The Administrative Risk Analysis Index (RAI-A) Does Not Predict Reintervention or Mortality Within 30 Days in Patients Who Undergo Elective Open or Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Frailty scores are increasingly utilized to predict postoperative complications. The purpose of this study is to determine whether the administrative risk analysis index (RAI-A) can be used to predict reintervention or mortality within 30 days in patients who undergo elective open or endovascular abdominal aortic aneurysm (AAA) repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to query data from elective open or endovascular aortic aneurysm repairs from 2011 to 2018. The administrative risk analysis index (RAI-A) score was calculated for each patient using two approaches (conservative versus liberal) due to discrepancies in NSQIP data categorization. Multivariable regression analysis was performed to determine whether there were statistical or clinical significance for incremental increases of RAI-A for both the open and endovascular repair group. Outcome measures were re-intervention or death within 30 days. RESULTS: Data from 4106 and 11,733 patients who underwent open and endovascular repair, respectively, were included in the analysis. The number of reinterventions within 30 days was 9.1% (375 out of 4106 patients) in the open repair group and 4.0% (463 out of 11,685 patients) in the endovascular group. Thirty-day mortality was 4.7% (192 out of 4106 patients) in the open repair group, and 0.9% (109 out of 11,685 patients) in the endovascular group. In the conservative calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 7 (mean 8.31) and 9 (mean 9.51), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.535 (OR 1.02) for the open repair group and 0.532 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.626 (OR 1.07) in the open repair group and 0.701 (OR 1.09) in the endovascular repair group. In the liberal calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 6 (mean 6.19) and 7 (mean 7.65), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.527 (OR 1.02) for open repair and 0.529 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.625 (OR 1.07) in the open repair group and 0.695 (OR 1.08) in the endovascular repair group. CONCLUSIONS: The RAI-A is not useful in predicting 30 d reintervention or mortality in patients who undergo elective open or endovascular AAA repair.

Endovascular Repair of Ascending Aortic Pseudoaneurysm Using Transfemoral Frame-Coiling Under Total Cerebral Protection.

Ascending aortic pseudoaneurysms are associated with prior cardiac surgery and have a high chance of rupture. Open surgery is challenging given its likely reoperative nature. Various endovascular therapies have been described but are sometimes complicated by stroke. We present a patient with a prior coronary artery bypass grafting who was referred for an incidental 3-cm saccular ascending aortic pseudoaneurysm who was successfully treated with frame coiling under total cerebral embolic protection using the SENTINEL device. We propose that endovascular obliteration of ascending aortic pseudoaneurysms is a viable option in patients unfit for open repair and advocate for total cerebral embolic protection as an important adjunct.

Supraclavicular Versus Transaxillary First Rib Resection for Thoracic Outlet Syndrome.

Background: Thoracic outlet syndrome (TOS) results from compression of neurovascular structures supplying the upper extremity as they exit the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. Objectives: Transaxillary (TA) and supraclavicular (SC) approaches are both widely utilized and deemed effective. Our objective was to review the outcomes for both approaches at our institution. Methods: A retrospective review was conducted on patients who underwent thoracic outlet decompression between 2010 and 2015. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected. Operative times, length of hospital stay, perioperative complications, and outcomes were also studied. Results: A total of 82 thoracic outlet decompression procedures were performed during the study period: 42% neurogenic TOS, 46% venous TOS, and 12% arterial TOS. In total, 49% underwent TA approach and 51% underwent SC approach. Adjunct procedures were performed in 13% of patients. There were no significant differences in average operative time (151.3 ± 54.1 minutes versus 126.1 ± 36.1 minutes, P = .11) or hospital stay (2.3 ± 1.9 days versus 2.4 ± 1.4 days, P = .23) between both groups, respectively. Minor complications were seen in 6% of patients with no significant difference in both groups, whereas 6% had major complications. No perioperative or 30-day mortalities were observed. In total, 49% of patients had complete resolution of symptoms, 46% had partial improvement, and 5% had no improvement. There was no difference in symptom resolution between either group. Conclusions: TA and SC approaches are equally safe and effective for the treatment of TOS. SC decompression allows for adjunct procedures and vascular reconstructions.

Unique Presentation of an Inflammatory Abdominal Aortic Aneurysm With Rhabdomyolysis.

OBJECTIVE: This study reports the case of a 72 year old male who presented with rhabdomyolysis and a symptomatic juxtarenal inflammatory abdominal aortic aneurysm (IAAA). He underwent open repair of his IAAA with a polytetrafluoroethylene graft using the transperitoneal approach. RESULTS: The patient's aneurysm had significant inflammation with a thick rind of friable tissue overlying the native aorta. He had no history of autoimmune disease to serve as a potential trigger of his symptomatic IAAA. Prior to his presentation, however, he did experience three months of myalgia, with a concomitant creatine kinase elevation to 20,000 U/L and gross haematuria. CONCLUSION: It is proposed that rhabdomyolysis and its accompanying inflammatory state may serve as a trigger for IAAA.

Lymphedema Liposuction with Immediate Limb Contouring.

