Low-grade, metastasizing splenic littoral cell angiosarcoma presenting with hepatic cirrhosis and splenic artery aneurysm.

The behavior of littoral cell neoplasms ranges from benign (littoral cell angioma, LCA) to highly malignant (angiosarcoma). Two unusual cases of low-grade metastatic littoral cell angiosarcoma (LCAS) have been reported with late recurrence and bulky metastases. We present the third case of this rare neoplasm in a 38-year-old man with cirrhosis and a large splenic artery aneurysm, without extrasplenic masses. The spleen showed nodules resembling LCA, immunoreactive for CD31, factor VIII, CD68, and CD163 but not CD8 or CD34. Also present were solid areas of immunophenotypically identical bland spindle cells, although lighter CD31 immunostaining distinguished them from LCA-like angiomatous channels. Similar cells diffusely infiltrated the cirrhotic liver. After splenectomy, pancytopenia resolved, and he is asymptomatic 19 months later. Low-grade LCAS is a previously unreported cause of cirrhosis and may metastasize without forming masses. In cases of LCA, CD31 immunohistochemistry may facilitate detection of LCAS and indicate metastatic potential.

Integrin and matrix metalloproteinase expression in human carotid plaque.

BACKGROUND: Neointimal thickening is the major cause of restenosis after carotid endarterectomy (CEA) and carotid stenting. The biologic behavior of these lesions is regulated by the interaction between smooth muscle cells (SMCs), endothelial cells (ECs), and extracellular matrix (ECM) proteins. Although the contribution of the cellular components of neointimal lesions has been extensively studied, the role of the ECM proteins in lesion remodeling is less well defined. METHODS: We examined primary and restenotic carotid endarterectomy specimens to determine their cellular morphology. Tissue was also preserved for protein extraction for Western immunoblotting and mRNA for RT-PCR and cDNA microarray analysis. RESULTS: All primary lesions demonstrated the features of complex atherosclerotic plaque. Restenotic lesions were composed of SMCs embedded in ECM. Microarray analysis demonstrated altered expression of 13 of 96 genes. Eight genes were increased more than 3-fold and five genes were decreased more than 3-fold in primary plaque compared with restenotic lesions. RT-PCR confirmed alpha2-, alpha6-, and beta3-integrin gene expression in reference tissue, primary plaque, and restenotic lesions, with the greatest expression in primary plaque. Primary plaque demonstrated increased protein expression of plasminogen activator inhibitor-1 (PAI-1) and tissue inhibitor of metalloproteinase (TIMP-1). By zymography, pro-MMP-2, pro-MMP-9 levels, and MMP-2 activity were also increased in primary plaque compared with reference and restenotic tissues. CONCLUSIONS: The decreased integrin expression and protease activity in restenotic lesions versus primary carotid plaques suggests that the neointimal lesions were in a quiescent phase. These alterations in protein expression and protease activity demonstrate the importance of proteinase/inhibitor imbalance in regulating plaque remodeling.

Metalloproteinase expression in venous aneurysms.

INTRODUCTION: Although recognized with increasing frequency, the pathogenesis of venous aneurysms (VA) remains poorly understood. We evaluated 8 patients with 10 VA for the presence, localization and activity of metalloproteinases (MMPs). METHODS: Tissue specimens from VA (n=8), normal saphenous vein (NSV n=7) and varicose veins (VV n=7 were compared by histology and immunohistochemistry (IHC). Histologic sections were stained with H&E, Movats pentachrome and toluidine blue, and IHC specimens with antibodies to CD68, MMP2, MMP9, and MMP13. Protein expression and enzyme activity were determined by Western immunoblotting and zymography. RESULTS: Three of 4 patients with popliteal VA presented with edema and leg pain and the remaining patient with deep venous thrombosis (DVT) and pulmonary embolism (PE). The 5 popliteal VA were treated by; excision and reanastomosis (n=2) lateral venorrhaphy (n=2) and spiral saphenous vein graft (n=1). The 3 patients with 4 upper extremity VA had discomfort over a compressible mass. Two of the VA were excised and the remaining patients aneurysm ruptured spontaneously. The mesenteric VA, an incidental finding at laparotomy was excised. Thrombus was present in 2 popliteal, 1 upper extremity and in the mesenteric aneurysm. Histologically, VA and VV were characterized by fragmentation of the elastic lamellae, loss of smooth muscle cells (SMCs) and attenuation of the venous wall when compared to NSV. Varicose veins and VA also demonstrated increased expression of MMP-2, MMP-9 and MMP-13 in endothelial cells (ECs), SMCs and adventitial microvessels compared to NSV. Both pro-MMP-2 and pro-MMP-9 were detected by zymography in VA,VV and NSV but only MMP-2 activity was demonstrable. CONCLUSIONS: The structural changes in the venous wall in addition to the increased expression of MMP-2, MMP-9 and MMP-13 in VA compared to NSV and VV suggests a possible causal role for these MMPs in their pathogenesis.

