Role of neuropeptide Y in the development of two-kidney, one-clip renovascular hypertension in the rat

AbstractObjective: Along with the renin-angiotensin system, sympathetic stimulation may contribute to renovascular hypertension. The vasoactive peptide neuropeptide Y (NPY) is co-released with and potentiates the pressor effects of norepinephrine through the Y-1 receptor. NPY, by exaggerating sympathetic activity, may contribute to renovascular hypertension, possibly by augmenting adrenergic-mediated renin release. This was studied by determining the effect of continuous Y-1 blockade on the development of two-kidney, one-clip renovascular hypertension and the effect of NPY on in vitro renin release. Methods: Mean arterial pressure and renal blood flow responses to NPY (10 μg/kg, administered intravenously) were measured in five anesthetized Sprague-Dawley rats before and after BIBO3304TF administration to test the Y-1 antagonist BIBO3304TF. In hypertension studies, 28 rats underwent left renal artery clipping. Of these, 13 were implanted with a mini-osmotic pump for continuous BIBO3304TF infusion (0.3 μg/h, administered intravenously); the other 15 underwent sham implantation. Systolic blood pressure was then monitored for 4 weeks. Finally, in vitro renin release was measured from renal cortical slices (n = 6-12) incubated with NPY (10–8 to 10–6 mol/L) or NPY plus the adrenergic agonist isoproterenol (10–4 mol/L). Results: BIBO3304TF attenuated the NPY-induced increase in mean arterial pressure by 54% (P <.02) and the NPY-induced decrease in renal blood flow by 38% (P <.05). In 4-week hypertension studies, systolic blood pressure in clipped controls increased from 130 ± 3 mm Hg to 167 ± 6 mm Hg (P <.01), whereas BIBO3304TF-treated rats had no significant increase (125 ± 3 mm Hg to 141 ± 8 mm Hg). Final systolic blood pressure was 26 mm Hg lower in BIBO3304TF-treated rats than in controls (P <.01). In renal cortical slices, no NPY effect was observed in basal or isoproterenol-stimulated renin release. Conclusions: The Y-1 receptor antagonist BIBO3304TF attenuated acute pressor responses to NPY and blunted the development of two-kidney, one-clip renovascular hypertension in rats. NPY may contribute to the hypertensive response in this renovascular hypertension model. Our in vitro data do not suggest that this is due to NPY enhancement of renin release. (J Vasc Surg 2000;32:1015-21.

Success Rate of Embolization for Type II Endoleaks at a Major Tertiary Referral Center

Objective: The rise of endovascular aneurysm repair (EVAR) as the preferred treatment for abdominal aortic aneurysm (AAA) has introduced endoleaks as a major complication following AAA repair. The objective of this study is to assess the outcomes associated with endovascular embolization of type II endoleaks after EVAR. Methods: The institutional Radiology database at our tertiary referral hospital was queried for type II endoleak during the period 2006-2018. A retrospective chart review was then carried out. Only patients who underwent intervention for isolated type 2 endoleaks were analyzed. The primary outcome was success of the endoleak repair as determined by cessation of growth (i.e., ≤5mm change in diameter over follow-up period) of the native aneurysm sac. Patient outcomes for each failure of the above criterion were also collected. Other data pertaining to the location of endoleak, type of occlusion performed, type of embolic agent used, type of endograft used for EVAR, and incidence of aneurysm rupture were collected as secondary outcomes.Results:During this period 41 patients were treated for type II endoleaks. Demographics are shown in table 1. Cessation of growth was achieved in 28/41 (68.3%) of the patients after one embolization procedure. In 13/41 (31.7%) of patients, growth of the native aneurysm sac continued. Of the patients whose aneurysms continued to grow, 61.5% (8/13) did not undergo a second embolization. The remaining 38.5% (5/13) underwent a second embolization.Patient outcomes for both of these groups are presented in table II. None of the patients were found to have ruptured their aneurysm sac during follow-up after embolization. None of gender, race, the embolization site, or method of embolization were associated with embolization failure. Conclusions: Embolization of type II endoleaks is associated with a cessation of growth in the majority of cases and seems to be protective regarding the risk of aneurysm sac rupture. Future studies and additional follow-up will be important to elucidate the most significant risk factors for expansion and/or rupture of the endovascularly repaired abdominal aneurysm.Table I: Demographics for patients with type II endoleaks who underwent endovascular embolizationVariableValue Age (years +/- sd)75.66 +/- yearsAverage follow-up (months)62.65 monthsSex (%)71.7% male28.3% femaleRace (%)77.7% white17.8% black4.4% otherInflow vessel (%)43.2% lumbar only36.4% IMA only20.5% mixEmbolization site (%)40.5% vessel only14.3% cavity only20.5% mixEmbolization type (%)66.7% coil9.5% glue23.8% mixTable II: Outcomes for patients with continued growth after embolizationThose that did no undergo further embolizationThose that underwent a second embolization 3 were found to have type III endoleak and were successfully repaired with lining of the graft.2 whose aneurysm sac ceased growing. 2 who declined further treatment. 2 whose aneurysm sac continued to grow with persistent evidence of endoleak.1 who died from non-vascular complications. 1 who was lost to follow-up. 1 who is scheduled future surgical repair. 1 who was lost to follow-up.https://scholarlycommons.henryford.com/merf2019clinres/1026/thumbnail.jp

