Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort.

Objective: Patients with peripheral arterial disease (PAD) have a significant risk of myocardial infarction and death secondary to concomitant coronary artery disease (CAD). This is particularly true in patients with critical limb-threatening ischemia (CLTI) who exceed a 20% mortality rate at 6 months despite standard treatment with risk factor modification. Although systematic preoperative coronary testing is not recommended for patients with PAD without cardiac symptoms, the clinical manifestations of CAD are often muted in patients with CLTI due to poor mobility and activity intolerance. Thus, the true incidence and impact of "silent" CAD in a CLTI cohort is unknown. This study aims to determine the prevalence of ischemia-producing coronary artery stenosis in a CLTI cohort using coronary computed tomography angiography (cCTA) and computed tomography (CT)-derived fractional flow reserve (FFRCT), a noninvasive imaging modality that has shown significant correlation to cardiac catheterization in the detection of clinically relevant coronary ischemia. Methods: Patients presenting with newly diagnosed CLTI at our institution from May 2020 to April 2021 were screened for underlying CAD. Included subjects had no known history of CAD, no cardiac symptoms, and no anginal equivalent complaints at presentation. Patients underwent cCTA and FFRCT evaluation and were classified by the anatomic location and severity of CAD. Significant coronary ischemia was defined as FFRCT ≤0.80 distal to a >30% coronary stenosis, and severe coronary ischemia was documented at FFRCT ≤0.75, consistent with established guidelines. Results: A total of 170 patients with CLTI were screened; 65 patients (38.2%) had no coronary symptoms and met all inclusion/exclusion criteria. Twenty-four patients (31.2%) completed cCTA and FFRCT evaluation. Forty-one patients have yet to complete testing secondary to socioeconomic factors (insurance denial, transportation inaccessibility, testing availability, etc). The mean age of included subjects was 65.4 ± 7.0 years, and 15 (62.5%) were male. Patients presented with ischemic rest pain (n = 7; 29.1%), minor tissue loss (n = 14; 58.3%) or major tissue loss (n = 3; 12.5%). Significant (≥50%) coronary artery stenosis was noted on cCTA in 19 of 24 patients (79%). Significant left main coronary artery stenosis was identified in two patients (10%). When analyzed with FFRCT, 17 patients (71%) had hemodynamically significant coronary ischemia (FFRCT ≤0.8), and 54% (n = 13) had lesion-specific severe coronary ischemia (FFRCT ≤0.75). The mean FFRCT in patients with coronary ischemia was 0.70 ± 0.07. Multi-vessel disease pattern was present in 53% (n = 9) of patients with significant coronary stenosis. Conclusions: The use of cCTA-derived fractional flow reserve demonstrates a significant percentage of patients with CLTI have silent (asymptomatic) coronary ischemia. More than one-half of these patients have lesion-specific severe ischemia, which may be associated with increased mortality when treated solely with risk factor modification. cCTA and FFRCT diagnosis of significant coronary ischemia has the potential to improve cardiac care, perioperative morbidity, and long-term survival curves of patients with CLTI. Systemic improvements in access to care will be needed to allow for broad application of these imaging assessments should they prove universally valuable. Additional study is required to determine the benefit of selective coronary revascularization in patients with CLTI.

Disparities in Outcomes Between Sexes in Type B Aortic Dissection Patients Treated with TEVAR.

