Evaluation of non-stenotic carotid atherosclerotic plaques with combined FDG-PET imaging and CT angiography in patients with ischemic stroke of unknown origin.

OBJECTIVES: Non-stenotic plaques are an underestimated cause of ischemic stroke. Imaging aspects of high-risk carotid plaques can be identified on CT angiography (CTA) and 18F-fluoro-deoxyglucose positron emission tomography (FDG-PET) imaging. We evaluated in patients with cryptogenic ischemic stroke the usefulness of FDG-PET-CTA. METHODS: 44 patients imaged with CTA and FDG-PET were identified retrospectively. Morphological features were identified on CTA. Intensity of FDG uptake in carotid arteries was quantified on PET. RESULTS: Patients were imaged 7 ± 8 days after stroke. 44 non-stenotic plaques with increased 18F-FDG uptake were identified in the carotid artery ipsilateral to stroke and 7 contralateral. Most-diseased-segment TBR on FDG-PET was higher in artery ipsilateral vs. contralateral to stroke (2.24 ± 0.80 vs. 1.84 ± 0.50; p < .05). In the carotid region with high FDG uptake, prevalence of hypodense plaques and extent of hypodensity on CTA were higher in artery ipsilateral vs. contralateral to stroke (41% vs. 11%; 0.72 ± 1.2 mm2 vs. 0.13 ± 0.43 mm2; p < .05). CONCLUSIONS: In patients with ischemic stroke of unknown origin and non-stenotic plaques, we found an increased prevalence of high-risk plaques features ipsilateral vs. contralateral to stroke on FDG-PET-CTA imaging suggesting a causal role for these plaques.

Oral microbiota and atherothrombotic carotid plaque vulnerability in periodontitis patients. A cross-sectional study.

BACKGROUND: An increased risk of atherothrombotic vascular events has been reported in periodontitis patients. Periodontitis is associated with dysbiotic subgingival biofilms and bacteremia. OBJECTIVE: We hypothesized (a) that the oral microbiome is associated with the carotid microbiome and (b) that periodontitis could contribute to plaque vulnerability. The aim of this study was to determine the associations between periodontitis, the carotid microbiome, and the local innate immune response in carotid atherothrombotic plaques vulnerable to rupture. METHODS: In this cross-sectional study, 45 patients admitted for carotid endarterectomy underwent a preoperative periodontal examination. The volume of intraplaque hemorrhage reflected by the hemoglobin level released in carotid-conditioned media was considered as a criterion of carotid plaque vulnerability. Levels of antibodies against periodontal bacteria were determined in sera. The signature of the oral microbiota was assessed by microbial whole-genome sequencing, nested PCR, and immunostaining in carotid plaque samples. Markers of neutrophil recruitment (leukotriene B4), neutrophil activation (myeloperoxidase, defensins), and cytokines were measured in carotid-conditioned media and/or plasma. RESULTS: All patients exhibited periodontitis. One hundred and forty-four bacterial genera were detected in the carotid microbiome. While Streptococcus was found in 84% of the carotid samples, periodontitis-associated genera were detected in 21%. P. gingivalis DNA and gingipains were also identified in carotid samples. There were significant inverse correlations between periodontal attachment loss/serum anti-P. gingivalis Immunoglobulin A and cytokine inhibiting neutrophils (all P < .01). There were also significant positive correlations between lipopolysaccharides, myeloperoxidase/human neutrophil peptides1-3, and hemoglobin levels (all P < .01). CONCLUSIONS: In patients at risk of stroke, the carotid plaque microbiome was highly diverse and compatible with an oral origin. Periodontitis was significantly associated with neutrophil activation markers and plaque vulnerability to rupture.

Spontaneous and isolated dissection of the superior mesenteric artery: proposal of a management algorithm.