Pathogenesis of varicose veins and implications for clinical management.

Varicose veins (VVs) classically result from venous hypertension owing to incompetence of the major communications between the superficial and deep veins of the lower extremity. In a significant number of patients, there is no demonstrable truncal saphenous reflux and varicosities are the result of isolated perforating and nonsaphenous vein incompetence. The clinical and histologic features of VVs are the result of disruption of the normal architectural structure of the venous wall as a consequence of remodeling of the extracellular matrix (ECM) in response to increased venous distention and altered hemodynamic shear stress. Although a number of genes, growth factors, proteases, and their inhibitors known to modulate the ECM have been implicated in the pathogenesis of VVs, their etiology remains unknown. The complex variations in venous anatomy in patients with VVs require detailed vein mapping to determine the source and drainage locations of reflux if the rates of residual and recurrent varicosities are to be reduced. The distinct pathogenic mechanisms involved in the development of VVs have important implications for the management of VVs that include a wide spectrum of treatment modalities ranging from reassurance, alternative medicines, conservative management or compression therapy, and surgical or endovascular therapy.

Amino acids stimulate leg muscle protein synthesis in peripheral arterial disease.

OBJECTIVE: Older patients with peripheral arterial disease (PAD) and intermittent claudication have impaired walking ability resulting from reduced lower extremity blood flow. Evidence suggests that leg muscle abnormalities may also contribute to walking intolerance in claudicants. In healthy elderly people, leg muscle protein synthesis can be augmented by nutritional supplementation with amino acids; preliminary data suggest that this increases muscle mass, walking ability, and functional status. In this study, we investigated whether amino acid supplementation would improve leg muscle protein synthesis in elderly PAD subjects, given that reduced leg blood flow might restrict the availability of amino acids to muscle. METHODS: Two groups participated in the study: a group of 11 claudicants (mean age, 62 years; mean ankle-brachial index, 0.62; 46% male) and a group of 9 age- and sex-matched healthy controls (mean ankle-brachial index, 1.1). Both groups underwent measurement of leg blood flow by using strain gauge plethysmography, as well as measurement of baseline and amino acid-stimulated protein synthesis in leg muscle. Protein synthesis was quantified from calf muscle biopsy samples by measurement of the fractional synthetic rate (FSR) of protein, by using the incorporation of the stable isotope l-[ring-(2)H(5)]-phenylalanine into muscle protein. Total protein was extracted from muscle samples, and gas chromatography/mass spectroscopy methodology was used to measure incorporation rates. After measurement of basal FSR, all subjects were given an oral drink of 15 g of essential amino acids, and the measurements of FSR were repeated. Data are expressed as mean +/- SD; statistical analysis of differences between the two groups (with and without amino acid supplementation) was performed by using analysis of variance with repeated measures. RESULTS: Calf blood flow was reduced in the PAD subjects compared with controls (1.44 +/- 0.53 mL/min per 100 mg of tissue vs 2.40 +/- 0.57 mL/min per 100 mg of tissue; P = .005; t test). FSR in the basal state was equivalent between the two groups (healthy, 0.060% +/- 0.025% per hour; PAD, 0.061% +/- 0.029% per hour; P = .97). Equivalent increases (P < .05) occurred in both groups in response to oral amino acid supplementation (healthy, 0.087% +/- 0.012% per hour; PAD, 0.104% +/- 0.041% per hour; P > .05; analysis of variance). CONCLUSIONS: Despite reduced leg blood flow, elderly PAD patients synthesize calf muscle protein in the basal state in a fashion similar to that in healthy elderly people. More importantly, administration of exogenous amino acids produces a significant increase in protein synthesis in these patients that is also equivalent to that in healthy elderly people. Our goal is to use these results as the basis for an intervention study to determine whether long-term oral amino acids, by augmenting calf muscle protein synthesis, increase calf muscle mass, walking ability, and functional status in elderly claudicants.