BACKGROUND: To evaluate differences in presentation and outcomes between sexes in patients who underwent thoracic endovascular aortic repair for type B aortic dissection (TBAD). METHODS: Between January 1, 2012 and January 1, 2017 186 patients underwent thoracic endovascular aortic repair for TBAD at a single institution. Men (n = 112) and women (n = 74) were compared based on presenting demographics, comorbidities, and postoperative complications. Primary outcomes were survival and need for reintervention. RESULTS: Women were older (P = 0.04) and had a lower body mass index (P = 0.03). More women (F) presented with continued pain or refractory hypertension (51.0% F, 30.0% M), while more men (M) presented with acute complicated dissections (19.0% F, 39.0% M) (P = 0.008). At presentation, women had statistically higher relative rates of chronic obstructive pulmonary disease (P = 0.05), hyperlipidemia (P = 0.03), and smoking (P = 0.03). Significantly more women were on Medicare without Medicaid (55.0% F, 34.0% M), while men had private insurance (35.0% F, 13.0% M) (P = 0.005). There was no significant difference in blood pressure control at presentation, discharge, or at 30 days. When normalized by body surface area, women had larger ascending aortic diameters (19.2(3.10)F, 17.5(2.40)M, P = 0.0002), as well as proportionally larger true lumens at the left subclavian artery (14.9(2.90)F, 13.4(2.50)M, P = 0.0002), carina (12.6(5.80)F, 9.90(4.80)M, P = 0.0009), and celiac (10.5(4.50)F, 8.50(4.10)M, P = 0.006) levels, and at the largest point of dissection (11.6(6.50)F, 9.60(4.80)M, P = 0.04), as well as proportionately smaller false lumens at the carina (5.90(5.60)F, 9.30(6.10)M, P = 0.003). Despite not being statistically significant, women had lower rates of stroke (6.80% F, 8.00% M, P = 0.7) and acute kidney injury (5.40% F, 11.6% M, P = 0.2), as well fewer days in the intensive care unit (ICU) (3.20(4.30)F, 4.60(6.60)M, P = 0.2) and an overall shorter length of stay (6.80(6.70)F, 8.00(8.20)M, P = 0.5). Kaplan-Meier estimates for survival for women versus men were 96.0% vs. 92.0%, 90.0% vs. 79.0%, and 70.0% vs. 69.0% at 30 days, 1 year, and 3 years, respectively (P = 0.042). Kaplan-Meier estimates for freedom from reintervention for women versus men were 89.0% vs. 90.0%, 58.0% vs. 72.0%, and 48.0% vs. 58.0% at 30 days, 1 year, and 3 years, respectively (P = 0.13). CONCLUSIONS: Women present with TBAD at an older age, have more comorbidities, lower socioeconomic status, and have larger ascending aortic diameters for their size. Despite having less severe dissections as evidenced by smaller false lumens and wider true lumens, it does not appear that this correlates with improved outcomes for women when compared to men. It appears that this is one of the few, if not only, aortic pathologies that result in comparable outcomes between sexes.

The Amazonian Tropical Bites Research Initiative, a hope for resolving zoonotic neglected tropical diseases in the One Health era.

BACKGROUND: Neglected tropical diseases (NTDs) disproportionately affect populations living in resource-limited settings. In the Amazon basin, substantial numbers of NTDs are zoonotic, transmitted by vertebrate (dogs, bats, snakes) and invertebrate species (sand flies and triatomine insects). However, no dedicated consortia exist to find commonalities in the risk factors for or mitigations against bite-associated NTDs such as rabies, snake envenoming, Chagas disease and leishmaniasis in the region. The rapid expansion of COVID-19 has further reduced resources for NTDs, exacerbated health inequality and reiterated the need to raise awareness of NTDs related to bites. METHODS: The nine countries that make up the Amazon basin have been considered (Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Surinam and Venezuela) in the formation of a new network. RESULTS: The Amazonian Tropical Bites Research Initiative (ATBRI) has been created, with the aim of creating transdisciplinary solutions to the problem of animal bites leading to disease in Amazonian communities. The ATBRI seeks to unify the currently disjointed approach to the control of bite-related neglected zoonoses across Latin America. CONCLUSIONS: The coordination of different sectors and inclusion of all stakeholders will advance this field and generate evidence for policy-making, promoting governance and linkage across a One Health arena.

Omental Free Flap Coverage for Extracavitary Vascular Bypass Graft Salvage.

BACKGROUND: Prosthetic vascular graft infection is a serious complication associated with significant morbidity and mortality often requiring graft excision and numerous additional operations. Pedicled flaps are often used for the coverage of exposed deep tissue or hardware for graft salvage. In the absence of pedicled options, the properties of omentum make it an excellent choice for free flap tissue coverage, particularly in cases involving implanted prostheses. METHODS: A 63-year-old woman developed a mycotic right subclavian arterial aneurysm requiring ligation and extra-anatomic bypass grafting to restore right-sided intracranial and right upper extremity arterial perfusion. Subsequent wound breakdown and poor healing left the grafts exposed, resulting in contamination. Given the profound risks associated with graft excision in this patient, salvage was attempted with IV antibiotics, serial wound/graft washouts, and graft coverage with an omental free flap. RESULTS: The patient tolerated the procedure well. The remainder of her hospital course was uneventful, and she was discharged home in good clinical condition. She will remain on long-term suppressive antibiotics per Infectious Disease recommendations. CONCLUSIONS: Contemporary literature reporting novel and effective applications of omental free flap coverage is rare. This report demonstrates that omental free flap coverage is safe and can provide healthy tissue to protect implanted grafts and even aid in the salvage of infected extra-anatomic bypass grafts.