Liposuction is the treatment of choice for solid predominant extremity lymphedema. The classic lymphedema liposuction technique does not remove skin excess created following bulk removal. The skin excess is presumed to resolve with spontaneous skin contracture. We investigated the technique of simultaneously performing liposuction with immediate skin excision in patients with solid predominant lymphedema and compared the outcome with that from the classic technique. METHODS: Modified liposuction with skin excision (mLIPO) and standard liposuction without skin excision (sLIPO) were offered to patients with solid predominant extremity lymphedema. Skin traction of 4 cm and undulating skin mobility constituted positive "flying squirrel" sign. Patients with negative "flying squirrel" sign were excluded. mLIPO patients underwent skin excision. Surgical outcomes and postoperative complications were compared. RESULTS: The study enrolled 15 and 26 patients into the sLIPO and mLIPO groups, respectively. mLIPO patients demonstrated statistically significant decrease in seroma/hematoma, contour irregularity, and skin necrosis, while experiencing increased procedural satisfaction. CONCLUSIONS: Skin excision following liposuction for solid predominant lymphedema is safe. It decreases postoperative complication and improves surgical outcome.

Distal landing zone optimization before endovascular repair of aortic dissection.

BACKGROUND: The general goals of endovascular management in chronic distal thoracic aortic dissection are optimizing the true lumen, maintaining branch patency, and promoting false lumen (FL) thrombosis. Distal seal can be challenging in chronic distal thoracic aortic dissection due to the well-established secondary fenestrations and fibrotic septum. We describe our approach of distal landing zone optimization (DLZO) to enable full-diameter contact of the distal endoprosthesis. MATERIALS AND METHODS: Our experience includes 19 procedures in 16 patients (12 male, age 68 ± 8 years) between May 2014 and November 2017. A history of previous ascending repair for type A dissection was present in 8 patients. Treatment indication was enlarging aneurysm in all subjects, and 4 patients had associated chronic visceral or distal ischemia. Point septal fenestrations were expanded by serial balloon dilation and/or wire-pull approaches. Balloon molding was used to ensure complete endograft apposition and FL collapse. RESULTS: One death occurred due to aortic perforation during wire-pull fenestration in a patient with heavily calcified and angulated aorta. The remaining procedures were accomplished safely and successfully. Balloon fenestration was used in 16 procedures, alone or in combination with a limited wire pull component. Adjunct procedures for distal seal included surgeon-modified fenestrated stent graft (3), iliac branch device (3), parallel superior mesenteric artery stent-graft (1), renal artery or superior mesenteric artery stent-graft (4), iliac stent (3), and plug obliteration of FL (5). Reintervention was required in 3 patients due to delayed loss of seal after the initial procedure (3, 8, and 12 months). Two were managed by repeat DLZO and distal extension. The third had distal extension via a surgeon-modified fenestrated stent-graft component. Follow-up imaging was available in 14 patients (16.0 ± 12.5 months, range: 1-33), with stable or regressed sac diameter with complete or near-complete thrombosis of the FL in all patients. CONCLUSIONS: DLZO enabled creation of a distal seal zone in all patients. Residual retrograde filling of the FL is a marker of procedure failure, especially when seal segment length or feasible endoprosthesis oversizing are marginal. Insufficient landing segment can be circumvented with the use of a fenestrated or branched device to accomplish seal in the visceral aorta or iliac bifurcation. Adjunct FL ablation is also a valuable technique to promote FL thrombosis.

Endovascular management of an acute type B aortic dissection in a patient with fibromuscular dysplasia.

We report the case of a 44-year-old woman who developed an acute type B aortic dissection caused by an entry tear from an aneurysmal left common iliac artery that extended retrograde to the proximal descending thoracic aorta. She experienced refractory chest pain despite optimal medical management, thereby indicating repair. Endovascular aortic repair was subsequently performed. Intraoperatively, fibromuscular dysplasia was diagnosed by the characteristic appearance of her renal arteries. The patient tolerated the procedure and had resolution of her chest pain. In summary, we present a highly unusual case of type B aortic dissection resulting from a retrograde common iliac artery tear in a patient with fibromuscular dysplasia.

Galectin-1 regulates tissue exit of specific dendritic cell populations.

During inflammation, dendritic cells emigrate from inflamed tissue across the lymphatic endothelium into the lymphatic vasculature and travel to regional lymph nodes to initiate immune responses. However, the processes that regulate dendritic cell tissue egress and migration across the lymphatic endothelium are not well defined. The mammalian lectin galectin-1 is highly expressed by vascular endothelial cells in inflamed tissue and has been shown to regulate immune cell tissue entry into inflamed tissue. Here, we show that galectin-1 is also highly expressed by human lymphatic endothelial cells, and deposition of galectin-1 in extracellular matrix selectively regulates migration of specific human dendritic cell subsets. The presence of galectin-1 inhibits migration of immunogenic dendritic cells through the extracellular matrix and across lymphatic endothelial cells, but it has no effect on migration of tolerogenic dendritic cells. The major galectin-1 counter-receptor on both dendritic cell populations is the cell surface mucin CD43; differential core 2 O-glycosylation of CD43 between immunogenic dendritic cells and tolerogenic dendritic cells appears to contribute to the differential effect of galectin-1 on migration. Binding of galectin-1 to immunogenic dendritic cells reduces phosphorylation and activity of the protein-tyrosine kinase Pyk2, an effect that may also contribute to reduced migration of this subset. In a murine lymphedema model, galectin-1(-/-) animals had increased numbers of migratory dendritic cells in draining lymph nodes, specifically dendritic cells with an immunogenic phenotype. These findings define a novel role for galectin-1 in inhibiting tissue emigration of immunogenic, but not tolerogenic, dendritic cells, providing an additional mechanism by which galectin-1 can dampen immune responses.

