Contrast Enhanced Ultrasound (CEUS) Is Not Able to Identify Vulnerable Plaques in Asymptomatic Carotid Atherosclerotic Disease

OBJECTIVES: Contrast enhanced ultrasound (CEUS) has been suggested as an imaging tool for detection of asymptomatic carotid atherosclerotic disease (ACAD) at high risk of cerebral embolisation. The objective of this study was to evaluate CEUS and immunohistochemical (IHC) patterns in ACAD (i.e., without any neurologic symptoms in the last 6 months) and their correlations with histology. METHODS: CEUS analysis was classified on a semiquantitative basis using a three-point classification scale. Plaque morphology was assessed using the American Heart Association (AHA) classification of atherosclerotic plaques, then accordingly assigned as non-vulnerable (AHA Type IV/V) or vulnerable (AHA Type VI). IHC analysis for intra-plaque neo-angiogenesis (IPN) was identified by CD34/VEGF immunostaining and classified on a semiquantitative basis using a four-point classification scale. Both CEUS and IHC analyses were performed and scored by single observers. RESULTS: Fifty-eight consecutive asymptomatic patients (mean age 73 years, 33 males) undergoing carotid endarterectomy were included in the final analysis. Nineteen had AHA Class IV/V plaques, and the remaining 39 had AHA Class VI plaques. There were two main findings of the study: (a) histologically proven vulnerable plaques compared with histologically proven non-vulnerable plaques had denser IPN (p = .004), but did not show more pronounced contrast enhancement; (b) the correlation between IHC analysis and CEUS analysis was significant for both vulnerable and non-vulnerable plaques (p = .04 and p = .01, respectively), but it was direct for AHA Type IV/V plaques and inverse for AHA Type VI plaques. CONCLUSIONS: The main findings of the study were that histologically proven vulnerable plaques (i.e., AHA Class VI) as compared with histologically proven non-vulnerable plaques (i.e., AHA Class IV/V) had denser neo-vascularisation, but not more pronounced contrast enhancement

Implication of Laboratory Findings in Clinical Protocols for CAD-CAM Blocks Adhesion

Introdução: Espera-se que protocolos que conseguem bons resultados nos testes laboratoriais in vitro, relativamente à adesão dos blocos CAD-CAM, provoquem impacto nos protocolos clínicos do profissional médico dentista no tratamento de seus pacientes, sempre que tais protocolos sejam aplicáveis à rotina clínica. Objetivo: Analisar as implicações dos achados laboratoriais obtidos in vitro nos protocolos clínicos in vivo para a adesão eficiente de blocos de CAD-CAM, pela realização de uma revisão sistemática integrativa. Materiais e Método: A pesquisa foi realizada nos bancos de dados PUBMED, EbscoHost e ScienceDirect, pela combinação dos termos na fórmula de busca [(CAD/CAM) E (adesivo OU adesão OU colagem OU cimentação) E (cerâmica OU bloco) E protocolo] publicados em inglês, com texto integral disponível e entre 01jan2015 e 31jul2021. Resultados: A pesquisa recuperou 508 artigos, mas apenas 39 foram selecionados de acordo com os critérios de inclusão, 37 estudos laboratoriais e 2 casos clínicos. Vita Enamic® (VITA) e IPS e.max® (Ivoclar) são os blocos CAD-CAM mais usados. Rely X® Ultimate Dual (3M) foi a resina de cimentação mais usada, e μSBS o teste de força adesiva mais usado. Conclusões: Embora tenhamos padrões precisos de testes in vitro individuais, é necessário um maior nível de padronização entre os pesquisadores, a fim de promover maior fidelidade na reprodução de protocolos na prática cotidiana