BACKGROUND: Spontaneous and isolated dissection of the superior mesenteric artery (SIDSMA) is a rare pathology, and the treatment of symptomatic forms is not consensual. The objective of this study was to analyze the management of a series of patients presenting a symptomatic SIDSMA within a structure taking care of intestinal vascular emergencies. METHODS: From January 2010 to January 2014, the patients presenting a symptomatic SIDSMA were included retrospectively. The clinical and radiologic data as well as the treatment and the follow-up were analyzed. RESULTS: Nine patients were included. Among them, 2 patients presenting with acute mesenteric ischemia were revascularized surgically in emergency, and 1 patient presenting a rupture of a superior mesenteric artery aneurysm had an arteriography followed by medical care. The 6 other patients received medical treatment. Among these, 2 patients developed mesenteric angina requiring surgical revascularization during the follow-up. CONCLUSIONS: The revascularization of spontaneous and isolated dissections of the superior mesenteric artery is indicated in the cases complicated with acute mesenteric ischemia, aneurysmal rupture, or in the event of appearance of mesenteric angina or aneurysmal evolution. It should also be discussed in the event of failure of the medical treatment.

Survival benefit of lung transplant for cystic fibrosis since lung allocation score implementation.

RATIONALE: The survival benefit of lung transplantation (LT) in adult patients with cystic fibrosis (CF) is debated. OBJECTIVES: We sought to assess the survival benefit of LT in adult patients with CF. METHODS: We used data from the United Network for Organ Sharing Registry to identify adult patients with CF on a wait list for LT in the United States between 2005 and 2009. Survival times while on the wait list and after LT were modeled by use of a Cox model that incorporated transplantation status as a time-dependent covariate. Evolution in lung allocation score (LAS) while on the wait list was used as a surrogate for disease severity. We fitted a model for the joint distribution of survival and longitudinal disease process (LAS over time). MEASUREMENTS AND MAIN RESULTS: A total of 704 adult patients with CF were registered on a wait list during the study period. The cumulative incidence of LT was 39.3% (95% confidence interval, 35.6-42.9%) at 3 months and 64.7% (61.0-68.4%) at 12 months, whereas the incidence of death while on the wait list at the same times was 8.5% (6.4-10.6%) and 12.9% (10.3-15.5%), respectively. Survival after LT was 96.5% (94.7-98.2%) at 3 months; 88.4% (85.1-91.8%) at 12 months; and 67.8% (59.9-76.8%) at 3 years. LT conferred a 69% reduction in the instantaneous risk of death (51-80%). The interaction between LAS and LT was significant: the higher the LAS, the greater the survival benefit of LT (P < 0.001). CONCLUSIONS: LT confers a survival benefit for adult patients with CF.

Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure.

BACKGROUND & AIMS: Acute mesenteric ischemia (AMI) is an emergency with a high mortality rate; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multimodal management approach, focused on intestinal viability. METHODS: In an Intestinal Stroke Center, we developed a multimodal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, nonocclusive AMI, chronic mesenteric ischemia, and other emergencies were excluded. Patients received specific medical management: revascularization of viable small bowel and/or resection of nonviable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients who survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidity. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early or late-stage disease. RESULTS: Patients were followed up for a mean of 497 days (range, 7-2085 d); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P = .03). Among patients with early or late-stage AMI, rates of resection were 18% and 71%, respectively (P = .049). Patients with early stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm; P = .02), and spent less time in intensive care (2.5 vs 49.8; P = .02). CONCLUSIONS: A multidisciplinary and multimodal management approach might increase survival of patients with AMI and prevent intestinal failure.