Beyond the Linguistic/Medical Anthropology Divide: Retooling Anthropology to Face COVID-19.

Differing analytics and ethnographic practices impede conversations between linguistic and medical anthropologists. Here I juxtapose articles in this special issue that use diverse ethnographic sites to rethink anthropological concepts of health, disease, care, the body, language, and communication in the light of the 2020 COVID-19 pandemic. I track how anthropologists and their interlocutors envision relations between ideologies, embedded modeling (or metacommunication), and ordinary pragmatics, particularly by projecting their actual or ideal consonance versus exploring how sounds, bodies, technologies, and practices emerge from disjunctures. Comparing H1N1 in 2009 and COVID-19 prompts reflection on why anthropologists must transcend this foundational divide to tackle pandemic complexities.

Cocaine use is associated with worse outcomes in patients treated with thoracic endovascular repair for type B aortic dissection.

OBJECTIVE: To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections. METHODS: Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172). RESULTS: Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions. CONCLUSIONS: These results suggest that special care should be taken to provide close follow-up for these patients.

Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection.

BACKGROUND: The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). METHODS: Between January 2012 and January 2017, there were 186 patients who underwent TEVAR for TBAD at a multidisciplinary aortic center. Patients who developed RTAD after TEVAR (n = 15) were compared with those who did not (no-RTAD group, n = 171). Primary outcomes were survival and need for reintervention. RESULTS: The incidence of RTAD in our sample was 8% (n = 15). Kaplan-Meier estimates found that no-RTAD patients had better survival (P = .04). Survival rates at 30 days, 1 year, and 3 years were 93%, 60%, and 60% for RTAD patients and 94%, 87%, and 80% for no-RTAD patients. One RTAD was diagnosed intraoperatively, 5 were diagnosed within 30 days of the index procedure, 6 were diagnosed within 1 year, and 3 were diagnosed after 1 year. Reintervention for RTAD was undertaken in 10 of 15 patients, with a 50% survival rate after reintervention. Partial or complete false lumen thrombosis was more frequently present in RTAD patients (P = .03). RTAD patients more frequently presented with renal ischemia (P = .04). Most RTAD patients (93%, RTAD patients; 64%, no-RTAD patients; P = .02) had a proximal landing zone in zone 0, 1, or 2. Aortic diameter was more frequently ≥40 mm in the RTAD group (47%, RTAD patients; 21%, no-RTAD patients; P = .05). Patients with RTAD had stent grafts placed in the renovisceral arteries for complicated dissections, and this approached significance (P = .05). Three RTAD patients had a type II arch (20%) compared with 53 no-RTAD patients (31%; P = .6), but a comparison of type II arch with type I or type III found no statistical significance (P = .6). No correlations were found between ratio of descending to ascending diameters, average aortic sizing, graft size, or bare-metal struts at proximal attachment zone and development of RTAD. We found no statistically significant differences in demographics, genetic disease, comorbidities, or previous repairs. CONCLUSIONS: The development of RTAD after TEVAR for TBAD does not appear to be correlated with any easily identifiable demographic feature but appears to be correlated with proximal landing zones in zone 1 and 2 and an ascending diameter >4 cm. Furthermore, the presence of partial or complete false lumen thrombosis as well as more complicated presentation with renal ischemia was significantly more frequent in patients with RTAD. TBAD patients should be observed long term, as type A dissections in our patients occurred even after 1 year.

Advanced Techniques for Treating Juxtarenal and Pararenal Abdominal Aortic Aneurysms: Chimneys, Periscopes, Sandwiches and Other Methods.

The complex aortic anatomy of patients who present with juxtarenal and pararenal abdominal aortic aneurysms requires advanced techniques to ensure adequate coverage and complete exclusion of the aneurysm. Parallel stent grafting is one option for endovascular repair of complex aneurysms. Using chimneys, periscopes, or snorkels, it is possible to extend the length of the proximal seal zone and maintain perfusion to branch vessels. Because readily available stent grafts and covered stents are used, this technique is highly adaptable to each patient's unique anatomical challenges. However, the complexity of these procedures requires careful preoperative planning, excellent intraoperative imaging capabilities, a thorough understanding of technique, and anticipation of potential procedural pitfalls and complications. We present our experience with chimney/snorkel and sandwich techniques as a reliable and effective treatment strategy for complex aortic aneurysm repair.

Anatomic and clinical characterization of the narrow distal aorta and implications after endovascular aneurysm repair.

