Accuracy of intravascular ultrasound for diameter measurement of phantom arteries.

BACKGROUND: Uniplanar quantitative angiography (QA) is the standard method for measuring vessel diameter during surgical and endovascular procedures. Intravascular ultrasound (IVUS), a relatively new technology, is another means of obtaining this measurement. This study was designed to validate the accuracy of these two modalities by comparing each to direct caliper measurement, the gold standard, using phantom femoral artery segments (PAS). MATERIALS AND METHODS: PAS diameter was measured with a 12.5-MHz mechanically rotating IVUS catheter (Boston Scientific Corp.) and QA (OEC Corp.) was compared to the direct caliper measurement (Mitutoyo Corp.) at 60 different locations within PAS. At each location minimal lumen diameter and perpendicular lumen diameter were measured and their mean was calculated. The intraclass correlation coefficients (ICCC) between direct caliper measurement and IVUS and uniplanar and biplanar angiography were calculated. Fisher's Z transformation was used to compare the correlation coefficients. RESULTS: The ICCC for IVUS was 0.89. The ICCCs for uniplanar and biplanar angiography were 0.73 and 0.82, respectively. IVUS correlated more closely with direct caliper measurement than uniplanar and biplanar angiography (P = 0.00008, 0.02) Biplanar angiography correlated more closely with direct caliper measurement than uniplanar angiography (P = 0.04). CONCLUSIONS: IVUS more accurately measures lumen diameter than uniplanar or biplanar angiography. Diameter measurement with biplanar angiography is more accurate than uniplanar angiography.

Can preoperative spiral CT scans alone determine the feasibility of endovascular AAA repair? A comparison to angiographic measurements.

PURPOSE: To determine whether computed tomography (CT) alone can be used for excluding patients from endovascular repair for abdominal aortic aneurysms (AAA). METHODS: Among 71 patients evaluated for endovascular AAA repair using spiral CT imaging and angiography, 31 were selected who had both studies performed within 6 months of each other using a graduated measuring catheter or guidewire. Measurements of aneurysm neck diameter, neck length, and infrarenal aortic length were made from the CT and angiographic images using handheld calipers with calibration markers as guides. Infrarenal aortic length and neck length were determined from CT images by multiplying the width of the cuts by the number of slices between the lowest renal artery and the aortic bifurcation or the top of the aneurysm, respectively. RESULTS: CT neck diameter measurements differed significantly from the angiographic dimensions (6.3 +/- 5.1-mm mean difference, p < 0.001). In the majority of patients (25, 81%), CT neck diameters were larger (mean 7.3 +/- 3.8 mm). The mean difference in neck length measurements was 0.5 +/- 15.9 mm (p = NS). Twenty-two (71%) patients had aortic length measurements that were longer on the angiogram (mean 15.4 +/- 17.2 mm, p = NS). Five patients who would have been excluded as candidates based on overestimated CT neck diameter measurements subsequently underwent successful endovascular aneurysm repair. CONCLUSIONS: Considerable discrepancies exist between preoperative neck diameter and infrarenal aortic length measurements obtained from CT scans and angiograms used to evaluate candidates for endovascular aortic aneurysm repair. CT alone may not be adequate for predicting the feasibility of endovascular AAA repair.

Histology and electron microscopy of explanted bifurcated endovascular aortic grafts: evidence of early incorporation and healing.