Current advances in the pathogenesis of varicose veins.

Varicose veins have a wide prevalence and are characterized by their tortuous, dilated, and serpentine appearance. This pattern is the result of disruption of the normal arrangement of the extracellular matrix (ECM) and smooth muscle cells (SMC) in veins. Valvular incompetence and the effect of increased hydrostatic pressure have been implicated in the pathogenesis of varicose veins. Alterations in the ECM and varied expression of metalloproteinases and their inhibitors can effect changes in venous wall remodeling. Gene expression and specific candidate markers have been identified in varicose veins. Differential gene transcription may influence the adaptive response of the venous wall to stimuli and the remodeling of the ECM that leads to the development of varicose veins.

The use of covered nitinol stents to salvage dialysis grafts after multiple failures.

The increasing number of patients requiring hemodialysis and the limited number of access sites have resulted in an increase in multiple graft revisions to maintain access for hemodialysis. Venous outflow or anastomotic stenoses in vascular grafts tend to recur and contribute to the difficulty in maintaining a functioning graft. Thus, extending the life of a failed graft becomes an important objective of this study, which was to assess the use of covered nitinol stents to salvage expanded polytetrafluoroethylene (ePTFE) grafts with venous anastomotic or outflow stenosis that have failed after multiple revisions. This is a review of 8 failed non-autogenous ePTFE grafts with isolated venous anastomotic or proximal outflow stenoses that had undergone multiple previous revisions, had failed percutaneous transluminal angioplasty (PTA), and required placement of a covered nitinol stent. Graft locations were forearm (2), upper arm (4), and femoral (2). The mean number of interventions per patient before stent placement was 5.87 thrombectomies (range 2-28) and 3.38 balloon angioplasties (range 2-19). Five patients had 0.62 interposition grafting and 3 had patch angioplasty. All 8 patients (100%) underwent successful dialysis after thrombectomy and stenting. The primary and secondary patency rates after stent placement were 50% and 75%, and 25% and 75%, at 3 and 6 months, respectively. Percutaneous thrombectomy, balloon angioplasty, and concomitant covered nitinol stent placement extend the function of hemodialysis access grafts that have previously failed multiple times.

Entrapment of a cerebral embolic protection device--a case report.

Cerebral protection devices have significantly reduced the incidence of embolic events in patients undergoing carotid stenting. With the increasing availability of such devices an awareness of the potential complications associated with their deployment is essential. Here we report a patient with entrapment of a filter device within a carotid stent that required surgical removal. The mechanisms underlying this complication and measures to prevent its occurrence are discussed.

Delayed presentation of traumatic aortocaval fistula: a report of two cases and a review of the associated compensatory hemodynamic and structural changes.

Chronic aortocaval fistula (ACF) is a rare complication of gunshot wounds to the abdomen. Herein we report two cases of traumatic ACF: one asymptomatic and the other presenting with congestive heart failure (CHF) 20 and 30 years, respectively, after their initial injury. The recent onset of CHF, the presence of a continuous abdominal bruit, and, in the second patient, a history of penetrating trauma suggested the diagnosis of ACF. The diagnosis was confirmed by computed tomography scanning in both patients. Surgical repair of the ACF in the symptomatic patient resulted in resolution of the CHF and reversed the dilatation of the aorta and inferior vena cava. The asymptomatic patient was lost to follow-up. CHF in a young male patient with a history of penetrating abdominal trauma should alert the surgeon to this rare complication.

