Subclavian artery reconstruction with femoral vein for ballistic injury in a 3-year-old boy.

Few descriptions of using the femoral vein as an arterial replacement exist in the pediatric surgical literature. A 3-year-old child sustained a gunshot wound to the right subclavian artery, which resulted in ischemia to the upper extremity. The left femoral vein was harvested and used to reconstruct the subclavian artery. This report highlights a rare case of subclavian artery reconstruction using a femoral vein conduit in a young child after a penetrating injury.

Supra-Aortic Arterial Injuries Following Central Venous Catheterization Managed with Percutaneous Closure Devices: A Comprehensive Literature Review of Current Evidence.

BACKGROUND: Inadvertent supra-aortic arterial injuries during central venous catheterization can lead to devastating outcomes. These have been traditionally been managed with open repair or covered stent placement; only recently have percutaneous closure been incorporated into the management of these iatrogenic arterial injuries. METHODS: We performed a MEDLINE literature search in the English language, using the PubMed web-based search engine across years 2000 to 2020. This report reviews 34 published case reports and series reporting 71 iatrogenic supra-aortic arterial injuries managed with percutaneous vascular closure devices. RESULTS: In our review, the use of a closure device was successful in 87% of cases, even in some cases involving sheath sizes greater than 8F. The devices used in these situations caused minimal complications and offered a quick means to control bleeding. Thus, percutaneous closure devices are a helpful tool that offers an alternative to more invasive open surgical repair. CONCLUSIONS: Vascular closure devices offer a minimally invasive and effective approach to the treatment of inadvertent supra-aortic arterial injury following CVC.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. METHODS: We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. RESULTS: During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. CONCLUSIONS: Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Endovascular Management of Bleeding Aortoenteric Fistula May be Feasible as a Definitive Repair.

Aorto-enteric fistula (AEF) is a complication with devastating sequelae and significant morbidity. Although open surgery remains primary treatment endovascular approach may be used as a temporary bridge but rarely as a definitive therapy. We present a case of a patient who presented with a secondary AEF, due to hemodynamic instability we chose to treat the fistula with an aortic endograft. The patient underwent bowel resection due to bowel obstruction with omental patch over the aortic rent, 6 weeks of antibiotics. Patient is now at 8-year follow-up without evidence of infection. Although there is scarce literature on this topic, endovascular treatment of bleeding AEF may be feasible as a definitive option. Due to high risk of graft infection we recommend close observation and suppressive antibiotics.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Thigh Compartment Syndrome After Thrombolytic Therapy of an Occluded Lower Extremity Bypass Graft.

Compartment syndrome is caused by increased pressure within fascial compartment. We present a unique case of a thigh compartment syndrome that occurred after overnight catheter delivered Tissue plasminogen activator (tPA) thrombolysis of an acutely thrombosis femoral-to above knee popliteal artery Propaten® PTFE (WL Gore & Associates, Flagstaff, AZ) bypass graft. The condition was treated by emergency fasciotomy and the patient recovered uneventfully.

Angiotensin converting enzyme inhibitors and angiotensin receptor blockers have no effect on the outcomes of endovascular revascularization in tibial arterial occlusive disease.

The effects of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs) on angiogenesis, myocardial remodeling and intermittent claudication have been studied. Clinical studies have shown reduced re-intervention after cardiac stenting with the use of ACEI/ARBs. We hypothesized that the use of ACEI/ARBs decreases re-interventions after endovascular revascularization in tibial artery disease (TAD) patients. This is a retrospective study comparing the effects of ACEI/ARBs on the outcomes after endovascular revascularization for TAD. We divided all patients that underwent endovascular revascularization into Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (ACEI/ARBs) and No Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (NoACEI/ARBs) groups. A total of 360 patients underwent endovascular intervention for TAD. One hundred and ninety-six (54%) patients, 124 (57%) males, were on ACEI/ARBs after endovascular intervention for TAD, whereas 164(46%) patients, 87 (53%) males were not. The groups were well matched in the demographic variables except higher incidence of congestive heart failure, coronary artery disease and dialysis in the ACEI/ARBs group (p = .001, 0.02, 0.01 respectively). Reintervention rates were not associated with ACEI/ARBs use (p = .097). Even when corrected for statin use and antiplatelet therapy, no difference was seen in the reintervention rates in the two groups (p = .535, 0.547 respectively). Primary patency, assisted primary patency and secondary patency did not differ with the use of ACEI/ARBs (p = .244 0.096,0.060 respectively). No difference was seen in overall survival between the two groups (p = .690). ACEI/ARBs do not appear to affect the patency and reintervention rates for patients undergoing endovascular revascularization for TAD.