PURPOSE: To report an examination of explanted bifurcated endovascular aortic grafts for histologic evidence of early healing and incorporation. METHOD: Two bifurcated endovascular aortic grafts composed of polycarbonate urethane and Elgiloy wire were explanted 42 and 21 days after successful endovascular exclusion of abdominal aortic aneurysms. Both patients expired from causes unrelated to endograft deployment. The explanted devices were examined using immunohistochemical analysis and electron microscopy. RESULTS: On explantation, both grafts appeared to have excluded the aneurysm with no evidence of endoleak, graft migration, or thrombosis. Histological examination showed numerous inflammatory cells and good ingrowth of tissue into the proximal 2 cm of the graft. Collagen and smooth muscle cells were evident in the proximal portion of the graft with only collagen in the distal segments. Neointimal formation was seen within the proximal 2 cm also, but not at the distal segments. Macrophages were present in the graft. Scanning electron microscopy showed an extensive matrix of fibers that most likely represented collagen. CONCLUSIONS: Bifurcated endovascular aortic grafts show inflammatory and mild foreign body reactions, collagen formation, and intimal ingrowth during healing. These findings are similar to some of the healing properties reported for sutured grafts, as well as other endovascular grafts.

Endoluminal repair of aneurysms containing ostia of essential branch arteries: an experimental model.

PURPOSE: To examine experimentally the feasibility of transfemoral endoluminal repair of aneurysms containing the ostia of essential branch arteries. METHODS: In a canine model (n = 4), suprarenal aortic aneurysms were created by suturing an artificial patch onto an anterior arteriotomy. Following a 2-week recovery period, the dogs underwent endovascular exclusion of their aneurysms using an aortic stent-graft with separate renal artery branch grafts. Outcome was evaluated using angiography, intravascular ultrasound (IVUS), Doppler flow, invasive pressure monitoring, and autopsy, respectively. RESULTS: Successful creation and subsequent endovascular exclusion of the aneurysm using aortic stent-grafts and separate bilateral renal artery stent-grafts was achieved in all trials. Angiographically, all aneurysms were excluded from aortic flow and all renal arteries were patent at completion of the procedure. With IVUS, good graft apposition and absence of perigraft flow were demonstrated in all animals. Mean pressure in the aneurysmal sac at completion of the procedure was 40 +/- 7 mmHg, compared to a mean systemic blood pressure of 105 +/- 8 mmHg (p < 0.05). At autopsy, no gross intimal damage was seen in the aorta or the renal arteries, and intact aortic grafts and branch grafts without twisting, coiling, or kinking were found in all trials. CONCLUSIONS: In an acute animal model, suprarenal aortic aneurysms can be excluded from the circulation with preservation of renal flow using an endoluminally placed aortic stent-graft with separate branch grafts.

Medium molecular weight pentastarch reduces reperfusion injury by decreasing capillary leak in an animal model of spinal cord ischemia.

PURPOSE: The medium molecular weight fraction of pentastarch (HES-Pz) has been shown to decrease reperfusion injury to myocardium and brain by reducing capillary leak. This study was undertaken to assess the effects of HES-Pz on neurologic function, microvascular permeability, and spinal cord infarction after temporary aortic cross-clamping in a rabbit model. METHODS: In 30 New Zealand White rabbits, a snare occlusion device was placed around the infrarenal aorta and tunneled into a subcutaneous position. Animals were allowed to recover for 48 hours and were randomized into three groups. In each group, the infrarenal aorta was occluded by tightening the snare in the awake animal for 21 minutes. Immediately after unclamping, animals received an intravenous infusion of 4% of their estimated blood volume of one of the following solutions: normal saline solution (NS; group 1); 6% standard hydroxyethyl starch (HES), molecular weight 10 to 3400 kD (group 2); and 6% HES-Pz, molecular weight 100 to 1000 kD (group 3). During 5 days of observation, neurologic recovery was graded by an independent observer using the Tarlov scale. Animals were then killed and their spinal cords harvested for histologic examination using hematoxylin-eosin and 2,3,5-triphenyltetrazolium chloride staining. In a separate group of animals (n = 15), the occurrence of spinal cord capillary permeability after NS, HES, and HES-Pz infusions was evaluated by spectrophotometric analysis of extravasated Evans blue. RESULTS: Complete paraplegia and marked histologic evidence of spinal cord cellular injury were seen in 90% of group 1 (NS) and in 78% of group 2 (HES). Treatment with HES-Pz (group 3) resulted in full neurologic recovery in 89% of animals (p < 0.05) and a threefold reduction of extravasated Evans blue compared with controls (p < 0.05). CONCLUSIONS: These results indicate that microvascular hyperpermeability plays an important role in reperfusion injury to the spinal cord. Treatment with HES-Pz reduced the capillary permeability, neuron membrane injury, and incidence of paraplegia after reperfusion of ischemic spinal cord in a rabbit model.