Apoptosis of allospecifically activated human helper T cells is blocked by calcineurin inhibition.

BACKGROUND: Classical transplantation immunosuppression relies heavily upon the interruption of interleukin-2 (IL-2) signaling by calcineurin inhibition. However, recent evidence in murine models suggests that IL-2 is necessary for activation-induced cell death (AICD) of allograft-specific lymphocytes. METHODS: We examined the apoptotic effects of the calcineurin inhibitor cyclosporine A and mTOR inhibitor rapamycin on the apoptotic alterations that occur in allospecifically activated human lymphocytes in a one-way mixed lymphocyte culture (MLC). RESULTS: Cyclosporine increased caspase-3 activation in MLC, which corresponded with a decrease in lymphocyte apoptosis in MLC. Cyclosporine also reduced apoptosis in the CD4+ helper T cell subset, while CD8+ cells had similar or increased apoptosis when compared to controls. In contrast, rapamycin-treated cultures had normal levels of CD4+ T cell apoptosis when compared to control MLC, with decreases seen in CD8+ T lymphocytes. CONCLUSIONS: In humans, blockade of IL-2 receptor signal with rapamycin allows apoptosis of allospecifically activated CD4+ lymphocytes to occur, while blockade of IL-2 production with cyclosporine results in decreased apoptosis in this T cell subset. As helper T cells are integral to the immune response, these results may explain the tolerogenic effects of rapamycin.

A changing pattern of infection after major vascular reconstructions.

Wound and graft infection can occur in more than 40% of patients undergoing vascular reconstructions for peripheral arterial disease (PAD). A recent increase in the frequency and severity of infections, as well as a change in the microorganisms recovered, led us to undertake a retrospective case-controlled study of wound/graft infections at this institution. The medical records of all patients undergoing vascular reconstruction for PAD during the previous 36 months were reviewed. Patient demographics, graft location and conduit, infection location, causative microorganisms, and factors potentially associated with development of infection were recorded. Infections were classified according to a modification of the CDC criteria into superficial incisional, deep incisional, or involving the graft (body only, anastomosis without disruption, or anastomosis with disruption). Univariate and multivariate regression analyses were used to identify factors associated with the development of infection. Four hundred ten (84 aortic, 41 extraanatomic, and 285 infrainguinal) revascularization procedures were performed in 217 men and 193 women with a mean age of 62 years (range 43-88). The infection rate for the entire group was 11.0% (45/410). Eighty percent (36/45) occurred after infrainguinal reconstructions and 64% (29/45) of the infections involved the groin incision. Direct involvement of the graft occurred in 67% (30/45), and 27% (12/45) presented with anastomotic disruption. Of the infrainguinal infections, in situ and prosthetic reconstructions were associated with a significantly higher rate of infection than reversed vein grafts tunneled anatomically (p <0.001, chi-square analysis). Patients with nonautogenous grafts (24 expanded polytetrafluoroethylene and 2 bovine) presented with more advanced infections involving the graft (20/26 procedures) and were more likely to present with anastomotic disruption (11/26). Staphylococcus aureus was isolated in the majority of infections (64%) and in all cases involving graft disruption. Multivariate regression analysis identified the following factors associated with development of infection: previous hospitalization (p = 0.03), a younger age (p = 0.047), and the presence of a groin incision (p = 0.04). Twenty-five percent of graft infections resulted in major amputation, and 11% of patients with graft infection died as a result. The incidence, morbidity, and mortality of infections in vascular reconstructions for PAD are increasing dramatically, particularly in infrainguinal reconstructions involving groin incisions. Perioperative antibiotic selection should be modified to include coverage for all Staphylococcal subspecies and hospitalization before surgical procedures should be avoided.

Arterialization of deep dorsal vein of penis for penile ischemia.