OBJECTIVE: The purpose of this analysis was to compare 1-year clinical outcomes after endovascular repair of abdominal aortic aneurysms with the EXCLUDER device in patients with standard and narrow aortic bifurcations (AOBs). METHODS: Data were prospectively collected from a 1055-participant subset of the multicenter Global Registry for Endovascular Aortic Treatment (GREAT) treated for abdominal aortic aneurysm repair between August 2010 and September 2015. There were 117 patients with a narrow AOB (NB; defined as <16 mm) and 938 patients with a standard bifurcation (SB). The 30-day and 1-year morbidity, mortality, and reintervention outcomes were analyzed, with Kaplan-Meier survival curve analysis conducted on freedom from mortality and freedom from reintervention. RESULTS: The mean distal aortic neck diameter was 12.4 mm in the NB cohort and 25.3 mm in the SB cohort (P < .001), with NB patients also exhibiting significantly smaller diameter proximal aortic necks (P < .001). Patients in the NB cohort were more often female (25.6% vs 15.1%; P = .004) and with more severe comorbidity burden. There was a significantly higher rate of surgical cutdown access in the NB cohort (P < .001). Procedural survival was 100% in both groups. The 30-day mortality and safety outcomes were similar; however, all-cause mortality was significantly higher in the SB cohort through 1 year (P = .02). The 1-year freedom from mortality was estimated as 92.1% in the SB cohort and 99.1% in the NB cohort. Freedom from reintervention was estimated as 95.1% in the SB cohort and 92.8% in the NB cohort at 1 year. Through 1-year follow-up, 24 SB patients (2.6%) and 4 NB patients (3.4%) exhibited an endoleak requiring reintervention (P > .99). Type II endoleaks represented 72% and 60% of treated endoleaks, respectively. Through 1 year, 10 SB patients (1.0%) and 2 NB patients (1.7%) exhibited occlusive/thrombotic events (P = .54). There were no reported instances of kinking, migration, fracture, compression, or dissection through 1 year in either cohort. One SB patient experienced thoracic aortic aneurysm rupture. CONCLUSIONS: The 1-year outcomes after endovascular aneurysm repair with the EXCLUDER device were comparable in the NB and SB cohorts. A narrow AOB was not found to be associated with a higher incidence of later limb occlusions or endoleaks. Female patients were disproportionately more likely to have a narrow AOB, which correlated with narrowed proximal necks and access vessels, and a more severe comorbidity burden.

Short-term and midterm survival of ruptured abdominal aortic aneurysms in the contemporary endovascular era.

OBJECTIVE: Endovascular aneurysm repair (EVAR) has been shown to reduce mortality in the emergent repair of ruptured abdominal aortic aneurysms (AAAs). However, long-term survival data for this group of patients are lacking with contemporary endovascular endografts. The purpose of this study was to evaluate both 30-day mortality rates and 1-year survival in patients undergoing emergent EVAR in a 43-facility hospital system with a quaternary referral center with an established ruptured aneurysm protocol. METHODS: Retrospective analysis of patients captured prospectively in an Institutional Review Board-approved registry for patients treated emergently for AAA were reviewed between 2012 and 2017 was conducted. Primary outcome measures were 30-day mortality and 1-year survival for the entire group as well as for symptomatic and ruptured aneurysms. Data were analyzed using logistic regression survival curves, and a log-rank test was performed to compare survival between open and endovascular repair. Patients were evaluated on an intent-to-treat basis, and outcomes were evaluated in a multivariate model. RESULTS: A total of 249 patients were referred as part of the protocol. Of these, 102 (41%) were treated emergently. Kaplan-Meier estimates of 30-day and 1-year survival were 64% and 53% for all patients, 58% and 46% for ruptured patients, and 86% and 81% for symptomatic patients. EVAR resulted in improved 30-day survival (64% vs 31%; odds ratio, 4.0; P = .03) and 1-year survival (40% vs 23%; odds ratio, 2.3; P = .4) over open repair. Significant predictors for 30-day mortality included hypotension (P = .0003), blood transfusion (P < .0001), length of stay (P = .0005), extravasation (P = .01), preoperative cardiopulmonary resuscitation (P = .04), open repair (P = .007), aortouni-iliac reconstruction (P = .008), and abdominal compartment syndrome (P = .007). Significant predictors for 1-year mortality included advanced age (P = .04), hypotension (P = .01), blood transfusion (P = .006), extravasation (P = .03), reintubation (P = .03), and abdominal compartment syndrome (P = .03). There were no differences in outcomes based on race, gender, or outside transfer. Peripheral arterial disease (P = .04), hypertension (P = .04), coronary artery disease (P = .03), and familial history of aneurysms (P = .05) were related to increased 30-day mortality. Peripheral arterial disease (P = .06) and coronary artery disease (P = .07) were nearly significant, with increased 1-year mortality. CONCLUSIONS: EVAR is associated with improved survival compared with open repair in patients requiring emergent AAA repair. However, in the first year, there is a significant risk of death based on initial presentation as well as underlying comorbidities. To improve long-term survival, aggressive medical management and medical surveillance are warranted.