The hedgehog system machinery controls transforming growth factor-ß-dependent myofibroblastic differentiation in humans: involvement in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a devastating disease of unknown cause. Key signaling developmental pathways are aberrantly expressed in IPF. The hedgehog pathway plays a key role during fetal lung development and may be involved in lung fibrogenesis. We determined the expression pattern of several Sonic hedgehog (SHH) pathway members in normal and IPF human lung biopsies and primary fibroblasts. The effect of hedgehog pathway inhibition was assayed by lung fibroblast proliferation and differentiation with and without transforming growth factor (TGF)-ß1. We showed that the hedgehog pathway was reactivated in the IPF lung. Importantly, we deciphered the cross talk between the hedgehog and TGF-ß pathway in human lung fibroblasts. TGF-ß1 modulated the expression of key components of the hedgehog pathway independent of Smoothened, the obligatory signal transducer of the pathway. Smoothened was required for TGF-ß1-induced myofibroblastic differentiation of control fibroblasts, but differentiation of IPF fibroblasts was partially resistant to Smoothened inhibition. Furthermore, functional hedgehog pathway machinery from the primary cilium, as well as GLI-dependent transcription in the nucleus, was required for the TGF-ß1 effects on normal and IPF fibroblasts during myofibroblastic differentiation. These data identify the GLI transcription factors as potential therapeutic targets in lung fibrosis.

Microparticles from human atherosclerotic plaques promote endothelial ICAM-1-dependent monocyte adhesion and transendothelial migration.

RATIONALE AND OBJECTIVE: Membrane-shed submicron microparticles (MPs) released following cell activation or apoptosis accumulate in atherosclerotic plaques, where they stimulate endothelial proliferation and neovessel formation. The aim of the study was to assess whether or not MPs isolated from human atherosclerotic plaques contribute to increased endothelial adhesion molecules expression and monocyte recruitment. METHOD AND RESULTS: Human umbilical vein and coronary artery endothelial cells were exposed to MPs isolated from endarterectomy specimens (n=62) and characterized by externalized phosphatidylserine. Endothelial exposure to plaque, but not circulating, MPs increased ICAM-1 levels in a concentration-dependant manner (3.4-fold increase) without affecting ICAM-1 mRNA levels. Plaque MPs harbored ICAM-1 and transferred this adhesion molecule to endothelial cell membrane in a phosphatidylserine-dependent manner. MP-borne ICAM-1 was functionally integrated into cell membrane as demonstrated by the increased ERK1/2 phosphorylation following ICAM-1 ligation. Plaque MPs stimulated endothelial monocyte adhesion both in culture and in isolated perfused mouse carotid. This effect was also observed under flow condition and was prevented by anti-LFA-1 and anti-ICAM-1 neutralizing antibodies. MPs isolated from symptomatic plaques were more potent in stimulating monocyte adhesion than MPs from asymptomatic patients. Plaque MPs did not affect the release of interleukin-6, interleukin-8, or MCP-1, nor the expression of VCAM-1 and E-selectin. CONCLUSION: These results demonstrate that MPs isolated from human atherosclerotic plaques transfer ICAM-1 to endothelial cells to recruit inflammatory cells and suggest that plaque MPs promote atherosclerotic plaque progression.

Absence of inflammatory conditions in human varicose saphenous veins.

INTRODUCTION: Varicose veins affect one-third of the adult population in western countries, but their pathogenesis is incompletely characterized. One of the most controversial issues is the role of inflammation. It is well known that inflammation involves an increased expression/activity of inflammatory mediators. OBJECTIVE: The aim of this study was to investigate the presence or absence of mediators of inflammation in varicose as compared to healthy veins. METHODS AND RESULTS: Using immunohistofluorescence on varicose and healthy veins, we investigated the presence of inflammatory cells. They were not detectable. Venous wall C-reactive protein (CRP), fibrinogen (EIA) and pentraxin-3 (Western blot) content were measured. CRP was significantly lower in varicose veins, but no difference was found for fibrinogen or pentraxin-3 between varicose and healthy veins. No difference was observed for enzymes involved in inflammation and responsible for arachidonic acid metabolism such as the acute phase reactant secreted phospholipase A2-IIA and cyclooxygenase-2, as determined in varicose and healthy veins by Western blot and real-time qRT-PCR. CONCLUSIONS: Our experiments demonstrate no increase in the presence of mediators of inflammation in varicose as compared to healthy veins, suggesting that inflammation may not be an important contributor to the pathogenesis of varicose veins.