Groin wound infection after vascular exposure (GIVE) multicentre cohort study

Surgical site infections (SSIs) of groin wounds are a common and potentially preventable cause of morbidity, mortality, and healthcare costs in vascular surgery. Our aim was to define the contemporaneous rate of groin SSIs, determine clinical sequelae, and identify risk factors for SSI. An international multicentre prospective observational cohort study of consecutive patients undergoing groin incision for femoral vessel access in vascular surgery was undertaken over 3 months, follow-up was 90 days. The primary outcome was the incidence of groin wound SSI. 1337 groin incisions (1039 patients) from 37 centres were included. 115 groin incisions (8.6%) developed SSI, of which 62 (4.6%) were superficial. Patients who developed an SSI had a significantly longer length of hospital stay (6 versus 5 days, P = .005), a significantly higher rate of post-operative acute kidney injury (19.6% versus 11.7%, P = .018), with no significant difference in 90-day mortality. Female sex, Body mass index≥30 kg/m2, ischaemic heart disease, aqueous betadine skin preparation, bypass/patch use (vein, xenograft, or prosthetic), and increased operative time were independent predictors of SSI. Groin infections, which are clinically apparent to the treating vascular unit, are frequent and their development carries significant clinical sequelae. Risk factors include modifiable and non-modifiable variables

Groin wound infection after vascular exposure ( GIVE ) multicentre cohort study

Surgical site infections (SSIs) of groin wounds are a common and potentially preventable cause of morbidity, mortality, and healthcare costs in vascular surgery. Our aim was to define the contemporaneous rate of groin SSIs, determine clinical sequelae, and identify risk factors for SSI. An international multicentre prospective observational cohort study of consecutive patients undergoing groin incision for femoral vessel access in vascular surgery was undertaken over 3 months, follow‐up was 90 days. The primary outcome was the incidence of groin wound SSI. 1337 groin incisions (1039 patients) from 37 centres were included. 115 groin incisions (8.6%) developed SSI, of which 62 (4.6%) were superficial. Patients who developed an SSI had a significantly longer length of hospital stay (6 versus 5 days, P = .005), a significantly higher rate of post‐operative acute kidney injury (19.6% versus 11.7%, P = .018), with no significant difference in 90‐day mortality. Female sex, Body mass index≥30 kg/m2, ischaemic heart disease, aqueous betadine skin preparation, bypass/patch use (vein, xenograft, or prosthetic), and increased operative time were independent predictors of SSI. Groin infections, which are clinically apparent to the treating vascular unit, are frequent and their development carries significant clinical sequelae. Risk factors include modifiable and non‐modifiable variables

In silico assessment of histotripsy-induced changes in catheter-directed thrombolytic delivery

Introduction: For venous thrombosis patients, catheter-directed thrombolytic therapy is the standard-of-care to recanalize the occluded vessel. Limitations with thrombolytic drugs make the development of adjuvant treatments an active area of research. One potential adjuvant is histotripsy, a focused ultrasound therapy that lyses red blood cells within thrombus via the spontaneous generation of bubbles. Histotripsy has also been shown to improve the efficacy of thrombolytic drugs, though the precise mechanism of enhancement has not been elucidated. In this study, in silico calculations were performed to determine the contribution of histotripsy-induced changes in thrombus diffusivity to alter catheter-directed therapy.Methods: An established and validated Monte Carlo calculation was used to predict the extent of histotripsy bubble activity. The distribution of thrombolytic drug was computed with a finite-difference time domain (FDTD) solution of the perfusion-diffusion equation. The FDTD calculation included changes in thrombus diffusivity based on outcomes of the Monte Carlo calculation. Fibrin degradation was determined using the known reaction rate of thrombolytic drug.Results: In the absence of histotripsy, thrombolytic delivery was restricted in close proximity to the catheter. Thrombolytic perfused throughout the focal region for calculations that included the effects of histotripsy, resulting in an increased degree of fibrinolysis.Discussion: These results were consistent with the outcomes of in vitro studies, suggesting histotripsy-induced changes in the thrombus diffusivity are a primary mechanism for enhancement of thrombolytic drugs