Chronic Limb-Threatening Ischemia: Revascularization Versus Primary Amputation

Purpose of Review: This discussion will review and investigate the indications for amputation, specifically for primary amputation (amputation performed without an attempt at a limb salvage revascularization procedure) in lower extremity chronic limb-threatening ischemia (CLTI). We will further investigate the results of lower extremity revascularization and discuss the factors that are associated with an adverse outcome after revascularization. In this way, we will define when primary amputation may be warranted or, minimally, should be strongly considered over what may be overtly futile attempts at limb salvage procedures. Recent Findings: The incidence of amputation, after two decades in which amputation rates have declined, has recently been on the rise, related to an increase in diabetic-associated amputation. Endovascular options have extended treatment for those high-risk patients with CLTI. Despite this, there is little comparative data regarding the appropriate selection for the initial revascularization attempt. Revascularization procedures do fail and factors associated with adverse outcome are being continuously elucidated and re-affirmed, including patient comorbidities (end-stage renal disease, frailty, dementia), wound assessment (wound, ischemia, foot infection classification), and anatomic patterns of the occlusive disease. Indications for primary amputation include major tissue loss, non-ambulatory status and declining functionality, un-reconstructable vascular occlusive disease, and situations in which either the risks exceed the benefit or there is limited benefit due to high probability of an adverse outcome. Summary: Primary amputation remains an important alternative in the management of CLTI. Further staging and classification of variables and of the disease pattern will hopefully allow for a more evidence-based decision-making process and further define the role of primary amputation

Treatment of Acute Compartment Syndrome Is an Essential Part of Acute Limb Ischemia Management

Objectives: There is a scarcity of studies looking at outcomes of patients with acute lower limb ischemia (ALI) requiring fasciotomy. We present the results of fasciotomies performed in the treatment of ALI at our institution. Methods: We retrospectively analyzed data on a prospectively collected database of all ALI patients that presented to out tertiary referral hospital between May 2016 and November 2019. We included all patients who underwent fasciotomies for ALI. Prophylactic fasciotomies were defined as those done in the absence of clinical evidence compartment syndrome on presentation, and without visible bulging nor necrosis intraoperatively. Limb outcomes for each of the fasciotomy groups (therapeutic and prophylactic) were analyzed. Results: During the study period 250 patients were treated for ALI at our institution involving 279 lower limbs. Sixty-three patients required 69 lower extremity fasciotomies. Rutherford ALI classification for the patients requiring fasciotomy was 32% class 2a, 55% class 2b, and 13% class 3. Early fasciotomy (during the primary operation) was performed on 81% of limbs; 13 patients (19%) had delayed fasciotomies. Fasciotomies were deemed therapeutic in 67% of limbs (16% of the total cohort) and prophylactic in 33% (Figure). Mean time until fasciotomy closure was 2.3 ± 2.9 days. Compared to ALI without fasciotomy, therapeutic fasciotomy was associated with a higher incidence of 30-day limb loss (40% vs 18%; P =.002) and prolonged length of hospital stay (18 days vs 10 days; P \u3c.001). When comparing delayed fasciotomy for compartment syndrome to prophylactic fasciotomy at the time of the initial operation, there was a trend to increase 30 -ay limb loss (22% vs 5%; P =.2). Conclusions: In the setting of ALI, 16% of lower limbs needed therapeutic fasciotomies due to acute compartment syndrome. As expected patients requiring therapeutic fasciotomy experience a significant higher rate of in limb loss and prolonged hospital length of stay. Although not statistically significant, delayed fasciotomy had a higher rate of limb loss when compared to prophylactic fasciotomy. Physicians who treat ALI need to be able to manage acute compartment syndrome

Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada

PURPOSE: Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. MATERIALS AND METHODS: In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients\u27 hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10-13 g/dL for men and 10-12 g/dL for women), moderate (Hb=8-9.9 g/dL), and severe (Hb/dL). RESULTS: A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25-5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p\u3c0.001). CONCLUSION: The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. CLINICAL IMPACT: The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms

Objectives: It is not clear whether endovascular repair of abdominal aortic aneurysms (EVAR) Results in more decline in renal function over the long-term when compared to open repair (OR). We reviewed our experience with abdominal aortic aneurysm (AAA) repair to determine whether there was a significant difference in immediate postoperative and long-term renal outcomes between OR and EVAR. Methods: A retrospective cohort study was conducted on all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Δ GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categoric data and linear regression for continuous variables. Results: During the study period, 769 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (315 OR and 360 EVARs). Mean age was 73.9 years, 79% were males, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as a GFR \u3c60 mL/min. A multivariate logistic model to control for all variables found that OR had a 1.6-times greater chance of developing immediate postoperative AKI compared with EVAR (P =.038). Hypertension and aneurysm size were also independent risk factors for developing AKI (P =.012 and P =.022, respectively). Using a linear regression model, we found a greater decline in GFR postoperatively in the EVAR group. This was significant starting at postoperative year 4 (Fig). AKI and preoperative renal dysfunction were other independent risk factors for long-term decline in renal function. Conclusions: Despite the deleterious effect of OR on immediate postoperative renal function, patients undergoing OR experience a slower decline in GFR over time compared to EVAR patients. The basis for this greater decline in renal function in EVAR patients is undefined but could relate to the need for postoperative EVAR surveillance. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function

Surgical complications of transaxillary arteriography: A case-control study

AbstractPurpose: The purpose of this study was to review the complications of transaxillary arteriography (TRAX), determine clinical factors associated with their occurrence, and define optimal treatment methods.Methods: A retrospective review of 842 consecutive TRAX studies performed in a large, urban, tertiary care, academic medical center was undertaken. Patients with complications were compared with a concurrent randomized control group without complications with the use of a multivariate analysis model. Results of operative therapy for nerve injury were compared with those of nonoperative therapy.Results: Nineteen (2.3%) complications were identified including 14 nerve injuries, four expanding hematomas/pseudoaneurysms without neurologic deficit, and one puncture site thrombosis. Several statistically significant or suggestive findings associated with the occurrence of complications were identified: female sex (odds ratio [OR[ = 4.7), systolic blood pressure ≥150 mm Hg at the conclusion of TRAX (OR = 9.5), periprocedural systemic heparin anticoagulation (OR = 7.9), concomitant use of intraarterial thrombolysis or percutaneous angioplasty (OR = 12.0), and duration of procedure ≥90 minutes (OR = 4.0). Patients who underwent prompt exploration (≤4 hours from symptom onset) for nerve injuries were more likely to have complete resolution of their neurologic deficits (five of six patients) than those who were observed or underwent delayed operation (three of eight patients) (OR = 8.3).Conclusions: Aggressive treatment of post-TRAX hypertension, limitation of TRAX duration, delay of postprocedure anticoagulation, and use of alternative sites for arterial puncture in female patients or patients undergoing catheter-based intervention may reduce the incidence of TRAX-related complications. In patients who have neurologic deficits prompt surgical exploration of the puncture site with decompression of the involved nerve(s) may reduce the incidence of prolonged deficits. (J Vasc Surg 1996;23:844-50.

