Endovascular repair of carotid artery pseudoaneurysm after carotid endarterectomy with self-expanding covered stents-a long-term follow-up.

A 66-year-old Caucasian man with type 2 diabetes mellitus, peptic ulcer disease, peripheral vascular disease, and a 70% symptomatic carotid stenosis underwent a successful carotid endarterectomy with intraoperative shunting and Dacron patch closure in October 2000. Three months later, he developed a pseudoaneurysm at the site of the surgical repair. This was successfully treated with endovascular covered stents and has continued to remain patent at 9-year follow-up. Carotid artery pseudoaneurysms are secondary to trauma, infection, or previous surgery. Open surgical repair has been the treatment of choice for these pseudoaneurysms. However, open repairs are difficult and carry a high morbidity. Thus, endovascular therapy is a valid treatment for carotid artery pseudoaneurysm. Reviewing the published data, this is the first case report with successful endovascular covered stent placement for a carotid pseudoaneurysm with 9-year follow-up.

Open repair and endovascular covered stent placement in the management of bilateral axillary artery aneurysms.

A 72-year-old male with chronic obstructive pulmonary disease and hyperlipidemia presented with acute right upper limb ischemia. Arterial occlusion was found to be secondary to a thrombosed axillary artery aneurysm. An open repair was performed with a polytetrafluoroethylene (PTFE) graft. On further workup, the patient was found to have an asymptomatic axillary artery aneurysm on the left-hand side. Endovascular repair with a covered stent was chosen to treat this aneurysm.

Effects of cilostazol on human venous smooth muscle.

In this study, we evaluated the effect of therapeutic doses of cilostazol on human venous smooth muscle. Saphenous vein rings (two to four per patient sample) were suspended in tissue baths for isometric tension recordings. At the beginning of the experiment, optimal tension for isometric contraction was achieved for each ring in a stepwise fashion in the presence of norepinephrine (10(-2) M). Norepinepherine was then added cumulatively in half-molar increments and isometric tension developed by the rings was measured, thereby obtaining a dose-response curve. Following washout and reequilibration, the rings were precontracted with a 30-50% submaximal dose of norepinepherine determined from the dose-response curve and allowed to contract until a stable plateau was reached. Cilostazol was then added in a cumulative manner (680-2,720 microg/L), and the tension generated was recorded. A total of 76 venous rings were tested, and all relaxed in the presence of cilostazol. The amount of relaxation increased as the concentration of cilostazol increased. Relaxation of 15 +/- 1.9% (mean +/- SEM) at low cilostazol doses (680 microg/L) to 37+/-3% at high cilostazol doses (2,720 microg/L) was demonstrated. A second finding of this study was demonstrated when the patient samples were divided according to the presence or absence of risk factors for arteriosclerosis. The specific risk factors examined included diabetes mellitus, smoking, hypercholesterolemia, and hypertension. The presence or absence of hypertension (n = 52) or hypercholesterolemia (n = 18) did not affect the amount of relaxation of the venous rings. Smokers (n = 46) had less relaxation 16 +/- 2.4% (680 microg/L) to 41 +/- 3.6% (2,720 microg/L) compared to nonsmokers (n = 53) who relaxed 22 +/- 3.5% (680 microg/L) to 48 +/- 5.7% (2720 microg/L). This did not reach statistical significance at any concentration cilostazol (p = 0.11-0.18). Diabetics (n = 53) did have statistically significantly less relaxation at every concentration of cilostazol compared to nondiabetics (n = 11, p < 0.05). All venous rings relaxed in the presence of cilostazol. Veins of nondiabetics relaxed statistically significantly more than those of diabetics. Smokers had less relaxation than non-smokers, but this was not statistically significant. We are the first to demonstrate that human venous smooth muscle cells undergo relaxation when exposed to therapeutic concentrations of cilostazol.

Takayasu's arteritis presenting as uveitis in a 5-year-old girl.

A 5-year-old patient presented with uveitis as initial manifestation of Takayasu's arteritis. Our patient is unique not only in the initial presentation but also in the extent of arteritis in the aortic arch and great vessels. This is only the second case reported in the literature with this unusual presentation.

Long-term follow up and prognostic factors for cryotherapy of malignant liver tumors.

BACKGROUND: The aims of this study were to determine the long-term outcomes of cryotherapy in patients with hepatic malignancies and to describe prognostic factors that may affect survival. METHODS: Ninety-eight patients (56 colorectal metastases, 28 noncolorectal metastases, 14 hepatocellular carcinomas) undergoing hepatic cryosurgery were identified in a retrospective review from January 1994 to December 2002. RESULTS: Overall survival rates at 1-, 2-, 3-, and 5- years were 81%, 62%, 48%, and 28%, respectively(median survival, 33 months) compared to a hepatic recurrence-free survival of 76%, 42%, 24%, and 16%, respectively (median hepatic recurrence-free survival, 20 months). Median follow-up was 54 months. Three hundred lesions were cryoablated; the recurrence per cryolesion was 5%. Major complications were the lone factor that significantly reduced overall (P=.0005) and hepatic recurrence-free survival (P=.0005). The number of lesions (TNL) and total estimated area (TEA) cryoablated did not significantly affect overall or hepatic recurrence-free survival. Additionally, outcomes depending on tumor type were not significantly different. CONCLUSIONS: Cryotherapy is an important option for a wide range of unresectable malignant hepatic tumors and provides the potential for long-term survival. Patients with major complications at the time of cryotherapy suffer a decreased overall and hepatic recurrence-free survival.