Ethnic disparities in outcomes of patients with complicated type B aortic dissection.

OBJECTIVE: The objective of this study was to evaluate the difference in outcomes after endovascular intervention in patients with complicated type B aortic dissection (TBAD) based on ethnicity and blood pressure control. METHODS: Between 2012 and 2016, there were 126 patients who underwent endovascular procedures for complicated TBAD at a single-institution quaternary referral center. Patients self-identified as African American (n = 53), white (n = 70), and Asian (n = 3). African American and white patients were compared on a number of variables, including age, ethnicity, insurance type, blood pressure, comorbidities, number of previous interventions, and number of antihypertension medications they were taking before intervention. Primary outcomes were survival and need for reintervention. RESULTS: Kaplan-Meier estimates for survival for African Americans vs whites were 94% vs 89%, 91% vs 83%, 89% vs 79%, and 89% vs 76% at 30 days, 1 year, 3 years, and 5 years, respectively (P = .05). African Americans were younger overall (52.5 ± 11 years) vs whites (63.7 ± 14.7 years; P < .0001). African Americans required a significantly greater number of reinterventions (P = .007). They also had higher rates of chronic kidney disease (P = .01), smoking (P = .03), and cocaine use (P = .02) and were more likely to be on Medicaid (P = .02). Hypertension was poorly controlled in both groups, with the percentage of patients with uncontrolled hypertension (systolic >140 mm Hg) preoperatively, postoperatively, and 30 days after intervention at 32%, 32%, and 39%. There was no significant difference between the cohorts in uncontrolled hypertension preoperatively (P = .39) or postoperatively (P = .63). However, more African Americans had uncontrolled hypertension at 30 days (African Americans, 49%; whites, 31%; odds ratio, 2.1; P = .09). African Americans were taking a greater number of antihypertension medications at presentation than whites (P = .01) and specifically had higher use rates of beta blockers (P = .02), diuretics (P = .02), and angiotensin-converting enzyme inhibitors (P = .04). CONCLUSIONS: African Americans with TBAD present at a younger age than their white counterparts do and have a survival advantage up to at least 5 years. However, African Americans have a higher rate of reintervention that is probably associated with poor blood pressure control despite taking more antihypertension medications both before and after the repair. It appears that optimal medical therapy is difficult to achieve in all groups. More aggressive medical management is needed, particularly more so in African Americans, which may in turn decrease the number of interventions and potentially improve long-term survival.

Descubriendo una falla trágica en las políticas revolucionarias de salud: Desde las inequidades en salud y comunicación a la justicia comunicativa en salud / Uncovering a tragic flaw in revolutionary health policies: From health and communicative inequities to communicative justice in health

RESUMEN Este artículo analiza una contradicción enfrentada por los gobiernos de izquierda de América Latina en sus esfuerzos por transformar la salud en un derecho social fundamental. Las políticas y prácticas que confrontan las desigualdades en salud, en general, no llegan a dirigirse a las inequidades en salud y comunicación; las distribuciones jerárquicas de los derechos dan forma al conocimiento legítimo en salud. El artículo presenta un análisis etnográfico sobre la epidemia de una enfermedad misteriosa -identificada clínicamente como rabia trasmitida por murciélagos- en la selva del Delta Amacuro en Venezuela, en 2007-2008, centrado en cómo los padres y las madres que perdieron entre 1 y 3 hijos e hijas lidian con inequidades agudas en salud y comunicación en entornos clínicos, investigaciones epidemiológicas, trabajo con sanadores/as, la cobertura de las noticias, las políticas de salud y la comunicación en salud. A partir de demandas por parte de los y las residentes de la selva por una justicia comunicativa en salud, el análisis utiliza la noción de autoatención propuesta por Menéndez para explorar cómo la labor en salud y comunicación se coproduce con la labor de cuidado.

