Predictors of early and late mortality following open extent IV thoracoabdominal aortic aneurysm repair in a large contemporary single-center experience

ObjectiveThe primary purpose of this study was to examine outcomes following open repair of extent IV thoracoabdominal aortic aneurysms (TAAAs) at a single university hospital. As a secondary aim, comparison was made to patients who underwent open abdominal aortic aneurysm (AAA) repair with supraceliac clamping but without left renal artery bypass to assess the effect of left renal artery bypass on outcomes.MethodsPatients undergoing open extent IV TAAA repair from 1998 to 2008 were identified (n = 108). Primary outcomes were 30-day and long-term survival. Secondary outcomes were major complication, renal failure, and postoperative change in renal function. A second analysis was performed, comparing patients undergoing extent IV TAAA repair with patients undergoing AAA repair with supraceliac clamping but without left renal artery bypass (n = 50).ResultsEighty-three men (76.9%) and 25 women (23.1%), with a mean age of 72.9 years, underwent open extent IV TAAA repair. Nine patients (8.3%) were ruptured. Mean aneurysm maximal diameter was 6.5 ± 1.3 cm. Supraceliac and left renal ischemic times were 22.9 ± 9.3 and 40.6 ± 16.2 minutes, respectively. Six patients (5.6%) died at 30 days. The only predictor of 30-day mortality was decreased preoperative estimated glomerular filtration rate (eGFR) (P = .044 by multivariate analysis; and P = .011 by univariate analysis). One-year and 5-year survival rates were 87% and 50%, respectively. Patients with a history of cerebrovascular disease (P = .001) and postoperative renal insufficiency (P = .034) had increased long-term mortality by log-rank test. Twenty-five (25.3%) patients sustained a postoperative decrease in renal function, while 19 (19.2%) patients had an improvement in renal function. There was no difference in 30-day mortality (5.6% vs 6.0%; P = 1.000), 5-year survival (50% vs 48%; P = .886), major complications (37.0% vs 38.0%; P = 1.000), renal failure (6.1% vs 0%; P = .215), or postoperative change in renal function, in patients undergoing extent IV TAAA repair vs AAA repair with supraceliac clamping but without left renal artery bypass.ConclusionsOpen extent IV TAAA repair can be performed with low morbidity and mortality rates. The performance of left renal artery bypass does not appear to contribute to the morbidity and mortality of extent IV TAAA repair. While decreased preoperative eGFR appears to increase the risk of 30-day mortality, a history of cerebrovascular disease and postoperative renal insufficiency appear to increase the risk of long-term mortality. Finally, open extent IV TAAA repair not uncommonly improves renal function

The JNK Pathway Regulates the In Vivo Deletion of Immature CD4+CD8+ Thymocytes

The extracellular signal-regulated kinase (ERK), the c-Jun NH2-terminal kinase (JNK), and p38 MAP kinase pathways are triggered upon ligation of the antigen-specific T cell receptor (TCR). During the development of T cells in the thymus, the ERK pathway is required for differentiation of CD4−CD8− into CD4+CD8+ double positive (DP) thymocytes, positive selection of DP cells, and their maturation into CD4+ cells. However, the ERK pathway is not required for negative selection. Here, we show that JNK is activated in DP thymocytes in vivo in response to signals that initiate negative selection. The activation of JNK in these cells appears to be mediated by the MAP kinase kinase MKK7 since high levels of MKK7 and low levels of Sek-1/MKK4 gene expression were detected in thymocytes. Using dominant negative JNK transgenic mice, we show that inhibition of the JNK pathway reduces the in vivo deletion of DP thymocytes. In addition, the increased resistance of DP thymocytes to cell death in these mice produces an accelerated reconstitution of normal thymic populations upon in vivo DP elimination. Together, these data indicate that the JNK pathway contributes to the deletion of DP thymocytes by apoptosis in response to TCR-derived and other thymic environment– mediated signals

Novel Anti-Infective Compounds from Marine Bacteria

As a result of the continuous evolution of microbial pathogens towards antibiotic-resistance, there have been demands for the development of new and effective antimicrobial compounds. Since the 1960s, the scientific literature has accumulated many publications about novel pharmaceutical compounds produced by a diverse range of marine bacteria. Indeed, marine micro-organisms continue to be a productive and successful focus for natural products research, with many newly isolated compounds possessing potentially valuable pharmacological activities. In this regard, the marine environment will undoubtedly prove to be an increasingly important source of novel antimicrobial metabolites, and selective or targeted approaches are already enabling the recovery of a significant number of antibiotic-producing micro-organisms. The aim of this review is to consider advances made in the discovery of new secondary metabolites derived from marine bacteria, and in particular those effective against the so called “superbugs”, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE), which are largely responsible for the increase in numbers of hospital acquired, i.e., nosocomial, infections

Hybrid Technique: Reoperative Thoracoabdominal Aneurysm Repair

Hybrid thoracoabdominal repair is a useful aneurysm repair method for specific patients who would not tolerate a standard open surgical repair. A 60-year-old male patient presented with previous thoracoabdominal repair and subsequent mesenteric patch aneurismal dilation. This video details the use of thoracic endovascular stent grafting, as well as abdominal mesenteric and renal debranching, for which the authors used both standard surgical bypass and the Viabahn open revascularization technique (VORTEC)

Right Heart Transvalvular Embolus with High Risk Pulmonary Embolism in a Recently Hospitalized Patient: A Case Report of a Therapeutic Challenge

Thrombus-in-transit is not uncommon in pulmonary embolism but Right Heart Transvalvular Embolus (RHTVE) complicating this is rare. A 54-year-old obese male with recent hospitalization presented with severe dyspnea and collapse. Initial investigations revealed elevated d-dimer and troponin. CTA showed saddle pulmonary embolus and bedside echocardiogram revealed right ventricular (RV) pressure overload and dilatation (RV > 41 mm), McConnell’s sign, and mobile echodensity attached to tricuspid valve. Patient was immediately resuscitated and promptly transferred for surgical embolectomy under cardiopulmonary bypass. A long segment of embolus traversing through the tricuspid valve and extensive bilateral pulmonary artery embolus were removed. IVC filter was placed for a persistent right lower extremity DVT. Hypercoagulable work-up was negative. Patient continued to do well after discharge on Coumadin. Open embolectomy offers great promises where there is no consensus in optimal management approach in such patients. Bedside echocardiogram is vital in risk stratification and deciding choice of advanced PE treatment