Long-term survival after hepatic and pulmonary resection of colorectal cancer metastases.

BACKGROUND: Recent changes in adjuvant therapies improved the prognosis of metastatic colorectal cancers. Curative resection may be considered, even for both pulmonary and hepatic metastases, but prognostic factors are not well identified. METHODS: From 1995 to 2010, 69 patients had curative resection of pulmonary metastases of colorectal cancer; 31 had also hepatic metastases. Pulmonary and hepatic resection occurred in 2 steps (87%). We studied overall and disease-free survival and prognostic factors. RESULTS: Primary tumor location was the rectum in 10 cases (32%). Pulmonary metastases were synchronous in 5 (16%) and bilateral in 6 (19%). One patient (3%) died after pulmonary surgery. One (3%) had positive surgical margins for pulmonary metastases. Median overall survival was 44 months (5-year rate = 36%); median disease-free survival was 22 months (5-year rate = 10%). Factors linked to impaired survival were rectal primary tumor (P = 0.04) and bilateral pulmonary metastases (P = 0.02) for overall survival, and pulmonary metastase ≥ 20 mm (P = 0.04) for disease-free survival. CONCLUSION: When associated to adjuvant therapy, complete resection of pulmonary and hepatic metastases of colorectal cancer allows long-term survival in one third of the patients.

A comparative study of PGI2 mimetics used clinically on the vasorelaxation of human pulmonary arteries and veins, role of the DP-receptor.

Prostacyclin (PGI2) and its mimetics (iloprost, treprostinil, beraprost and MRE-269) are potent vasodilators (via IP-receptor activation) and a major therapeutic intervention for pulmonary hypertension (PH). These PGI2 mimetics have anti-proliferative and potent vasodilator effects on pulmonary vessels. We compared the relaxant effects induced by these recognized IP-agonists in isolated human pulmonary arteries (HPA) and veins (HPV). In addition, using selective antagonists, the possible activation of other prostanoid relaxant receptors (DP, EP4) was investigated. Iloprost and treprostinil were the more potent relaxant agonists when both vessels were analyzed. HPA were significantly more sensitive to iloprost than to treprostinil, pEC50 values: 7.94±0.06 (n=23) and 6.73±0.08 (n=33), respectively. In contrast, in HPV these agonists were equipotent. The relaxations induced by treprostinil were completely or partially inhibited by IP-antagonists in HPA or HPV, respectively. The effects of the IP-agonists were not significantly modified by the EP4 antagonist. Finally, DP-antagonists inhibited the relaxations induced by treprostinil in HPV, suggesting that the DP-receptor plays a role in treprostinil-induced relaxation in the HPV. These data suggest that iloprost and treprostinil should be the most effective clinically available agonists to decrease pulmonary vascular resistance and to prevent oedema formation (by similar decrease in HPA and HPV resistance) in PH patients.

Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients.

OBJECTIVE: This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE). METHODS: From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed. RESULTS: Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2. CONCLUSIONS: This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management.

Aortic rupture due to pneumococcal infection in aortoiliac stents.

We report a rare case of pneumococcal aortitis secondary to endovascular bare-metal stent infection. The patient was a 70-year-old man presenting with back pain 1 year after aortoiliac implantation of bare-metal kissing stents. Final diagnosis was microbial aortitis due to Streptococcus pneumoniae involving the stents that resulted in a contained aortic rupture requiring urgent surgical treatment. Emergency extra-anatomic revascularization, excision of the infected tissues, and appropriate antibiotic therapy led to a favorable outcome. A high index of suspicion is required in such a situation because the mortality rate is very high in the absence of appropriate treatment.

Carotid endarterectomy in the acute phase of crescendo cerebral transient ischemic attacks is safe and effective.

