Endoleak after endovascular repair of abdominal aortic aneurysm.

PURPOSE: We sought to assess the role of endovascular techniques in the management of perigraft flow (endoleak) after endovascular repair of an abdominal aortic aneurysm. METHOD: We performed endovascular repair of abdominal aortic aneurysm in 114 patients, using a variety of Gianturco Z-stent-based prostheses. Results were evaluated with contrast-enhanced computed tomography (CT) at 3 days, 3 months, 6 months, 12 months, and every year after the operation. An endoleak that occurred 3 days after operation led to repeat CT scanning at 2 weeks, followed by angiography and attempted endovascular treatment. RESULTS: Endoleak was seen on the first postoperative CT scan in 21 (18%) patients and was still present at 2 weeks in 14 (12%). On the basis of angiographic localization of the inflow, the endoleak was pure type I in 3 cases, pure type II in 9, and mixed-pattern in 2. Of the 5 type I endoleaks, 3 were proximal and 2 were distal. All five resolved after endovascular implantation of additional stent-grafts, stents, and embolization coils. Although inferior mesenteric artery embolization was successful in 6 of 7 cases and lumbar embolization was successful in 4 of 7, only 1 of 11 primary type II endoleaks was shown to be resolved on CT scanning. There were no type III or type IV endoleaks (through the stent-graft). Endoleak was associated with aneurysm dilation two cases. In both cases, the aneurysm diameter stabilized after coil embolization of the inferior mesenteric artery. There were two secondary (delayed) endoleaks; one type I and one type II. The secondary type I endoleak and the associated aneurysm rupture were treated by use of an additional stent-graft. The secondary type II endoleak was not treated. CONCLUSIONS: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means. Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement.

Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection.

PURPOSE: To describe a case of presumed aortoduodenal fistula that was treated by endovascular implantation of a stent-graft. METHODS AND RESULTS: A 76-year-old man was transferred from another hospital where he had been treated for upper gastrointestinal hemorrhage over a 2-month period. Ten years previously, he had undergone aortobifemoral bypass, the right limb of which recently thrombosed. At the time of transfer, computed tomographic scanning showed a large false aneurysm between the aorta and the duodenum. Endoscopy disclosed mucosal erosions in the fourth portion of the duodenum. Following implantation of 2 overlapping stent-grafts, the bleeding ceased and the false aneurysm disappeared. At no time did the patient have a fever. The patient initially did well, but 8 months after treatment, he presented with fever and chills. Recurrent infection had caused erosion of the aorta so that a large portion of the stent-graft was visible from the duodenum. The infected graft and stent-grafts were removed in a two-part operation, from which the patient recovered satisfactorily. CONCLUSIONS: Endovascular stent-grafts may have a role to play in the management of aortoduodenal fistula, if only as a temporary measure to control bleeding.

Induction of muscle glutamine synthetase gene expression during endotoxemia is adrenal gland dependent.

Skeletal muscle plays a crucial role in maintaining nitrogen homeostasis during health and critical illness by exporting glutamine, the most abundant amino acid in the blood. We hypothesized that induction of glutamine synthetase (GS) expression, the principal enzyme of de novo glutamine biosynthesis, in skeletal muscle after endotoxin administration was adrenal gland dependent. We studied the expression of GS in normal and adrenalectomized rats after intraperitoneal administration of Escherichia coli lipopolysaccharide (LPS). Treatment of normal rats with LPS resulted in a marked increase in GS mRNA that was dose and time dependent, and preceded the increase in GS protein and specific activity. The increase in muscle GS mRNA observed in normal rats in response to LPS was abrogated in adrenalectomized rats at 3 h after high dose LPS treatment and markedly attenuated at 5.5 h after low dose LPS treatment. These and other studies implicate glucocorticoid hormones as a key, but not exclusive, regulator of skeletal muscle GS expression after a catabolic insult.

Induction of cytokine-induced neutrophil chemoattractant (CINC) mRNA in the lungs of septic rats.

