Outcomes of carotid artery stenting versus historical surgical controls for radiation-induced carotid stenosis

PurposeTo evaluate the outcomes of carotid artery stenting (CAS) and open surgical repair (OR) for treatment of radiation-induced carotid stenosis (RICS).MethodsWe retrospectively reviewed 60 patients treated for 73 RICSs from a group of 5,824 patients who had carotid interventions between 1992 and 2009. Thirty-three patients (37 arteries) were treated with CAS and 27 patients (36 arteries) with OR. CAS was performed using embolic protection as part of a prospective institutional registry since 2003. End-points included mortality, stroke, myocardial infarction (MI), cranial nerve injury (CNI), wound complication, restenosis, and reintervention.ResultsDemographics and cardiovascular risk factors were similar in both groups, with the exception of higher rates (P < .05) of hyperlipidemia (81% vs 56%) and coronary artery disease (63% vs 33%) in OR patients. There were more patients with tracheostomy (31% vs 4%) and time interval from irradiation to intervention was longer in the CAS group. There were no early deaths. At 30 days, OR was associated with one (3%) stroke, two (5.5%) MIs, six (17%) CNIs, and three (8%) wound complications. OR patients with prior radical neck dissections had more wound complications (14% vs 5%) and CNIs (28% vs 9%) compared with those without neck dissections. In the CAS group, there were two (6%) strokes and no MIs, CNIs, or wound complications. Mean length of hospital stay was longer after OR than CAS (4.1 ± 3.7 days vs 2.4 ± 2.1 days; P = .02). Median follow-up was 58 months. At 7 years, OR was associated with higher patient survival (75% ± 15% vs 29% ± 13%, P = .008) and freedom from neurological events (100% vs 57% ± 9.5%, P = .058), but similar freedom from restenosis (80% ± 10% vs 72% ± 9%) and reinterventions (87% ± 10% vs 86% ± 9%) compared with CAS.ConclusionCarotid artery stenting for radiation-induced stenosis has the advantages of no CNI or wound complications with similar early stroke rate compared with open carotid repair. However, the lower freedom from neurological events may offset the early benefits of carotid stenting in patients who are considered good candidates for open surgery

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Reinterventions for stent restenosis in patients treated for atherosclerotic mesenteric artery disease

ObjectiveMesenteric artery angioplasty and stenting (MAS) has been plagued by high restenosis and reintervention rates. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR).MethodsThe clinical data of 157 patients treated for chronic mesenteric ischemia with MAS of 170 vessels was entered into a prospective database (1998-2010). Fifty-seven patients (36%) developed MAISR after a mean follow-up of 29 months, defined by duplex ultrasound peak systolic velocity >330 cm/s and angiographic stenosis >60%. We reviewed the clinical data, radiologic studies, and outcomes of patients who underwent reintervention for restenosis. End points were mortality and morbidity, patient survival, symptom recurrence, reintervention, and patency rates.ResultsThere were 30 patients (25 female and five male; mean age, 69 ± 14 years) treated with reintervention for MAISR. Twenty-four patients presented with recurrent symptoms (21 chronic, three acute), and six had asymptomatic preocclusive lesions. Twenty-six patients (87%) underwent redo endovascular revascularization (rER) with stent placement in 17 (13 bare metal and four covered) or percutaneous transluminal angioplasty (PTA) in nine. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. Seven patients (27%) treated by rER developed complications, including access site problems in four patients, and distal embolization with bowel ischemia, congestive heart failure and stent thrombosis in one each. Symptom improvement was noted in 22 of the 24 symptomatic patients (92%). After a mean follow-up of 29 ± 12 months, 15 patients (50%) developed a second restenosis, and seven (23%) required other reintervention. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/9, 3/9, and 2/9 for PTA, 5/13, 8/13, and 5/13 for bare metal stents, and 1/4, 4/4, and 0/4 for open bypass. For all patients, freedom from recurrent symptoms, restenosis, and reinterventions were 70% ± 10%, 60% ± 10% and 50% ±10% at 2 years. For patients treated by rER, secondary patency rates were 72 ± 12 at the same interval.ConclusionsNearly 40% of patients developed mesenteric artery in-stent restenosis, of which half required reintervention because of symptom recurrence or progression to an asymptomatic preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%)

Common iliac artery aneurysm: Expansion rate and results of open surgical and endovascular repair

ObjectivesTo assess expansion rate of common iliac artery aneurysms (CIAAs) and define outcomes after open repair (OR) and endovascular repair (EVAR).MethodsClinical data of 438 patients with 715 CIAAs treated between 1986 and 2005 were retrospectively reviewed. Size, presentations, treatments, and outcomes were recorded. Kaplan-Meier method with log-rank tests and χ2 test were used for analysis.ResultsInterventions for 715 CIAAs (median, 4 cm; range, 2-13 cm) were done in 512 men (94%) and 26 women (6%); 152 (35%) had unilateral and 286 (65%) had bilateral CIAAs. Group 1 comprised 377 patients (633 CIAAs) with current or previously repaired abdominal aortic aneurysm (AAA). Group 2 comprised 15 patients (24 CIAAs) with associated internal iliac artery aneurysm (IIAA). Group 3 comprised 46 patients (58 isolated CIAAs). Median expansion rate of 104 CIAAs with at least two imaging studies was 0.29 cm/y; hypertension predicted faster expansion (0.32 vs 0.14 cm/y, P = .01). A total of 175 patients (29%) were symptomatic. The CIAA ruptured in 22 patients (5%, median, 6 cm; range, 3.8-8.5 cm), and the associated AAA ruptured in 20 (4%). Six (27%) ilioiliac or iliocaval fistulas developed. Repairs were elective in 396 patients (90%) and emergencies in 42 (10%). OR was performed in 394 patients (90%) and EVAR in 44 (10%). The groups had similar 30-day mortality: 1% for elective, 27% for emergency repairs (P < .001); 4% after OR (elective, 1%; emergency, 26%), and 0% after EVAR. No deaths occurred after OR of arteriovenous fistula. Complications were more frequent and hospitalization was longer after OR than EVAR (P < .05). Mean follow-up was 3.7 years (range, 1 month-17.5 years). The groups had similar 5-year primary (95%) and secondary patency rates (99.6%). At 3 years, secondary patency was 99.6% for OR and 100% for EVAR (P = .66); freedom from reintervention was similar after OR and EVAR (83% vs 69%, P = .17), as were survival rates (76% vs 77%, P = .70).ConclusionsThe expansion rate of CIAAs is 0.29 cm/y, and hypertension predicts faster expansion. Because no rupture of a CIAA <3.8 cm was observed, elective repair of asymptomatic patients with CIAA ≥3.5 cm seems justified. Although buttock claudication after EVAR remains a concern, results at 3 years support EVAR as a first-line treatment for most anatomically suitable patients who require CIAA repair. Patients with compressive symptoms or those with AVF should preferentially be treated with OR