Search

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease primarily characterized by cutaneous café au lait macules, benign neurofibromas, and iris hamartomas. A spectrum of vascular abnormalities is associated with NF-1. We present a case of a 49-year-old female with NF-1 and spontaneous rupture of the infrarenal aorta caused by invasion of a neurofibroma and treated with endovascular stent grafting. [ABSTRACT FROM AUTHOR]

Introduction: Ultrasound-guided thrombin injection (UGTI) is a well-established practice for the treatment of femoral artery pseudoaneurysm. This procedure is highly successful but dependent on appropriate pseudoaneurysm anatomy and adequate ultrasound visualization. Morbid obesity can present a significant technical challenge due to increased groin adiposity, resulting in poor visualization of critical structures needed to safely perform the procedure. We aim to evaluate the safety and efficacy of UGTI to treat femoral artery pseudoaneurysm in the morbidly obese. Methods: This is a retrospective cohort study in which all patients who underwent UGTI at The Ohio State University Ross Heart Hospital from 2009 to 2014 were analyzed for patient characteristics and stratified by body mass index (BMI). Patients with BMI ≥ 35 were considered morbidly obese and were compared to patients with a BMI < 35. Outcome was failed treatment resulting in residual pseudoaneurysm. Results: Our cohort consisted of 54 patients who underwent thrombin injection. There were 41 nonmorbidly obese and 13 morbidly obese patients. Mean age was 64.5 years. The cohort was 44.4% male. There were 6 failures, of which 1 underwent successful repeat injection and 5 underwent open surgical repair. There was no statistically significant difference in failure between nonmorbidly obese and morbidly obese patients (9.8% vs 15.4%, P = .45). There were no embolic/thrombotic complications. Conclusion: Ultrasoundguided thrombin injection is a safe and effective therapy in the morbidly obese for the treatment of femoral artery pseudoaneurysm. In the hands of experienced sonographers and surgeons with adequate visualization of the pseudoaneurysm sac, UGTI should remain a standard therapy in the morbidly obese. [ABSTRACT FROM AUTHOR]

Background: Positron emission tomography (PET)/computed tomography (CT) imaging with fluorine-18 (18F)-sodium fluoride (NaF) provides assessment of active vascular microcalcification, but its utility for evaluating diabetes mellitus (DM)- and chronic kidney disease (CKD)-induced atherosclerosis in peripheral arterial disease (PAD) has not been comprehensively evaluated. This study sought to use 18F-NaF PET/CT to quantify and compare active microcalcification on an artery-by-artery basis in healthy subjects, PAD patients with or without DM, and PAD patients with or without CKD. Additionally, we evaluated the contributions of DM, CKD, statin use and established CT-detectable calcium to 18F-NaF uptake for each lower extremity artery. Methods: PAD patients (n = 48) and healthy controls (n = 8) underwent lower extremity 18F-NaF PET/CT imaging. Fused PET/CT images guided segmentation of arteries of interest (i.e., femoral-popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, and peroneal) and quantification of 18F-NaF uptake. 18F-NaF uptake was assessed for each artery and compared between subject groups. Additionally, established calcium burden was quantified for each artery using CT calcium mass score. Univariate and multivariate analyses were performed to evaluate DM, CKD, statin use, and CT calcium mass as predictors of 18F-NaF uptake in PAD. Results: PAD patients with DM or CKD demonstrated significantly higher active microcalcification (i.e., 18F-NaF uptake) for all arteries when compared to PAD patients without DM or CKD. Univariate and multivariate analyses revealed that concomitant DM or CKD was associated with increased microcalcification for all arteries of interest and this increased disease risk remained significant after adjusting for patient age, sex, and body mass index. Statin use was only associated with decreased microcalcification for the femoral-popliteal artery in multivariate analyses. Established CT-detectable calcium was not significantly associated with 18F-NaF uptake for 4 out of 5 arteries of interest. Conclusions: 18F-NaF PET/CT imaging quantifies vessel-specific active microcalcification in PAD that is increased in multiple lower extremity arteries by DM and CKD and decreased in the femoral-popliteal artery by statin use. 18F-NaF PET imaging is complementary to and largely independent of established CT-detectable arterial calcification. 18F-NaF PET/CT imaging may provide an approach for non-invasively quantifying vessel-specific responses to emerging anti-atherogenic therapies or CKD treatment in patients with PAD. [ABSTRACT FROM AUTHOR]