OBJECTIVE: To study cytokine-induced neutrophil chemoattractant (CINC) mRNA induction in lungs of normal, neutropenic, and adrenalectomized rats after intraperitoneal Escherichia coli lipopolysaccharide (LPS) administration and in cultured rat pulmonary cell lines after exposure to mediators of the septic response. MATERIALS AND METHODS: Northern blotting was used to assay relative CINC mRNA levels and a colorimetric myeloperoxidase assay was used as a measure of neutrophil infiltration. RESULTS: After a single dose of LPS, rapid induction of CINC mRNA coincided with neutrophil infiltration into lungs, a response that lasted approximately 12 to 24 hours. Multiple LPS treatments resulted in a similar CINC response, but a more prolonged myeloperoxidase response. CINC mRNA induction in lungs was heightened 30% in adrenalectomized animals and 400% in neutropenic ones. LPS and cytokines induced CINC mRNA in cultured endothelial and epithelial cells. CONCLUSIONS: Induction of CINC mRNA expression in pulmonary endothelial and/or epithelial cells by systemic LPS or cytokines may play a role in mediating neutrophil infiltration into lungs during sepsis. Markedly increased CINC induction in the lungs of neutropenic animals suggests that neutrophils may act to inhibit expression of this chemoattractant via a negative feedback mechanism.

Glucocorticoids regulate glutamine synthetase expression in lung epithelial cells.

During septic states efflux of glutamine from the lung increases, a response sustained by an increase in glutamine synthetase (IGS) activity. We have used a cell culture model employing a rat epithelial cell line of pulmonary origin (L2 cells) to study the effect of several hormones and cytokines which mediate the septic shock response on GS expression. We found that GS mRNA and GS protein contents increased rapidly and severalfold in response to physiologically relevant levels of the synthetic glucocorticoid dexamethasone (Dex). In contrast, GS expression was not markedly induced by Escherichia coli lipopolysaccharide (LPS), cytokines, activated complement C5a, or prostaglandins. Dex did not alter the kinetics of GS mRNA decay in the presence of actinomycin D. The increase in GS mRNA in response to Dex was completely blocked by RU-38486 and by actinomycin D, but not by cycloheximide (CHX). CHX together with Dex caused a superinduction of GS mRNA. GS mRNA decay kinetics suggested that this superinduction is at least in part caused by an approximately twofold increase in GS mRNA half-life caused by CHX. In addition, actinomycin D was found to increase GS mRNA half-life by approximately 50%. Actinomycin D plus CHX acted synergistically to cause a profound inhibition of GS mRNA decay. Our results are consistent with regulation of lung GS expression via a direct glucocorticoid receptor-mediated response. In addition, GS mRNA decay in L2 cells seems to be regulated by two independent mechanisms, one which is sensitive to CHX and one which is sensitive to actinomycin D.

Hepatic uptake of glutamine and other amino acids during infection and inflammation.

Catabolic illness such as sepsis and injury induce profound changes in host amino acid metabolism, including increased hepatic amino acid uptake. Because many amino acid-dependent pathways such as gluconeogenesis and acute-phase protein synthesis are activated in the liver during severe infection, this review will focus on the control of hepatic plasma membrane amino acid transport by specific inflammatory mediators. We specifically review the role of cytokines, eicosanoids, and glucorticoids in this response. Collectively, these signaling molecules act in a concerted manner to exert local control of hepatic function including the stimulation of amino acid transport. In particular, we review the role of glutamine and its transport in the liver, as it occupies a unique role in interorgan ammonia metabolism during critical illness.

Unusual DNA structures at the integration site of an HIV provirus.

Supercoiled pHXBc2 DNA (containing the genome of the human immunodeficiency virus type 1 and human sequences) migrated more slowly than linear DNA in native and ethidium bromide agarose gel electrophoresis at 4.5 volts/cm, suggesting the presence of unusual DNA structures. S1 nuclease analysis of pHXBc2 revealed two S1 hypersensitive sites. Site I was located within a 25 bp direct repeat in host DNA 0.6 kB upstream from the 5' LTR. Site II was mapped 0.2 kB upstream from the vif gene start site. Sequence analysis showed that Site I sequences could assume different unusual DNA structures, whereas sequences at Site II could assume either slipped or H-DNA forms. Unusual DNA structures in host DNA may be associated with active chromatin regions and may favor proviral integration.