Symptomatic Extracranial Carotid Disease in COVID-19 Patients Is Related to Thrombus Formation

Background: Coronavirus disease-2019 (COVID-19) has been associated with an acquired hypercoagulable condition. This study was undertaken to review the clinical manifestations of COVID-related symptomatic extracranial carotid artery disease (ECCAD) and compare the carotid plaque composition of symptomatic COVID patients to non-COVID symptomatic patients with ECCAD. Methods: All patients with neurologic manifestations attributed to ECCAD who had clinical diagnosis of COVID-19 were reviewed. The clinical presentation, outcome, and carotid plaque characteristics of all patients were reviewed, and compared to symptomatic ECCAD patients prior to the COVID era (Table). Plaque composition was determined by analysis of calcium volume (mm3) within the carotid lesion with computed tomography angiography (CTA) using VitreaCore (version 6.7.6001.1) with manual outlining of calcium within the carotid lesions. Results: Between the period of March 28 and April 12, 2020, seven patients with COVID-19 were admitted with cerebrovascular manifestations (all ischemic strokes) related to carotid bifurcation lesions. Five patients were documented to have COVID-19 by nasal polymerase chain reaction, and two were clinically diagnosed. Two patients had significant clot in the contralateral carotid (Fig). In sic of the COVID patients (86%), their presenting symptom was the stroke, whereas one patient developed a stroke 24 hours after being admitted with respiratory symptoms. Three patients underwent procedural intervention: one with an open carotid thromboendarterectomy and two with macrovascular distal embolization, underwent percutaneous mechanical thrombectomy. The remaining four patients were treated with anticoagulation alone. Seven consecutive patients with strokes secondary to ECCAD were selected from the pre-COVID era for comparison (Fig). The calcium plaque volume was significantly lower in the COVID patients compared to non-COVID patients, 84 mm3 (mean) compared to 401 mm3 (mean) (P =.02). Conclusions: In COVID patients presenting with strokes and concomitant ipsilateral extracranial carotid lesions, there is more thrombus burden and less calcification than in typical carotid atherosclerotic lesions. This analysis reinforces that the underlying pathology of this COVID-related clinical entity is one of hypercoagulability

Utilization Of Preoperative Vein Mapping In Patients Undergoing Infra-inguinal Bypass Is Associated With Increased Use Of Venous Conduits

Objective: The objective of this study was to determine if preoperative vein mapping (PVM) was associated with increased use of autogenous venous conduits in a real-world registry of lower extremity infra inguinal bypass (IIB). Methods: A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2020 who underwent IIB. We excluded trauma patients and patients with acute limb ischemia, and previous lower extremity bypasses. Preoperative and intraoperative variables were analyzed, and postoperative outcomes were correlated with the use of PVM. Results: A total of 5540 patients were included in the study. The average age was 67 years. Sixty-nine percent of the cohort were male, and 81% were white. PVM was performed on 2532 patients (45%). Patients who underwent PVM were more likely to be white (83% vs 79%; P \u3c.001) and have commercial insurance (24% vs 21%; P =.001). A venous conduit was significantly more likely to be used in patients who underwent preoperative vein mapping (69% vs 28%; P \u3c.001). When looking at patients who underwent IIB with a venous conduit, intraoperative blood loss was significantly less, and 30-day transfusion tended to be lower in patients who had PVM (290 vs 323 mL; P =.032; 30% vs 26%; P =.07, respectively), although no significant difference was seen with the length of procedure (P =.44). Intraoperative angiogram/duplex ultrasonography to establish technical adequacy was more commonly used in the PVM subgroup (39% vs 32%; P \u3c.001) and was more likely to be reported as normal. No significant difference was found in terms of short-term outcomes (length of stay; neurologic, renal, or cardiac complications; 30-day patency; readmission; and death) or for surgical site infection variables (30-day readmission for wound infection, need to return to operating room for infection). Conclusions: Most patients do not have PVM before their IIB. Patients who undergo PVM are more than twice as likely to have a venous conduit used for their bypass. In patients who underwent autogenous venous conduit bypass, postoperative imaging to establish technical adequacy was performed more frequently in patients who underwent PVM and was more likely to be reported as normal. Despite no change in 30-day or 1-year patency, PVM may be a marker for physicians who are interested in best practices for IIB