Single Tertiary Care Center Outcomes After Lower Extremity Cadaveric Vein Bypass for Limb Salvage.

OBJECTIVE: Cadaveric saphenous vein (CV) conduits are used in rare instances for limb salvage in patients without autogenous veins although long-term outcome data are scarce. This study was designed to evaluate the outcomes of CV bypass in patients with threatened limbs. METHODS: We retrospectively reviewed the charts from 2010 to 2017 of 25 patients who underwent 30 CV allografts for critical limb ischemia and acute limb ischemia. Patient charts were reviewed for demographics, comorbidities, smoking status, indications for bypass, and outcomes. Primary outcomes included graft patency, major amputation rates, and mortality. Secondary outcomes measured included infection rates, 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE). Statistical analysis was performed using time series and Kaplan-Meier survival curves. RESULTS: A total of 30 limbs received CV lower extremity bypasses (20 males, 10 female), and the average age was 68 ± 4 years. Primary patency rates were 71%, 42%, and 28% at 3, 6, and 12 months, respectively. Assisted primary patency rates were 78%, 56%, and 37% at 3, 6, and 12 months, respectively. Secondary patency rates were 77%, 59%, and 28% at 3, 6, and 12 months, respectively. Minor amputations, defined as amputations below the transmetatarsal level occurred in 5 (20%) patients. Wound infection occurred in 8 (32%) patients which was managed with local wound care and no patients required an extraanatomic bypass for limb salvage. Thirty-day MALE occurred in 7 (23.3%) patients. We had no 30-day mortality or MACE. The average graft length was 64.2 ± 8 cm with an average graft diameter of 3.9 ± 2 mm. Amputation-free survival and overall survival at 12 months were 20 (68%) and 21 (84%), respectively. CONCLUSIONS: Cadaveric saphenous vein allograft may be used as a bypass conduit as a viable surgical option before limb amputation. Despite the poor patency rates, the limb salvage rates of cadaveric vein grafts demonstrate that this alternate conduit may be considered when no autogenous vein is available.

Peripheral Vascular Complication of Transgender Reassignment Surgery.

BACKGROUND: Gender-reassignment surgeries are technically challenging and associated with detrimental vascular complications. METHODS: A 49 year-old female status-post phalloplasty presented with peripheral vascular complication resulting in disabling claudication. Initial anastomotic attempt was rendered nonviable to sustain the constructed phallus resulting in superficial femoral artery stenosis. Covered stent placement corrected the stenosis and alleviated the claudication. RESULTS: As gender-reassignment surgeries increase, greater understanding of potential vascular complications is needed. Involvement of multidisciplinary teams is necessary to optimize patient safety and outcomes. CONCLUSIONS: Vascular surgery should play a larger role in these complex revascularizations and vessel anastomoses to ensure quality blood flow to the reconstructed genitalia.

Contemporary outcomes of infrapopliteal atherectomy with angioplasty versus balloon angioplasty alone for critical limb ischemia.