The preferential use of the external iliac artery as an inflow source for redo femoropopliteal and infrapopliteal bypass.

PURPOSE: It is believed that secondary operations involving the inguinal region are associated with a significant morbidity that includes infection, lymphatic obstruction, lymphorrhea, and neurovascular injury. To prevent these potentially important complications we have avoided a redo groin incision in 38 patients with severely symptomatic disease who had primary (23 cases) or secondary (15 cases) femoropopliteal bypass thrombosis during the past 3 years. METHODS: All patients were candidates for prosthetic bypasses because of lack of a suitable vein. Twenty-nine external iliac-to-popliteal bypasses (18 above-knee; 11 below-knee) and nine external iliac-to-infrapopliteal bypasses (five anterior tibial; two posterior tibial; two peroneal) were performed with 6 mm polytetrafluoroethylene ringed grafts in 38 patients. Adjunctive distal arteriovenous fistulas were constructed in all infrapopliteal bypasses. The external iliac artery was exposed via a retroperitoneal approach. The second incision was placed just below the scarred area and deepened to the level of the medial border of the sartorius muscle. A tunnel that connected both incisions was easily created by blunt dissection alongside the anterolateral border of the femoral artery. RESULTS: Four popliteal bypasses occluded at 4, 6, 10, and 28 months after operation. The remaining 25 grafts are patent (mean 14 months). Three of the infrapopliteal bypasses occluded at 0, 2, and 3 months after operation. The remaining six grafts are patent with follow-up from 4 to 18 months (mean 12 months). Only one patient had a superficial wound infection at the below-knee popliteal incision, which healed with local treatment. All other patients had an uneventful postoperative course. CONCLUSIONS: Thus we believe this approach to be simple, safe, and durable and should be used preferentially to avoid the difficult and hazardous dissection of a previously operated groin.

Silent myocardial ischemia is not predictive of myocardial infarction in peripheral vascular surgery patients.

Continuous ambulatory ECG (CAECG) monitoring has been advocated as an effective low-cost preoperative method for detecting silent myocardial ischemia in patients undergoing peripheral vascular surgery. In addition, silent ischemic events are associated with an increased incidence of postoperative myocardial infarctions. Ninety-six patients (mean age 73 years) admitted for elective aortic (24) or infrainguinal (72) operations over a 2-year period underwent 24-hour two- or three-lead CAECG monitoring. Results were reviewed by a single cardiologist blinded to the study. The criterion for ischemia was ST segment depressions of 1 mm or greater for 40 seconds or more 60 msec after the J point. Postoperative myocardial infarction was determined by ECG changes and/or elevated serum creatinine phosphokinase with positive MB isoenzymes. Risk factors included hypertension (71%), history of coronary artery disease (66%), smoking (61%), and diabetes mellitus (47%). Nine out of 96 patients (9.4%) had a positive CAECG test for silent myocardial ischemia. Only one patient (11.1%) developed postoperative myocardial infarction and there were no deaths in this group. The incidence of postoperative myocardial infarction in the nonischemic group was 16.1% (14/87). However, the mortality in this group was 6.9% (6/87). New and malignant arrhythmias requiring preoperative medical intervention were observed in seven patients (7.4%): two cases of ventricular tachycardia and five cases of atrial flutter/fibrillation. Contrary to previous reports, CAECG monitoring for silent ischemia was not a significant predictor of postoperative myocardial infarction or mortality in our patient population. However, we continue to recommend the preoperative use of CAECG monitoring as a diagnostic tool for unsuspected malignant arrhythmias.