Assessing the roles of galectins in regulating dendritic cell migration through extracellular matrix and across lymphatic endothelial cells.

Leukocyte migration from the bloodstream into tissues, and from tissues to lymph nodes, depends on expression of specific adhesion and signaling molecules by vascular endothelial cells and lymphatic endothelial cells. Tissue damage and microbial infection induce vascular endothelial cells to up-regulate expression of adhesion molecules to facilitate entry of several leukocyte populations from blood into tissues. Many of these cells then leave inflamed tissue and migrate to regional lymph nodes. A critical population that emigrates from inflamed tissue is dendritic cells. Dendritic cells in tissue have to migrate through extracellular matrix and across a layer of lymphatic endothelial cells to enter the lymphatic vasculature. Little is known about the adhesion molecules expressed by lymphatic endothelial cells or the processes required for the critical step of dendritic cell exit from tissues, specifically migration through the extracellular matrix and basal-to-apical migration across the lymphatic endothelial cell layer into lymphatic vasculature.Members of the galectin family of carbohydrate binding proteins are expressed in both vascular and lymphatic endothelial cells. Dynamic changes in galectin expression during inflammation are known to regulate leukocyte tissue entry during inflammation. However, the roles of galectin family members expressed by lymphatic endothelial cells in leukocyte tissue exit remain to be explored.Here, we describe an in vitro transmigration assay that mimics dendritic cell tissue exit in the presence and absence of galectin protein. Fluorescently labeled human dendritic cell migration through extracellular matrix and across human lymphatic endothelial cells is examined in the presence and absence of recombinant human galectin protein.

The diffusion of a community-level HIV intervention for women: lessons learned and best practices.

Abstract Early in the HIV/AIDS epidemic in the United States, relatively few women were diagnosed with HIV infection and AIDS. Today, the epidemic represents a growing and persistent health threat to women in the United States, especially young women and women of color. In 2005, the leading cause of HIV infection among African American women and Latinas was heterosexual contact. In addressing HIV prevention needs among women, community-level strategies are needed to increase consistent condom use by women and their partners and to change community norms to support safer sex behaviors. The Real AIDS Prevention Project (RAPP) is a community-based HIV prevention intervention for women and their partners. RAPP is based on a community mobilization model that involves a combination of activities, including street outreach, one-on-one discussions called stage-based encounters, role model stories, community networks, and small group activities. The objectives of RAPP are to increase consistent condom use by women and their partners and change community norms associated with perceptions of condom use and high-risk behaviors in an effort to make safer sex practice more acceptable. This paper describes the Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP) effort to nationally diffuse RAPP from March 2003 through May 2007 and lessons learned from that diffusion experience. The paper specifically discusses (1) collaborating and planning with researchers, (2) a diffusion needs assessment that was designed to assess prior implementation experiences among select agencies, (3) developing the intervention package, (4) developing and piloting training for community-based organizations (CBOs), (5) a rollout of national trainings for health departments and community-based organizations interested in implementing RAPP, and (6) ongoing quality assurance activities and the provision of technical assistance and support. RAPP has been proven effective in reducing HIV transmission risk behaviors and improving communication and negotiation skills necessary for African American women and Latinas to reduce their risk for HIV infection and improve their overall health status.

A framework for building organizational capacity integrating planning, monitoring, and evaluation.

BACKGROUND: HIV prevention organizations are increasingly adopting more intensive and evidence-based strategies with the goal of protecting targeted populations from HIV infection or transmission. Thus, capacity building has moved to the forefront as a set of activities necessary to enable HIV prevention organizations to plan, implement, monitor, and evaluate prevention programs and services. Cost-effective approaches to the provision of capacity building assistance traditionally use strategies that compromise efficaciousness and more intensive approaches can be cost prohibitive. In addition, traditional approaches treat program planning and implementation and program monitoring and evaluation as two separate entities, even though they are interdependent aspects of an efficient and effective service delivery system. OBJECTIVE: This article describes a framework for building sustainable organizational capacity that combines high- and low-intensity approaches; integrates program planning, monitoring, and evaluation; and focuses on building understanding of the value of appropriate organizational change. METHODS: The described framework was used over a 3-year period with 52 community-based organizations funded by the Centers for Disease Control and Prevention (CDC) and organizations funded by CDC-funded health departments. RESULTS AND CONCLUSIONS: The article includes lessons learned, recommendations for building long-term sustainability, organizational change at various levels, and the need to develop standardized indicators to measure changes in organizational capacity.