OBJECTIVE: Limited data exist comparing atherectomy (At) with balloon angioplasty for infrapopliteal peripheral arterial disease. The objective of this study was to compare the outcomes of infrapopliteal At with angioplasty vs angioplasty alone in patients with critical limb ischemia. METHODS: This is a retrospective, single-center, longitudinal study comparing patients undergoing either infrapopliteal At with angioplasty or angioplasty alone for critical limb ischemia, between January 2014 and October 2017. The primary outcome was primary patency rates. Secondary outcomes were reintervention rates, assisted primary patency, secondary patency, major adverse cardiac events, major adverse limb events, amputation-free survival, overall survival, and wound healing rates. Data were analyzed in multivariate generalized linear models with log rank tests to determine survival in Kaplan-Meier curves. RESULTS: There were 342 infrapopliteal interventions, 183 percutaneous balloon angioplasty (PTA; 54%), and 159 atherectomies (At) with PTA (46%) performed on 290 patients, with a mean age of 67 ± 12 years; 61% of the patients were male. The PTA and At/PTA groups had similar demographics, tissue loss (79% vs 84%; P = .26), ischemic rest pain (21% vs 16%; P = .51), mean follow-up (19 ± 9 vs 20 ± 9 months; P = .32), mean number of vessels treated (1.7 ± 0.8 vs 1.9 ± 0.8; P = .08) and the mean lesion length treated (6.55 ± 5.00 cm vs 6.02 ± 4.00 cm; P = .08), respectively. Similar 3-month (96 ± 1% vs 94 ± 1%), 6-month (85 ± 2% vs 86 ± 3%), 12-month (68 ± 3% vs 69 ± 4%), and 18-month (57 ± 4% vs 62 ± 4%) primary patency rates were seen in the two groups (P = .87). At/PTA patients had significantly higher reintervention rates as compared with the PTA patients (28% vs 16%; P = .02). Similar assisted primary patency rates (67 ± 4% vs 69 ± 4%; P = .78) and secondary patency rates (61 ± 4% vs 66 ± 4%; P = .98) were seen in the PTA and At/PTA groups at 18 months. The 30-days major adverse cardiac event rates (3% vs 2%; P = .13) and 30-day major adverse limb event rates (5% vs 4%; P = .2) were similar in both groups. Wound healing rates (72 ± 3% vs 75 ± 2%; P = .12), 1-year amputation-free survival (68 ± 4.1% vs 70 ± 2%; P = .5), and 1-year overall survival (76 ± 4% vs 78 ± 4%; P = .39) rates did not differ in the PTA and At/PTA groups. THE At/PTA group had higher local complication rates (7 [4%] vs 1 [0.5%]; P = .03) CONCLUSIONS: At with angioplasty provides similar patency rates compared with angioplasty alone for infrapopliteal peripheral arterial disease, but associated with higher reintervention and local complication rates. Further appropriately designed studies are required to determine the exact role of At in this subset of patients.

Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy.

BACKGROUND: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its use in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low yield and not cost-effective. METHODS: A retrospective review of 291 consecutive CEAs from February 2011 to July 2015 was performed. Two patients were excluded: one for postoperative noncardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and creatine kinase-MB levels taken postoperatively. A patient was judged to have an MI if troponin-I was greater than or equal to 0.6 ng/mL or CK-MB is >6.3 ng/mL. The incidence of postoperative MI was recorded, and a cost analysis was performed. RESULTS: The mean age was 70.2 years (range: 42-92). Of all, 59.5% were male, and 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% on both. Most (80.6%) were on preoperative statin therapy, 26.9% had a prior history of MI (37.2% within 5 years of surgery), and 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% coronary artery bypass grafting, and 11% both). All patients received general anesthesia. The mean procedure time was 121.5 min (range: 62-258). The mean postoperative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. Three of the 8 (38%) had a prior history of MI. In asymptomatic patients, the peak level of troponin-I ranges from 0.52 to 3.64 ng/mL and that of CK-MB from 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I level of 1.59 ng/mL, with a CK-MB level of 11.5 ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing in patients who underwent CEA would have saved an estimated $51,343 over the course of treatment of the studied population. CONCLUSIONS: Routine postoperative cardiac laboratory testing in asymptomatic patients after CEA increases the hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.

Safety and Feasibility of Transradial Access for Noncoronary and Peripheral Vascular Interventions.

BACKGROUND: Transradial access (TRad) is becoming the preferred access for cardiac catheterization. The use and safety of TRad in noncoronary and peripheral vascular interventions remains ill-defined and serves as the basis for this study. METHODS: Patients undergoing noncoronary and peripheral endovascular procedures via TRad from August 2010 to February 2013 at our institution were reviewed retrospectively. Demographic data, indications, interventions performed, sheath size, procedural outcomes, and access-site complications were evaluated. Postprocedural radial artery patency and hand ischemic symptoms were evaluated clinically and by duplex ultrasound. RESULTS: Nineteen patients underwent 24 procedures via TRad for both diagnostic (11/24) and therapeutic (13/24) purposes. Twelve (63%) were women, and 75% (18/24) were from left radial artery. Indications included absent femoral pulses in 12 (50%), morbid obesity in 6 (25%), previous bypass originating or terminating in the groin in 4 (17%), and groin wound infection in 2 (8%) cases. A 5F sheath was used in 13 (54%) cases, 6F in 10 (42%) cases, and 7F in 1 (4%) case. Thirteen therapeutic interventions included 7 (29%) iliac angioplasties and/or stent, 3 (13%) femoral anastomosis angioplasties, 2 (8%) superficial femoral artery angioplasties, and 1 (4%) mesenteric angioplasty. No access-site hematoma or procedure-related deaths were reported. Postprocedural radial artery occlusion was observed in 6 (31%) patients. All occlusions were asymptomatic, except for 1 (4%) patient with self-limiting forearm pain lasting for 1 day. Sheath size strongly correlated with radial artery occlusion. CONCLUSIONS: TRad appears to be a safe and feasible alternative option for patients undergoing noncoronary and peripheral interventions. Radial artery occlusion, mostly asymptomatic, can occur and is directly related to the sheath size. Smaller sheath sizes, longer platform devices, better radial access kits, and better closure devices could potentially eliminate some of the challenges associated with TRad.