In vitro study of placental trophoblast calcium uptake using JEG-3 human choriocarcinoma cells.

During human fetal development, placental syncytiotrophoblasts actively transport calcium from the maternal to the fetal circulation. Two functional components, a cytosolic Ca2(+)-binding protein (CaBP) and a Ca2(+)-ATPase have been identified in the syncytiotrophoblasts of the chorionic villi. We report here the calcium uptake properties of a human choriocarcinoma cell line, JEG-3, which was used as an in vitro model cell system for the syncytiotrophoblasts. In culture, JEG-3 proliferated as large syncytial aggregates expressing typical syncytiotrophoblast markers. 45Ca uptake by JEG-3 was a substrate- and temperature-dependent, membrane-mediated active process that exhibited linear kinetics for up to 7 min. Both the CaBP and the Ca2(+)-ATPase were expressed by JEG-3, on the basis of biochemical, histochemical, immunochemical and or mRNA assays. Immunohistochemistry and in situ hybridization revealed that JEG-3 cells were heterogeneous with respect to the expression of the CaBP. The Ca2(+)-ATPase activity of JEG-3 was similar to the placental enzyme in terms of sensitivity to specific inhibitors, and was detected histochemically along the cell membrane. Fura-2 Ca2+ imaging revealed that calcium uptake by JEG-3 was not accompanied by a concomitant increase in cytosolic [Ca2+], suggesting a specific Ca2+ sequestration mechanism. The involvement of calciotropic hormonal regulation was evaluated by studying the response of JEG-3 to 1,25-dihydroxy vitamin D3. Calcium uptake was significantly stimulated in a dose-dependent manner by a 24-h treatment of the cells with 1,25-dihydroxy vitamin D3 (optimal dose approximately 0.5 nM); the CaBP level doubled whereas steady-state CaBP mRNA did not, suggesting that CaBP expression was regulated by 1,25-dihydroxy vitamin D3. These observations strongly suggest that the JEG-3 human choriocarcinoma cells should serve as a convenient in vitro model system for studying the cellular mechanism and regulation of transplacental calcium transport.

Hemin enhances differentiation and maturation of cultured regenerated skeletal myotubes.

Satellite cells, isolated from marcaine-damaged rat skeletal muscle, differentiate in culture to form contracting, cross-striated myotubes. Addition of 20 microM hemin (ferriprotoporphyrin IX chloride) to the culture medium resulted in increases in the number, size, and alignment of myotubes; in the number of myotubes that exhibited cross-striations; and in the strength and frequency of myotube contractions. Hemin increased satellite cell fusion by 27%, but decreased cell proliferative rate by 30%. Hemin increased the specific activity of creatine kinase (CK), a sensitive indicator of muscle differentiation, by 157%. Separation of CK isoenzymes by agarose gel electrophoresis showed that hemin increased only the muscle-specific CK isoenzymes (MM-CK and MB-CK). Thus, hemin seems to duplicate some of the effects of innervation on cultured myotubes by increasing contraction frequency and strength, appearance of cross-striations, and muscle-specific isoenzymes. In contrast, 3-amino-1,2,4-triazole, an inhibitor of heme biosynthesis, decreased the number of cross-striated myotubes, the strength and frequency of myotube contractions, and CK activity. These inhibitory effects were reversed by hemin. Collectively, these results demonstrate a physiologically significant role for heme in myotube maturation.

Reversal of in vitro hepatic insulin resistance in chronic pancreatitis by pancreatic polypeptide in the rat.