Penile ischemia, a rare complication of diabetic end-stage renal disease, is usually treated by penectomy once conservative measures fail. We present a patient with diabetes mellitus and end-stage renal disease with penile ischemia that was successfully treated with an arteriovenous interposition bypass graft between the common femoral artery and the deep dorsal vein of the penis. Retrograde flow into the corpus spongiosum resulted in immediate pain relief and healing of the ischemic lesions.

Aortic eNOS expression and phosphorylation in Apo-E knockout mice: differing effects of rapamycin and simvastatin.

BACKGROUND: The inhibition of nitric oxide (NO) by hypercholesterolemia may be mediated, in part, by interactions with caveolin-1 (Cav-1). Because of the facilitatory effects of statins on endothelial function and the adverse effects of rapamycin (RAPA) on plasma lipids, we compared the effects of simvastatin (SMV) and RAPA on endothelial NO synthase (eNOS) and Cav-1 protein expression and phosphorylation in the aortas of apolipoprotein E (Apo-E) knockout (-/-) mice. METHODS: Apo-E -/- mice (n = 38) fed a high-cholesterol diet were given SMV (100 mg/kg/day po), RAPA (3 mg/kg/day ip), or no treatment for 10 weeks. Blood was drawn for serum lipid analysis, and protein was extracted for Western immunoblotting. Selected aortic specimens from 2 animals in each group were examined by histology and immunohistochemistry. The data are expressed as the mean +/- SEM and compared by the Student t test and ANOVA. Significance was established as P < .05. RESULTS: Lipid levels at 10 weeks were similar in the 3 groups except for higher triglyceride levels in RAPA-treated animals. eNOS expression was highest in RAPA-treated mice, but the p-eNOS to eNOS protein expression ratio was significantly greater in the SMV treatment group compared to both RAPA and controls (P < .05). Both Cav-1 and p-Cav-1 expression was significantly lower in the SMV-treated animals (P < .05) compared to mice treated with RAPA. CONCLUSIONS: Although eNOS expression was greatest in the RAPA-treated mice, the expression of p-eNOS was similar in the RAPA- and SMV-treated animals. The increase in eNOS induced by RAPA and the inverse relationship between p-eNOS and Cav-1 protein expression observed with SMV treatment suggest different mechanisms for the regulation of aortic eNOS expression in Apo-E mice by these 2 agents.

Methemoglobinemia: an unusual cause of postoperative cyanosis.

Methemoglobinemia, although rare, must be considered in surgical patients presenting with acute respiratory distress and cyanosis. We report two cases of methemoglobinemia in patients undergoing aortic reconstruction. The first patient developed methemoglobinemia while on a nitroglycerin infusion, and the second after receiving benzocaine spray before intubation. Both patients were treated with methylene blue and ascorbic acid, with resolution of their hypoxia and cyanosis. The pathophysiology, etiology, diagnosis, and treatment of methemoglobinemia are reviewed.

Altered expression of vascular endothelial growth factor and its receptors in normal saphenous vein and in arterialized and stenotic vein grafts.

BACKGROUND: Myointimal thickening is a major cause saphenous vein graft failure. The prominence of medial and adventitial microvessels in stenotic vein grafts and the known angiogenic effects of vascular endothelial growth factor (VEGF) lead us to investigate the expression of VEGF and its receptors in vein graft arterialization and stenosis. METHODS: Normal and arterialized vein graft segments were evaluated by reverse transcription-polymerase chain reaction (RT-PCR) for expression of VEGF-R1 (flt), VEGF-R2 (KDR), and neuropilin-1. The cells expressing VEGF, VEGF-R1, VEGF-R2, and neuropilin-1 were identified in normal, stenotic, and arterialized vein graft segments by immunohistochemistry. RESULTS: Vascular endothelial growth factor, detected in the wall in endothelial cells and adventitial microvessels in normal vein, localized to smooth muscle cells, endothelial cells and adventitial microvessels in arterialized and stenotic vein. VEGF-R1 and VEGF-R2 were expressed infrequently on endothelial cells, macrophages, and smooth muscle cells in arterialized and stenotic vein. Neuropilin-1 was detected in all specimens. RT-PCR demonstrated significantly greater expression of neuropilin-1 in normal vein compared with arterialized vein (P <0.05). CONCLUSIONS: The differential expression of VEGF and its receptors in normal, arterialized, and stenotic vein grafts suggests that alterations in VEGF/VEGF-R2/neuropilin-1 interactions may be important determinants of the adaptive response of vein grafts to arterialization.