OBJECTIVE: To document the 30- and 90-day outcomes in patients with severe internal carotid artery stenosis who underwent carotid endarterectomy in the acute phase of crescendo cerebral transient ischemic attacks (CcTIAs). METHODS: From January 2003 to December 2009, data from patients suffering CcTIAs with an ipsilateral severe internal carotid artery stenosis and consecutively operated in our department were prospectively collected. CcTIA patients operated in the acute phase were those who had experienced ≥ two cerebral TIAs and had been consecutively operated within 2 weeks of their first-ever TIA. Clinical assessment was by the vascular neurologist. Duplex ultrasonography was initially used for the diagnosis of severe (>70%) ipsilateral internal carotid artery and further assessed by magnetic resonance angiography and/or computed tomography angiography. Brain damage was assessed by magnetic resonance imaging or at default computed tomography scan. Perioperative medical treatment and operative techniques were standardized. Stroke, death, and major cardiac events were analyzed. RESULTS: Sixty-four patients sustained a median of four cerebral TIAs. Median delay to surgery from initial examination was 5 days. The mean degree of internal carotid artery stenosis was 87.9%. Of the 55 patients who had magnetic resonance imaging with diffusion-weighted imaging, 43 (78%) patients had new acute infarction in an area that corresponded to the clinical symptoms. All patients received antiplatelet therapy and statin during the intervening period. All patients underwent conventional carotid endarterectomy (CEA) with patch angioplasty (polytetrafluoroethylene). Fifty-six patients (87.5%) underwent CEA under local anesthesia with two (3.5%) utilizing selective shunting, and eight patients had general anesthesia with systematic shunting. From CEA to discharge, all patients had complete recovery of their unstable clinical syndrome. At discharge and at 1 and 3 months postoperatively, no stroke or death, or major cardiac event occurred in this series with a 100% complete follow-up. CONCLUSIONS: Short delay between symptom onset and neurological assessment, immediate start of secondary stroke prevention, optimal perioperative medical treatment, and standardized operative techniques enabled performance of CEA in the acute phase of CcTIAs with low combined risk of stroke, death, and major cardiac event.

Cryopreserved arterial allograft reconstruction for infected peripheral bypass.

Infection of peripheral bypass is a very severe complication associated to a high rate of morbimortality. The aim of this study was to prospectively evaluate cryopreserved arterial allografts (CAAs) performances in the treatment of this complication. Between April 1996 and June 2008, we prospectively collected data from patients presenting with major infections of peripheral bypasses who benefited from a CAA reconstruction in association with the excision of the infected bypass. CAA were taken from multi-organ donors and frozen at -80 °C. CAA mean conservation time was 115 days (±132). Over this 12-year study, 36 patients (31 men, five women, mean age = 68) benefited from CAA reconstruction for major infections of peripheral bypasses. Eighteen patients (50%) had a septic syndrome, five patients (14%) had an acute ischemia at the reconstruction time, and 12 patients (33%) had an anastomotic rupture. Emergency CAA reconstruction was performed on seven patients (19%). There were no perioperative deaths and no early amputations. Patient follow-up was complete, with a mean 42 -month duration (range, 3-116). There were no persisting or recurring infections. During the follow-up, 10 patients benefited from revision, excision, or replacement of the CAA and fifteen patients died from causes nonrelated to the initial infection. The cumulative rate of limb salvage was 87% at 3 years. Primary and secondary cumulative patency rates were 57% and 78% at 3 years, respectively. CAA reconstruction in association with infected bypass excision is an effective treatment for peripheral bypass major infections. Our results prompt us to go on with CAA reconstructions for this type of indication.

Survival after bilateral versus single-lung transplantation for idiopathic pulmonary fibrosis.