In vitro isolated liver perfusion in a rat model of chronic pancreatitis (CP) has been shown to demonstrate hepatic resistance to insulin. The ability of pancreatic polypeptide (PP) to reverse the resistance to insulin on glucagon-stimulated hepatic glucose production was therefore investigated in this model. CP was induced in 250 to 300 gm Sprague-Dawley rats by infusion of 50 microliters of 99% oleic acid into the pancreas via the common bile duct. After 6 to 8 weeks, isolated liver perfusion was performed on livers from both CP rats and sham-operated control animals (n = 12, 14), both with and without PP administration. Glucagon infusion (100 pg/ml for 30 minutes) produced a five- to sixfold increase in hepatic glucose production. The integrated hepatic glucose output (IHGO) response to glucagon alone was comparable in pancreatic and sham-operated animals; during period 1 (0 to 10 minutes) IHGO was 7.1 +/- 0.5 mg/gm-min for sham-operated controls (n = 8) and 7.1 +/- 0.4 mg/gm-min for pancreatitic animals (n = 6) without PP treatment. Animals that received PP (100 ng intraperitoneally 5 hours before liver harvest and perfusion with 4.2 ng/ml from 10 to 30 minutes) demonstrated an IHGO for period 1 for the sham (n = 6) and pancreatitic animals (n = 6) of 5.6 +/- 0.6 and 4.8 +/- 0.8 mg/gm-min, respectively. Insulin infusion (100 microU/ml added to perfusate from 10 to 30 minutes) in CP livers without PP revealed impaired responsiveness to insulin; the ratio of period 3 (20 to 30 minutes)/period 1 IHGO was 110% +/- 5% in CP livers compared with 77% +/- 5% in sham controls (p less than 0.01). In contrast, PP treatment restored hepatic responsiveness to insulin to control levels; the period 3/period 1 IHGO was 75% +/- 13% in CP livers treated with PP, which was indistinguishable from the 67% +/- 9% response seen in sham-operated control animals. These data provide the first in vitro evidence of a primary hepatic glucoregulatory role of PP. Therefore PP deficiency may contribute to altered glucose metabolism through the induction of a reversible hepatic resistance to insulin.

Immunocytochemical localization of estrogen and progesterone receptors in human thyroid.

The presence of steroid hormone receptors has previously been suggested in thyroid tissue by biochemical means. Our studies were designed to confirm these results and to localize the specific receptor-containing cell type using a novel immunocytochemical method. Monoclonal antibodies specific to estrogen receptors (ER) and progesterone receptors (PgR) were used to localize these steroid hormone receptors in the human thyroid gland. Frozen tissue sections from surgical specimens excised from 22 patients of both sexes with benign thyroid disease were studied. The sections were incubated with rat antiestrophilin and antiprogesterone receptor antibodies and were then exposed to rabbit anti-rat IgG and to rat peroxidase-antiperoxidase complex. The reaction product was visualized with diaminobenzidine tetrahydrochloride and hydrogen peroxide. Four specimens were positive for both ER and PgR, 16 were ER-positive and PgR-negative, and two were negative for both ER and PgR. Positive reactivity was limited to the follicular lining cell nuclei and varied from focal to diffuse. The immunohistochemical findings confirmed the presence of ER and PgR in the thyroid tissue and demonstrated for the first time that these receptors are present only in the nuclei of the lining cells of the thyroid follicle. The role of steroid hormone receptors in the thyroid in health and disease remains to be explained.

Mouse placental 57-kDa calcium-binding protein: I. Cloning of cDNA and characterization of developmental expression.

A cDNA clone to the mouse placental 57-kDa calcium-binding protein (MCaBP) [29] was isolated by immunoscreening a mouse placenta cDNA library constructed in the expression phage vector, lambda gt 11. The MCaBP cDNA was 0.7 kb in size, with restriction sites for StuI and Bg/II, and its identity to the MCaBP was confirmed by mRNA hybrid selection. RNA blot hybridization revealed a predominant, 3.9-kb transcript of the MCaBP in day-18 mouse placenta. The expression of the MCaBP during development was analyzed with respect to the levels of protein activity, translatable MCaBP mRNA, and total MCaBP transcript.