Deep venous thrombosis prophylaxis in trauma: improved compliance with a novel miniaturized pneumatic compression device.

OBJECTIVE: Intermittent pneumatic compression (IPC) devices prevent lower-extremity deep venous thrombosis (LEDVT) when used properly, but compliance remains an issue. Devices are frequently discontinued when patients are out of bed, and they are rarely used in emergency departments. Trauma patients are at high risk for LEDVT; however, IPCs are underused in this population because of compliance limitations. The hypothesis of this study was that a new miniaturized, portable, battery-powered pneumatic compression device improves compliance in trauma patients over that provided by a standard device. METHODS: This was a prospective trial in which trauma patients (mean age, 46 years; revised trauma score, 11.7) were randomized to DVT prophylaxis with a standard calf-length sequential IPC device (SCD group) or a miniaturized sequential device (continuous enhanced-circulation therapy [CECT] group). The CECT device can be battery-operated for up to 6 hours and worn during ambulation. Timers attached to the devices, which recorded the time each device was applied to the legs and functioning, were used to quantify compliance. For each subject in each location during hospitalization, compliance rates were determined by dividing the number of minutes the device was functioning by the total minutes in that location. Compliance rates for all subjects were averaged in each location: emergency department, operating room, intensive care unit, and nursing ward. RESULTS: Total compliance rate in the CECT group was significantly higher than in the SCD group (77.7% vs. 58.9%, P =.004). Compliance in the emergency department and nursing ward were also significantly greater with the CECT device (P =.002 and P =.008 respectively). CONCLUSIONS: Previous studies have demonstrated that reduced compliance with IPC devices results in a higher incidence of LEDVT. Given its ability to improve compliance, the CECT may provide superior DVT prevention compared with that provided by standard devices.

Immunomodulation of hepatic ischemic injury via increased Bcl-X(L) and decreased Bcl-X(S).

BACKGROUND: Although classic ischemia-reperfusion injury is mediated by reactive oxygen intermediaries, increasing evidence implicates a role for immune-mediated apoptosis during ischemic injury in transplantation. Herein, we report the effects of polyclonal rabbit anti-thymocyte globulin (rATG) on mediators of hepatic apoptosis during cold storage. METHODS: Three-month-old male Lewis rats were placed under halothane anesthesia and the portal vein cannulated. University of Wisconsin (UW) solution (35 ml) with (n = 5) and without (n = 5) 20 mg/kg anti-rat rATG was infused before hepatectomy. The liver was stored in UW solution +/- rATG (143 ng/ml) at 4 degrees C for various times up to 24 h. Specimens were terminal deoxyuridine nick end labeling-stained for apoptosis. Tissue lysates were analyzed by Western blotting and densitometry. RESULTS: Compared to UW alone, significantly fewer apoptotic cells were present in UW + rATG perfused and stored livers. There were early and sustained significant increases in Bcl-X(L) and decreases in Bcl-X(S) with rATG. There was an initial, but not sustained, significant decrease in Bax with rATG. Moreover, there was a significant one-third decrease in caspase-9 production with rATG at 0, 6, 12, and 18 h. CONCLUSION: Decreased proapoptotic Bcl-X(S) and increased antiapoptotic Bcl-X(L), as well as decreased downstream proapoptotic caspase-9 expression, during liver ischemia after treatment with rATG, all favor cell survival. Because apoptotic ischemic injury results in allograft dysfunction, preservation strategies that ameliorate such immunological effects may improve organ function.