Fate of the lower extremity in patients with VA-ECMO via femoral cannulation

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Femoral cannulation is associated with limb complications including ischemia, limb loss, arterial infections and wound infections. This study aims to evaluate these complications and management related to successful outcomes. Methods: A retrospective review was conducted in 17 patients requiring VA- ECMO support via femoral cannulation from 1/ 2010 till 4/2012. After cannulation, all patients had near infared spectroscopy (NIRS) monitoring after cannula placement and most had placement of distal arterial perfusion catheters (DPC). At decannulation, all patients had femoral cutdown with closure of arteriotomies by primary repair or patch angioplasty with bovine pericardium. Primary study endpoints included ischemia, limb loss, arterial infection; secondary endpoints were wound infection and post-discharge symptoms. Results: Seventeen patients were supported with VA-ECMO during the study period with arterial cannula size of 16-20 French. All patients had NIRS monitoring after cannula placement and 13/17 patients had DPC placement, with no subsequent ischemia. Two of 4 patients without DPC developed ischemia; one was decannulated and the other resolved spontaneously. At decannulation, open arterial repair was performed as described. In this study population, simple wound infection occurred in 3/17with Vacuum Assisted Closure (VAC) devices were placed at the timed if appropriate. There were no arterial infections and no instances of limb ischemia requiring amputation. There were no complaints of rest pain during outpatient follow-up. Conclusions: Limb complications related to femoral cannulation for VA-ECMO can lead to prolonged morbidity and limb loss. NIRS and placement of DPC, primary repair of arteriotomy or patch angioplasty, along with aggressive wound care, can dramatically decrease rates of limb ischemia, limb loss and infection

Robotic-Assisted Treatment of Median Arcuate Ligament Syndrome

Median arcuate ligament (MAL) syndrome, the external compression of the celiac axis by the MAL resulting in symptoms, can be difficult to diagnose and treat. Traditionally, open surgical decompression of the celiac axis was performed, followed by correction of residual arterial stenosis. More recently, less invasive methods involving laparoscopic lysis of the ligament, followed by endovascular treatment of residual stenosis, are being used. We describe our initial experience treating this rare disorder with minimally invasive methods involving the da Vinci SI Robot

Robotic-assisted median arcuate ligament release.

Median arcuate ligament syndrome results from external compression of the celiac axis by attachments of the diaphragmatic crura. It has been treated with open or laparoscopic surgical decompression of the celiac axis with neurolysis. We describe our initial experience treating three patients using a robotic-assisted technique with median arcuate ligament release and celiac neurolysis. Average operative time was 2.2 hours. No intraoperative complications occurred. At an average of 11 months postoperative (14, 11, and 8 months), two patients continue with resolution of preoperative symptoms. Our experience affirms that further study using the robotic approach appears warranted

Endothelial Differentiation of Adipose-Derived Stem Cells from Elderly Patients with Cardiovascular Disease

Adipose-derived stem cells (ASCs) possess significant therapeutic potential for tissue engineering and regeneration. This study investigates the endothelial differentiation and functional capacity of ASCs isolated from elderly patients. Isolation of ASCs from 53 patients (50–89 years) revealed that advanced age or comorbidity did not negatively impact stem cell harvest; rather, higher numbers were observed in older donors (>70 years) than in younger. ASCs cultured in endothelial growth medium-2 for up to 3 weeks formed cords upon Matrigel and demonstrated acetylated-low-density lipoprotein and lectin uptake. Further stimulation with vascular endothelial growth factor and shear stress upregulated endothelial cell-specific markers (CD31, von Willebrand factor, endothelial nitric oxide synthase, and VE-cadherin). Inhibition of the PI3K but not mitogen-activated protein kinase pathway blocked the observed endothelial differentiation. Shear stress promoted an anti-thrombogenic phenotype as demonstrated by production of tissue-plasminogen activator and nitric oxide, and inhibition of plasminogen activator inhibitor-1. Shear stress augmented integrin α5β1 expression and subsequently increased attachment of differentiated ASCs to basement membrane components. Finally, ASCs seeded onto a decellularized vein graft resisted detachment despite application of shear force up to 9 dynes. These results suggest that (1) advanced age and comorbidity do not negatively impact isolation of ASCs, and (2) these stem cells retain significant capacity to acquire key endothelial cell traits throughout life. As such, adipose tissue is a practical source of autologous stem cells for vascular tissue engineering

Median Arcuate Ligament Syndrome-Review of This Rare Disease.

IMPORTANCE: Median arcuate ligament (MAL) syndrome is a rare disease resulting from compression of the celiac axis by fibrous attachments of the diaphragmatic crura, the median arcuate ligament. Diagnostic workup and therapeutic intervention can be challenging. OBJECTIVE: To review the literature to define an algorithm for accurate diagnosis and successful treatment for patients with MAL syndrome. EVIDENCE REVIEW: A search of PubMed (1995-September 28, 2015) was conducted, using the key terms median arcuate ligament syndrome and celiac artery compression syndrome. FINDINGS: Typically a diagnosis of exclusion, MAL syndrome involves a vague constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Extrinsic compression of the vasculature and surrounding neural ganglion has been implicated as the cause of these symptoms. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical intervention involves open, laparoscopic, or robotic ligament release; celiac ganglionectomy; and celiac artery revascularization. There remains a limited role for angioplasty because this intervention does not address the underlying extrinsic compression resulting in symptoms, although angioplasty with stenting may be used in recalcitrant cases. CONCLUSIONS AND RELEVANCE: Median arcuate ligament syndrome is rare, and as a diagnosis of exclusion, diagnosis and treatment paradigms can be unclear. Based on previously published studies, symptom relief can be achieved with a variety of interventions including celiac ganglionectomy as well as open, laparoscopic, or robotic intervention