Catheter-Directed Therapy is Safe and Effective for the Management of Acute Inferior Vena Cava Thrombosis.

BACKGROUND: The management of acute thrombosis of inferior vena cava (AT-IVC) has evolved to catheter-based therapies, the results of which remain uncertain. We report our institution's experience treating AT-IVC using endovascular methods. METHODS: A 10-year retrospective review of patients presenting with symptomatic IVC thrombosis between the years 2005 and 2014 was performed. Demographic data, treatment modalities, and outcomes were reviewed. RESULTS: Twenty-five patients (44% men) underwent treatment for acute (<2 weeks) symptomatic IVC thrombosis. Presenting symptoms included pain and limb swelling in 23 (92%), motor dysfunction in 16 (64%), sensory loss in 14 (56%), and pulmonary embolism (PE) in 2 (8%) patients. Phlegmasia cerulea dolens was present in 5 patients, a history of malignancy was identified in 7 patients, and 21 patients had an IVC filter at presentation (Trapease 12, G2X 3, Option 2, Eclipse 2, Meridian 2). Four patients had a documented hypercoagulable state, 21 patients underwent venous angioplasty, and 7 (28%) patients underwent venous stenting of the IVC or iliofemoral veins. Significant (>50% luminal gain) angiographic resolution of venous thrombus was achieved in all 25 patients. Twenty-one (84%) patients reported moderate-to-complete symptomatic improvement immediately after completion of the procedures. Two patients had a clinically symptomatic PE and 1 patient underwent an above-knee amputation secondary to venous gangrene. Other complications included 6 minor bleeding complications (2 local hematoma, 4 hematuria) all of which resolved spontaneously. There were 2 major bleeding complications (1 disseminated intravascular coagulation, 1 retroperitoneal hematoma). CONCLUSIONS: Endovascular treatment of AT-IVC, regardless of etiology, is safe and effective with excellent short-term clinical results. An aggressive endovascular approach to treatment of AT-IVC is warranted even in the presence of a thrombosed vena cava filter.

Aortoiliac thrombi in inflammatory bowel disease.

Isolated arterial thrombi complicating inflammatory bowel disease occurs rarely. We encountered a case of a 28-year-old man with Crohn disease who presented with abdominal pain and severe claudication and was found to have an isolated aortoiliac thrombus. Bilateral aortoiliac thromboembolectomies were performed with successful restoration of femoral blood flow. Long-term anticoagulation therapy was instituted after an extensive hypercoagulable workup, which failed to reveal an etiology for the patient's coagulopathy. We present our case and perform an extensive literature review on this topic.

Demographic and laboratory data may predict positive temporal artery biopsy.

BACKGROUND: Temporal artery biopsy is performed in patients suspected of having giant cell arteritis. This study was conducted to evaluate clinical and laboratory criteria correlating with positive biopsy results in an effort to limit the number of negative biopsies performed. METHODS: A retrospective review was performed of patients who underwent temporal artery biopsy at two urban medical centers from 2002 to 2009. A multivariate analysis of patient demographics, clinically relevant signs and symptoms, laboratory data, and pathologic outcomes was performed. RESULTS: Temporal artery biopsy histologically confirmed giant cell arteritis in 24% of cases. The mean age of those with disease was 77.8 y and those without were 73.1 y; age was found to be statically significant (P = 0.0227); 76% were female and 24% were male; gender was not significant (P = 0.9594); 42% were Caucasian (39% had a positive temporal artery biopsy), 27% were Hispanic (17% positive), and 31% of the patients were African-American (3% positive); ethnicity was significant (P = 0.0005). The PPV of elevated ESR was 27%; sensitivity was 100%; specificity was 16%. A history of headache or visual disturbance was not predictive of a positive biopsy CONCLUSION: Fewer negative biopsy results may be achieved by screening patients with normal ESR or lower risk patients with other modalities.