Background: Tissue ischemia contributes to necrosis and infection. While angiogenic cell therapies have emerged as a promising strategy against ischemia, current approaches to cell therapies face multiple hurdles. Recent advances in nuclear reprogramming could potentially overcome some of these limitations. However, under severely ischemic conditions necrosis could outpace reprogramming-based repair. As such, adjunctive measures are required to maintain a minimum level of tissue viability/activity for optimal response to restorative interventions. Methods: Here we explored the combined use of polymerized hemoglobin (PolyHb)-based oxygen nanocarriers with Tissue Nano-Transfection (TNT)-driven restoration to develop tissue preservation/repair strategies that could potentially be used as a first line of care. Random-pattern cutaneous flaps were created in a mouse model of ischemic injury. PolyHbs with high and low oxygen affinity were synthesized and injected into the tissue flap at various timepoints of ischemic injury. The degree of tissue preservation was evaluated in terms of perfusion, oxygenation, and resulting necrosis. TNT was then used to deploy reprogramming-based vasculogenic cell therapies to the flaps via nanochannels. Reprogramming/repair outcomes were evaluated in terms of vascularity and necrosis. Results: Flaps treated with PolyHbs exhibited a gradual decrease in necrosis as a function of time-to-intervention, with low oxygen affinity PolyHb showing the best outcomes. TNT-based intervention of the flap in combination with PolyHb successfully curtailed advanced necrosis compared to flaps treated with only PolyHb or TNT alone. Conclusions: These results indicate that PolyHb and TNT technologies could potentially be synergistically deployed and used as early intervention measures to combat severe tissue ischemia. [ABSTRACT FROM AUTHOR]

Radiotracer imaging allows for noninvasive detection and quantification of abnormalities in angiosome foot perfusion in diabetic patients with critical limb ischemia and nonhealing wounds. A 60-year-old male presented with critical limb ischemia (CLI), which was associated with second toe gangrene of the left foot (Panel A-1), a left limb ankle-brachial index (ABI) of 0.65, and bilateral claudication. [Extracted from the article]

Controversies in the treatment of venous thoracic outlet syndrome (VTOS) have been discussed for decades, but still persist. Calls for more objective reporting standards have pushed practice towards comprehensive venous evaluations and interventions after first rib resection (FRR) for all patients. In our practice, we have relied on patient-centered, patient-reported outcomes to guide adjunctive treatment and measure success. Thus, we sought to investigate the use of thrombolysis versus anticoagulation alone, timing of FRR following thrombolysis, post-FRR venous intervention, and FRR for McCleery syndrome (MCS) and their impact on patient symptoms and return to function. All patients undergoing FRR for VTOS at our institution from 4 April 2000 through 31 December 2013 were reviewed. Demographics, symptoms, diagnostic and treatment details, and outcomes were collected. Per "Reporting Standards of the Society for Vascular Surgery for Thoracic Outlet Syndrome", symptoms were described as swelling/discoloration/heaviness, collaterals, concomitant neurogenic symptoms, and functional impairment. Patient-reported response to treatment was defined as complete (no residual symptoms and return to function), partial (any residual symptoms present but no functional impairment), temporary (initial improvement but subsequent recurrence of any symptoms or functional impairment), or none (persistent symptoms or functional impairment). Sixty FRR were performed on 59 patients. 54.2% were female with a mean age of 34.3 years. Swelling/discoloration/heaviness was present in all but one patient, deep vein thrombosis in 80%, and visible collaterals in 41.7%. Four patients had pulmonary embolus while 65% had concomitant neurogenic symptoms. In addition, 74.6% of patients were anticoagulated and 44.1% also underwent thrombolysis prior to FRR. Complete or partial response occurred in 93.4%. Of the four patients with temporary or no response, further diagnostics revealed residual venous disease in two and occult alternative diagnoses in two. Use of thrombolysis was not related to FRR outcomes (p = 0.600). Performance of FRR less than or greater than six weeks after the initiation of anticoagulation or treatment with thrombolysis was not related to FRR outcomes (p = 1). Whether patients had DVT or MCS was not related to FRR outcomes (p = 1). No patient had recurrent DVT. From a patient-centered, patient-reported standpoint, VTOS is equally effectively treated with FRR regardless of preoperative thrombolysis or timing of surgery after thrombolysis. A conservative approach to venous interrogation and intervention after FRR is safe and effective for symptom control and return to function. Additionally, patients with MCS are effectively treated with FRR. [ABSTRACT FROM AUTHOR]

Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta, such that the diameter exceeds 3 cm. The natural history of AAA is progressive growth leading to rupture, an event that carries up to 90% risk of mortality. Hence there is a need to predict the growth of the diameter of the aorta based on the diameter of a patient’s aneurysm at initial screening and aided by non-invasive biomarkers. IL-6 is overexpressed in AAA and was suggested as a prognostic marker for the risk in AAA. The present paper develops a mathematical model which relates the growth of the abdominal aorta to the serum concentration of IL-6. Given the initial diameter of the aorta and the serum concentration of IL-6, the model predicts the growth of the diameter at subsequent times. Such a prediction can provide guidance to how closely the patient’s abdominal aorta should be monitored. The mathematical model is represented by a system of partial differential equations taking place in the aortic wall, where the media is assumed to have the constituency of an hyperelastic material. [ABSTRACT FROM AUTHOR]

Invasive hemodynamic monitoring with a pulmonary catheter has been relatively routine in cardiovascular and complex surgical operations as well as in the management of critical illnesses. However, due to multiple potential complications and its invasive nature, its use has decreased over the years and less invasive methods such as transesophageal echocardiography and hemodynamic sensors have gained widespread favor. Unlike these less invasive forms of hemodynamic monitoring, pulmonary artery catheters require an advanced understanding of cardiopulmonary physiology, anatomy, and the potential for complications in order to properly place, manage, and interpret the device. We describe a case wherein significant resistance was encountered during multiple unsuccessful attempts at removing a patient’s catheter secondary to kinking and twisting of the catheter tip. These attempts to remove the catheter serve to demonstrate potential rescue options for such a situation. Ultimately, successful removal of the catheter was accomplished by simultaneous catheter retraction and sheath advancement while gently pulling both objects from the cannulation site. In addition to being skilled in catheter placement, it is imperative that providers comprehend the risks and complications of this invasive monitoring tool. [ABSTRACT FROM AUTHOR]

Vascular anomalies are extremely rare in patients with von Recklinghausen disease. This report presents a case of an acute spontaneous subclavian artery rupture in a patient with von Recklinghausen disease. A 44-year-old woman with a history of neurofibromatosis type 1, multiple sclerosis, and aortic valve replacement experienced a ‘‘popping sensation’’ in her neck. An emergent angiogram via a right brachial artery approach revealed active extravasation of contrast from the proximal part of the right subclavian artery between the vertebral and axillary arteries. An 8 mm × 5 cm endoprosthesis stent graft was placed across the area of extravasation via the brachial sheath. Completion angiography revealed brisk flow through the stent graft with resolution of the area of extravasation and no residual stenosis. Arterial rupture, aneurysm formation, stenosis, and dissection can be fatal in patients with neurofibromatosis. Further research is needed to determine screening guidelines and management algorithms for this patient population. [ABSTRACT FROM PUBLISHER]

The article focuses on the treatment and management of atherosclerotic disease. Topics discussed include risk factors associated with the same; role of the clinical pharmacist in an integrated heart and vascular clinic for the management of the same; and a table depicting type of intervention performed by the clinical pharmacist and acceptance rates such as aspirin, deletion of therapy and patient education.

Surgical management of acute aortic infection is challenging, including excision of the infected segment and reconstruction either through extra-anatomical bypass or in situ graft replacement with higher risk of re-infection. Here in, we present a case of delayed paralysis developed after an extra-anatomic (axillary-bifemoral) bypass of infected thoracic aorta in a 51 year old Caucasian male. Reversal of paralysis was successfully achieved via larger extra-anatomical ascending aorta to infra-renal aorta bypass and cerebrospinal fluid (CSF) drainage. [ABSTRACT FROM AUTHOR]