Prognostic determinants in duodenal injuries.

A retrospective review of 222 consecutive patients with duodenal injuries admitted to an urban Level 1 Trauma Center who subsequently underwent laparotomy during the period July 1980 to April 2002 was performed in an effort to elucidate factors associated with mortality, infectious morbidity, and length of stay in these patients. Predictably, the patients were predominantly male (92.7%) and young (mean age, 31.6 years). The overall mortality rate was 22.5 per cent, with a mortality rate of 18 per cent seen in the first 48 hours. Penetrating trauma was suffered by 88.3 per cent of the patients. Multivariate analysis revealed the performance of a thoracotomy, initial emergency department (ED) systolic blood pressure (SBP) <90 mm Hg, final operating room (OR) core body temperature less than 35 degrees C, and presence of a splenic injury to be the most important predictors of mortality (all P < 0.05). Mortality in the patients undergoing a resuscitative thoracotomy was 88.9 per cent versus 13.3 per cent in those patients not requiring thoracotomy. An initial SBP in the ED <90 was associated with a 46 per cent mortality rate, as compared with 4 per cent in those patients not in shock. A final OR core body temperature of less than 35 degrees C led to a 60 per cent mortality rate versus 8.3 per cent for warmer patients. Patients with a concomitant splenic injury were noted to have a 62.5 per cent mortality rate; those without had a 19.4 per cent mortality rate. The mean length of stay among survivors greater than 48 hours was 16.0 +/- 24.7 days. Univariate analyses revealed lowest OR core body temperature below 35 degrees C, initial OR SBP <90, presence of infection, >5 transfusions, initial ED SBP <90, final OR core temperature <35 degrees C, colon injury, spleen injury, and an injury severity score (ISS) >25 all to be significantly associated with increased length of stay. Multivariate analysis revealed an initial operating room blood pressure of less than 90 mm Hg systolic, the presence of an infection, and greater than 5 blood transfusions to be the factors most significantly correlated with increased length of stay (all P < 0.02). Of 182 patients surviving 48 hours, 98 (54%) developed an infection. Fifty-seven (31%) patients were noted to have wound-related infections, 92 (51%) patients had nosocomial infections, and 50 (27%) patients had both types. The presence of an abdominal arterial injury, an ISS >25, pancreatic injury, and lowest OR core body temperature <35 degrees C were the factors identified on multivariate analysis most significantly correlated with infectious morbidity (all P < 0.05). This data suggests that early efforts to prevent shock and rapidly control bleeding are the most likely efforts to reduce mortality rates in these patients. Those patients with duodenal injury presenting in shock or requiring a thoracotomy for resuscitation did poorly. Splenic injury was the associated injury found on multivariate analysis to be most closely associated with increased mortality. Early control of bleeding and the prevention of infection provide the most significant opportunity for decreasing length of stay. Infections are common with duodenal injuries, and aggressive surveillance should especially be performed in those patients with an abdominal arterial injury, an ISS >25, pancreatic injury, or lowest OR core body temperature <35 degrees C.

The extent of cryosurgery increases the complication rate after hepatic cryoablation.

Although there have been many reports on the use of cryosurgery to ablate hepatic malignancies none have specifically examined the relationship of complication rates to the extent of cryoablation. A retrospective review from January 1997 to May 2002 identified 98 patients treated with hepatic cryotherapy. The extent of the cryosurgery was determined by the total number of lesions (TNL) and total estimated area (TEA) of the lesions from preoperative evaluation by CT scan and intraoperative evaluation by ultrasound. The major complication rate was 11 per cent. The 30-day mortality was 0 per cent, but the late procedure-related mortality was 2 per cent. Increasing the extent of cryotherapy measured by intraoperative ultrasound demonstrated significant increases in the complication rate and length of stay (LOS). With cryoablation of TEA > or = 30 cm2 there was a significant increase in the overall complication rate (56% vs 23%; P = 0.003) and LOS (8.8 +/- 6.9 vs 6.1 +/- 4.2; P = 0.022) compared with TEA < 30 cm2. Performance of concurrent procedures also led to a significant increase in complications (69% vs 29%; P = 0.010) and LOS (8.6 +/- 6.8 vs 6.0 +/- 4.0; P = 0.019). Multivariate analysis, however, showed intraoperative TEA > or = 30 cm2 to be the most significant independent predictor of increased complications and prolonged LOS.

Augmentation of wound healing with translation initiation factor eIF4E mRNA.

BACKGROUND: Initiation of translation is the rate-limiting step in protein synthesis; eIF4E increases translational efficiency by facilitating ribosome scanning. eIF4E is present in cells in rate-limiting amounts; chronic overexpression of eIF4E causes cell transformation by upregulating growth-related proteins. Biolistic delivery of epidermal growth factor (EGF) increases wound healing; transiently increasing wound eIF4E levels with biolistic mRNA transmission may further augment wound healing without oncogenesis. PATIENTS AND METHODS: Midline fascial wounds were created in rats and biolistically treated with gold particles carrying mRNA encoding for hEGF with or without eIF4E prior to suture closure; control animals received blank bullets. The animals were sacrificed at 7 or 14 days for determination of peak wound bursting strength on a tensiometer. Results are expressed as means +/- standard deviation; statistics were via analysis of variance. RESULTS: [Table: see text]. CONCLUSIONS: Simultaneous biolistic delivery of EGF mRNA with eIF4E mRNA significantly increases wound breaking strength compared to that in control animals or treatment with EGF mRNA alone without risk of cellular transformation. Further studies of translational activation to augment wound healing are warranted.