Staged endovascular treatment of bilateral ruptured and intact ovarian artery aneurysms in a postmenopausal woman.

Ovarian artery aneurysms have rarely been reported in the literature, with almost all being unilateral and occurring in the peripartum period. We herein describe a unique case of a postmenopausal patient with a ruptured ovarian aneurysm and an intact contralateral aneurysm that were both successfully treated by endovascular techniques.

Percutaneous treatment of a traumatic renal-caval arteriovenous fistula presenting as high output cardiac failure.

A 67-year-old dialysis-dependent man presented to the cardiology service with worsening high output cardiac failure and was found to have a harsh, right-sided abdominal bruit on examination. Of significance, he had undergone several laparotomies related to a stab wound experienced 7 years earlier. A computed tomography scan revealed right renal artery pseudoaneurysms with fistulous communication to the vena cava. Successful percutaneous coil embolization and cyanoacrylate gluing enabled fistula closure without renal infarction. Symptoms of cardiac failure ultimately resolved following treatment. Catheter-based therapies provide minimally invasive and effective strategies for treating complicated fistulas involving the renal vasculature.

The effect of systemic anticoagulation in patients undergoing angioaccess surgery.

The benefit of intravenous heparin as an anticoagulant to avoid thrombotic complications during angioaccess surgery for hemodialysis is unknown. We prospectively randomized 115 consecutive patients referred to our institution for permanent hemodialysis access to receive systemic anticoagulation or no anticoagulation during angioaccess surgery. Patient demographics, comorbid conditions, procedure time, complications, and patency were recorded in accordance with standards recommended by the Society for Vascular Surgery. Of the 115 patients randomized, 58 received no anticoagulation and 57 received systemic anticoagulation with intravenous heparin. Arteriovenous fistulas were created in 84 patients and 31 arteriovenous grafts were inserted. Operative times were longer for grafts compared to fistulas, but there were no significant differences in operative times between patients receiving anticoagulation and those not (p = 0.31). Perioperative bleeding complications were more common in patients receiving heparin (p = 0.008). The primary 30-day patency was 84% for patients receiving heparin and 86% for those not (p = 0.79). The 3-month functional patency was 68% for both groups (p = 0.99). Age, gender, operative time, and incidence of bleeding complications had no impact on patency. In our experience, systemic anticoagulation for angioaccess surgery is associated with an increased incidence of bleeding complications and offers no advantage in terms of early patency.

The F11 receptor (F11R/JAM-A) in atherothrombosis: overexpression of F11R in atherosclerotic plaques.

F11R is the gene name for an adhesion protein, called the F11-receptor, aka JAM-A, which under normal physiological conditions is expressed constitutively on the surface of platelets and localized within tight junctions of endothelial cells (EC). Previous studies of the interactions between human platelets and EC suggested that F11R/JAM-A plays a crucial role in inflammatory thrombosis and atherosclerosis. The study reported here obtained in-vivo confirmation of this conclusion by investigating F11R/JAM-A protein and mRNA in patients with aortic and peripheral vascular disease and in an animal model of atherosclerosis. Molecular and immunofluorescence determinations revealed very high levels of F11R/JAM-A mRNA and F11R/JAM-A protein in atherosclerotic plaques of cardiovascular patients. Similar results were obtained with 12-week-old atherosclerosis-prone apoE-/- mice, an age in which atherosclerotic plaques are well established. Enhanced expression of the F11R/JAM-A message in cultured EC from human aortic and venous vessels was observed following exposure of the cells to cytokines. Determinations of platelet adhesion to cultured EC inflamed by combined cytokine treatment in the presence of F11R/JAM-A - antagonists provided data indicating that de novo expression of F11R/JAM-A on the luminal surface of inflamed EC has an important role in the conversion of EC to a thrombogenic surface. Further studies of these interactions under flow conditions and under in-vivo settings could provide a final proof of a causal role for F11R/JAM-A in the initiation of thrombosis. Based on our in-vitro and in-vivo studies to date, we propose that therapeutic drugs which antagonize the function of F11R/JAM-A should be tested as novel means for the prevention and treatment of atherosclerosis, heart attacks and stroke.