ABSTRACT This article analyzes a contradiction facing efforts by left-leaning governments in Latin America to transform health into a fundamental social right. Policies and practices that confront health inequities generally fail to address health/communicative inequities, hierarchical distributions of rights to shape what counts as legitimate knowledge of health. This ethnographic analysis focuses on an epidemic of a mysterious disease - identified clinically as bat-transmitted rabies - in the Delta Amacuro rainforest of Venezuela in 2007-2008, tracing how parents who lost 1-3 children faced acute health/communicative inequities in clinical settings, epidemiological investigations, work with healers, news coverage, health policy, and health communication. Taking as a point of departure rainforest residents' demands for communicative justice in health, the analysis draws on Menéndez's notion of autoatención in exploring how health/communicative labor is co-produced with the labor of care.

Towards Communicative Justice in Health.

This article approaches care from a different angle by looking ethnographically at how it is shaped by structural differences in the power to control the circulation of knowledge. I focus on an investigation conducted by people classified as "indigenous", of an epidemic that killed 38 children and young adults in a Venezuelan rainforest. I trace how health/communicative inequities structured clinical interactions, documents, epidemiological investigations, news stories, and dialogues with healers, thwarting the identification of the epidemic, clinically identified as rabies. Although the Bolivarian socialist government provided access to care, professionals denigrated parents' contributions to care and communication and reduced complex, unequal relations between languages to practical problems of translation. Pointing to parallels with US social movements, I suggest that responding to demands for communicative justice in health requires seeing how health inequities are entangled with health/communicative inequities. The typographical slash points to importance of challenging the subdisciplinary boundary-work that relegates their study to non-overlapping conversations in medical and linguistic anthropology.

Uncovering a tragic flaw in revolutionary health policies: From health and communicative inequities to communicative justice in health. / Descubriendo una falla trágica en las políticas revolucionarias de salud: Desde las inequidades en salud y comunicación a la justicia comunicativa en salud.

This article analyzes a contradiction facing efforts by left-leaning governments in Latin America to transform health into a fundamental social right. Policies and practices that confront health inequities generally fail to address health/communicative inequities, hierarchical distributions of rights to shape what counts as legitimate knowledge of health. This ethnographic analysis focuses on an epidemic of a mysterious disease - identified clinically as bat-transmitted rabies - in the Delta Amacuro rainforest of Venezuela in 2007-2008, tracing how parents who lost 1-3 children faced acute health/communicative inequities in clinical settings, epidemiological investigations, work with healers, news coverage, health policy, and health communication. Taking as a point of departure rainforest residents' demands for communicative justice in health, the analysis draws on Menéndez's notion of autoatención in exploring how health/communicative labor is co-produced with the labor of care.

Este artículo analiza una contradicción enfrentada por los gobiernos de izquierda de América Latina en sus esfuerzos por transformar la salud en un derecho social fundamental. Las políticas y prácticas que confrontan las desigualdades en salud, en general, no llegan a dirigirse a las inequidades en salud y comunicación; las distribuciones jerárquicas de los derechos dan forma al conocimiento legítimo en salud. El artículo presenta un análisis etnográfico sobre la epidemia de una enfermedad misteriosa -identificada clínicamente como rabia trasmitida por murciélagos- en la selva del Delta Amacuro en Venezuela, en 2007-2008, centrado en cómo los padres y las madres que perdieron entre 1 y 3 hijos e hijas lidian con inequidades agudas en salud y comunicación en entornos clínicos, investigaciones epidemiológicas, trabajo con sanadores/as, la cobertura de las noticias, las políticas de salud y la comunicación en salud. A partir de demandas por parte de los y las residentes de la selva por una justicia comunicativa en salud, el análisis utiliza la noción de autoatención propuesta por Menéndez para explorar cómo la labor en salud y comunicación se coproduce con la labor de cuidado.

Embolization of Onyx Causing Acute Limb Ischemia.

We present the case of a patient with a refractory type II endoleak treated with translumbar Onyx with passage of the Onyx material into the endograft and subsequent embolization to the infrainguinal vasculature. This report represents a new complication of Onyx embolization that, to our knowledge, has not previously been described in the literature.

Splenic artery as a conduit to facilitate visceral arterial reconstruction.

Splenic-to-superior mesenteric artery transposition was used to treat proximal celiac in-stent occlusion in one patient and to prepare a landing zone for thoracic endograft treatment of a dissection in another. The proximal splenic artery was used as a conduit to facilitate visceral aortic debranching in four patients. Using the splenic artery as a conduit to preserve or restore celiac perfusion without interrupting liver perfusion is feasible.