Role of focused ultrasound in CD40 mediated anti-tumor immunity

Advanced stage melanoma tumors are chemo- and radio-resistant, demonstrate poor antigenicity and defective antigen presentation mechanisms, and low tumor specific cytotoxic T cell population, resulting in poor survival rates in patients. Novel therapeutic approaches that can reprogram the tumor immune microenvironment and improve outcomes against refractory and aggressive melanoma is urgently needed. We hypothesized that focused ultrasound (FUS) and its combination with anti-CD40 agonistic antibody (CD40) will improve the melanoma therapy outcomes by activating the innate and adaptive immune cells in the tumors. Prior research has shown that FUS has an immunomodulatory effect in solid tumors, and CD40 is a known enhancer of antigen presenting cell (APC) function. To investigate our hypothesis, we exposed B16F10 murine melanoma to various FUS parameters (thermal and histotripsy [HT]) in the presence and absence of CD40 stimulation. We found that CD40 and FUS combination increased the anti-tumoral M1 macrophages and granzyme B+ cytotoxic T cell population in murine melanoma and suppressed both treated and untreated tumors. In particular, HT plus CD40 (HT40) caused a significant increase in the expression of immune checkpoints, namely CTLA4 and PD-L1, to aid the anti-CTLA4 and PD-L1 therapy (ICI), thereby prolonging the mice survival rates in HT40+ICI group compared to ICI therapy alone group. In conclusion, our data suggest that focused ultrasound and anti-CD40 agonistic antibody combination enhances the anti-tumor immunity and sensitization to checkpoint inhibitor therapy in advanced stages

Documenting the Recovery of Vascular Services in European Centres Following the Initial COVID-19 Pandemic Peak: Results from a Multicentre Collaborative Study

Objective: To document the recovery of vascular services in Europe following the first COVID-19 pandemic peak. Methods: An online structured vascular service survey with repeated data entry between 23 March and 9 August 2020 was carried out. Unit level data were collected using repeated questionnaires addressing modifications to vascular services during the first peak (March – May 2020, “period 1”), and then again between May and June (“period 2”) and June and July 2020 (“period 3”). The duration of each period was similar. From 2 June, as reductions in cases began to be reported, centres were first asked if they were in a region still affected by rising cases, or if they had passed the peak of the first wave. These centres were asked additional questions about adaptations made to their standard pathways to permit elective surgery to resume. Results: The impact of the pandemic continued to be felt well after countries’ first peak was thought to have passed in 2020. Aneurysm screening had not returned to normal in 21.7% of centres. Carotid surgery was still offered on a case by case basis in 33.8% of centres, and only 52.9% of centres had returned to their normal aneurysm threshold for surgery. Half of centres (49.4%) believed their management of lower limb ischaemia continued to be negatively affected by the pandemic. Reduced operating theatre capacity continued in 45.5% of centres. Twenty per cent of responding centres documented a backlog of at least 20 aortic repairs. At least one negative swab and 14 days of isolation were the most common strategies used for permitting safe elective surgery to recommence. Conclusion: Centres reported a broad return of services approaching pre-pandemic “normal” by July 2020. Many introduced protocols to manage peri-operative COVID-19 risk. Backlogs in cases were reported for all major vascular surgeries

Endovascular Aneurysm Sealing for Management of Aortic Occlusive Disease

: Introduction: Endovascular management of aortic occlusive disease is an alternative to open surgery. This case describes the use of a Nellix graft to treat infrarenal aortic stenosis, outwith the graft indication for use. Case report: A 71 year old man with multiple comorbidities, presented with bilateral buttock claudication. A computed tomography angiogram (CTA) showed significant infrarenal aortic stenosis. Under local anaesthetic, using a percutaneous approach, Nellix grafts were inserted. The patient was discharged within 24 hours. His claudication improved significantly. A 6 month follow-up CT showed stent patency. Conclusion: Although further research is necessary, this case suggests that Nellix is safe and effective for primary stenting of the stenotic infrarenal aorta. Keywords: Aortic occlusive disease, Endovascular procedures, Angioplasty, Stent, Nellix graf