BACKGROUND: Patients with end-stage idiopathic pulmonary fibrosis (IPF) are increasingly having bilateral rather than single-lung transplantation. OBJECTIVE: To compare survival after single and bilateral lung transplantation in patients with IPF. DESIGN: Analysis of data from the United Network of Organ Sharing registry. SETTING: Transplantation centers in the United States. PATIENTS: 3327 patients with IPF who had single (2146 patients [64.5%]) or bilateral (1181 patients [35.5%]) lung transplantation between 1987 and 2009. MEASUREMENTS: Survival times and causes of death after lung transplantation. Selection bias was accounted for by multivariate risk adjustment, propensity score risk adjustment, and propensity-based matching. RESULTS: Median survival time was longer after bilateral lung transplantation than single-lung transplantation (5.2 years [CI, 4.3 to 6.7 years] vs. 3.8 years [CI, 3.6 to 4.1 years]; P < 0.001). However, survival times for the 2 procedures did not differ after adjustment for baseline differences, with adjusted hazard ratios (HRs) for mortality with bilateral transplantation ranging from 0.89 (95% CI, 0.79 to 1.02) to 0.96 (CI, 0.77 to 1.20) in different analyses. Bilateral lung transplantation seemed to result in harm within the first year (HR, 1.18 [CI, 0.98 to 1.42]) but survival benefit thereafter (HR, 0.72 [CI, 0.59 to 0.87]). Primary graft failure was a more common cause of death among patients who had bilateral rather than single-lung transplantation (3.7% vs. 1.9%; P = 0.002). Cancer was a more common cause of death among patients who had single rather than bilateral lung transplantation (unadjusted HR for death among single vs. bilateral transplant recipients, 3.60 [CI, 2.16 to 6.05]; P <0.001). LIMITATION: Causes of death were ascertained without an adjudication committee and must be interpreted cautiously. CONCLUSION: Survival did not differ between patients who had single and bilateral lung transplantation. Single-lung transplantation confers short-term survival benefit but long-term harm, whereas bilateral transplantation confers short-term harm but long-term survival benefit. PRIMARY FUNDING SOURCE: None.

Survival after bilateral versus single lung transplantation for patients with chronic obstructive pulmonary disease: a retrospective analysis of registry data.

BACKGROUND: Both single and bilateral lung transplantation are recognised options for patients who have end-stage chronic obstructive pulmonary disease (COPD); however, which procedure leads to longer survival remains unclear. We aimed to compare survival after each procedure by analysing data from the registry of the International Society for Heart and Lung Transplantation. METHODS: We analysed data for 9883 patients with COPD, 3525 (35.7%) of whom underwent bilateral lung transplantation, and 6358 (64.3%) single lung transplantation, between 1987 and 2006. We accounted for possible selection bias with analysis of covariance, propensity-score risk adjustment, and propensity-based matching. FINDINGS: Median survival after either type of lung transplantation for patients with COPD was 5.0 years (95% CI 4.8-5.2). Survival for patients who had lung transplantation before 1998 was 4.5 years (4.3-4.8), compared with 5.3 years (5.0-5.5) for those who had it after 1998 (p<0.0001). The proportion of patients who had bilateral lung transplantation increased from 101/467 (21.6%) in 1993 to 345/614 (56.2%) in 2006. Median survival time after bilateral lung transplantation was longer than that after single lung transplantation: 6.41 years (6.02-6.88) versus 4.59 years (4.41-4.76) (p<0.0001). Pretransplant characteristics of patients who had single and bilateral lung transplantation differed, but whichever method was used to adjust for baseline differences, bilateral lung transplantation was associated with longer survival than was single lung transplantation; the hazard ratio ranged from 0.83 (0.78-0.92) for analysis of covariance to 0.89 (0.80-0.97) for propensity-based matching. However, bilateral lung transplantation had little benefit compared with single lung transplantation for patients who were 60 years and older (HR 0.95; 0.81-1.13). INTERPRETATION: Bilateral lung transplantation leads to longer survival than single lung transplantation in patients with COPD, especially those who are younger than 60 years.

