lymphatic disruption attends varicose vein removal and such lymphatic damage contributes to postoperative leg edema.

Management of infection of major amputation stumps after failed femorodistal grafts.

A retrospective review was performed of 174 patients who underwent 199 lower-extremity amputations for unreconstructable vascular insufficiency from 1976 to 1983 at the Northwestern University Medical Center. This study was initiated to identify the cause of amputation wound healing complications and secondary ascending prosthetic graft infection, as well as to propose a plan of management for the failed prosthetic grafts at the time of major limb amputation. Ninety-eight amputations were performed primarily, 12 were performed secondary to graft infection, and 89 were performed in patients who had previously undergone infrainguinal arterial bypass procedures. At the time of amputation, graft management consisted of high transection and suture ligation, allowing the graft to retract into the substance of the stump and away from the skin suture line and weight-bearing area of the limb. Delayed stump healing was noted to occur more commonly in the group who had undergone previous bypasses as opposed to those who had undergone primary amputation (34.8% versus 14.3%). Fourteen graft infections developed in 89 patients after amputation (15.7%), which is significantly higher than the overall 1.4% incidence of lower-extremity bypass infections that occurred during the same interval in patients with intact extremities. In addition, it was found that when infected grafts in amputated limbs were completely removed, stump healing without recurrent wound and graft sepsis was better than when treated locally or with partial graft removal. We therefore recommend removal of a thrombosed graft with an infected wound or an infected graft at the time of major limb amputation to decrease the incidence of wound complications and graft infection.