Defective mer receptor tyrosine kinase signaling in bone marrow cells promotes apoptotic cell accumulation and accelerates atherosclerosis.

OBJECTIVE: To study the role of Mer receptor tyrosine kinase (mertk) in atherosclerosis. METHODS AND RESULTS: We irradiated and reconstituted atherosclerosis-susceptible C57Bl/6 low-density lipoprotein receptor-deficient female mice (ldlr(-/-)) with either a mertk(+/+) or mertk(-/-) (tyrosine kinase-defective mertk) bone marrow. The mice were put on high-fat diet for either 8 or 15 weeks. Mertk deficiency led to increased accumulation of apoptotic cells within the lesions, promoted a proinflammatory immune response, and accelerated lesion development. CONCLUSIONS: Mertk expression by bone marrow-derived cells is required for the disposal of apoptotic cells and controls lesion development and inflammation.

Acute debranching and stent grafting for a ruptured penetrating ulcer of the aortic arch.

BACKGROUND: We report a hybrid treatment for a ruptured penetrating aortic ulcer (PAU) of the aortic arch in emergency conditions. METHODS: A 74-year-old man with severe comorbidity was diagnosed with a symptomatic rupture of a PAU of the aortic arch. As he was considered unfit for conventional open repair and it was an emergency condition, an acute endovascular repair with cervical debranching of the supra-aortic trunks could be proposed. The left common carotid artery and left subclavian artery were first debranched and revascularized through cervical access, and the endovascular stent graft was then deployed via femoral access in the aortic arch. At >or=2 years the patient is safe with no sign of progression of the disease. CONCLUSION: Acute debranching and stent grafting is feasible in emergency conditions to treat ruptured PAU of the aortic arch, with satisfying short- and mid-term outcomes, and can be proposed to patients considered unfit for conventional open repair.

Determinants of the survival benefit of lung transplantation in patients with chronic obstructive pulmonary disease.

RATIONALE: Although chronic obstructive pulmonary disease is the first indication for lung transplantation, the benefit of the procedure in terms of survival remains debated. OBJECTIVES: To estimate the determinants of the survival benefit of lung transplantation in patients with chronic obstructive pulmonary disease. METHODS: Using information from the United Network for Organ Sharing database on 8,182 patients, we developed an approach based on numerical simulations to estimate the survival effect of lung transplantation. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the difference between median survival with transplantation and that without transplantation measured from time of transplant list registration. Survival benefit was greater with double than with single lung transplantation (mean difference, 307 d [95% confidence interval, 217-523]). With double lung transplantation, 44.6% of patients would gain 1 year or more, 29.4% would gain or lose less than 1 year, and 26% would lose 1 year or more. Major determinants of the survival effect of transplantation were systolic pulmonary artery pressure, FEV(1), body mass index, exercise capacity, functional status, and the need for continuous mechanical ventilation or oxygen. For instance, 79% of patients with an FEV(1) less than 16% of the predicted value would gain 1 year or more with double lung transplantation as compared with only 11% of patients with an FEV(1) of more than 25%. CONCLUSIONS: We identified several factors associated with the survival benefit of lung transplantation. External validation of our models is required before translating these results into clinical practice.

Superficial femoral artery autograft reconstruction for complicated popliteal artery entrapment syndrome.

We present an alternative surgical approach to popliteal artery entrapment syndrome with vascular complications in the absence of a suitable saphenous vein. Three patients (29, 35, and 78 years old) with thrombotic and/or aneurysmal lesions of the popliteal artery from popliteal artery entrapment syndrome were treated with superficial femoral artery autograft reconstruction. The procedure was performed through a medial approach. The superficial femoral artery was harvested in the upper third of the thigh and used as the conduit for reconstruction and the harvested segment was replaced by a polytetrafluoroethylene graft. At follow-up, patients were asymptomatic and duplex ultrasound revealed patent reconstruction with no morphological abnormalities.