Technical and clinical success after endovascular therapy for chronic type B aortic dissections

ObjectiveTo analyze early technical success and late clinical success after endovascular entry sealing for chronic type B dissection with special emphasis on reintervention, false lumen thrombosis, and aortic remodeling.MethodsRetrospective analysis of a prospective database. From September 1999 to January 2011, 19 patients with chronic type B dissections were treated by endovascular entry sealing. Median age was 60 years. Median time between onset of acute dissection and surgical intervention was 36 (1 to 60) months. Median follow-up was 13 months (1 to 124).ResultsThe endografts used were: Medtronic Captivia (5), Medtronic Valiant (5), Gore TAG (6), Gore C-TAG (2), and Cook Zenith (1). In four patients, revascularization of the left subclavian artery was performed prior to entry sealing. Primary technical success rate (entry sealing, absence of type I leak) was 18/19 (94.7%). In-hospital mortality was 0%. Spinal cord injury with persistent paraplegia occurred in 1/19 (5.2%) patients. After a maximal follow-up of 124 months, reinterventions in 9/19 (47.3%) were necessary: distal/proximal extension of stent graft (8), replacement of the aortic arch due to retrograde dissection (1), and open infrarenal aneurysm repair (1). During follow-up, none of the patients died due to stent-related complications.ConclusionEndovascular treatment (EVT) in chronic type B dissections has a high technical success rate and low mortality/morbidity. However reintervention rates are not negligible which might reduce the clinical success of EVT. Future investigations should aim at identifying patients who benefit from EVT at better defining the timing of EVT and at determining if entry sealing alone is sufficient

Genome-wide association identifies nine common variants associated with fasting proinsulin levels and provides new insights into the pathophysiology of type 2 diabetes.

OBJECTIVE: Proinsulin is a precursor of mature insulin and C-peptide. Higher circulating proinsulin levels are associated with impaired β-cell function, raised glucose levels, insulin resistance, and type 2 diabetes (T2D). Studies of the insulin processing pathway could provide new insights about T2D pathophysiology. RESEARCH DESIGN AND METHODS: We have conducted a meta-analysis of genome-wide association tests of ∼2.5 million genotyped or imputed single nucleotide polymorphisms (SNPs) and fasting proinsulin levels in 10,701 nondiabetic adults of European ancestry, with follow-up of 23 loci in up to 16,378 individuals, using additive genetic models adjusted for age, sex, fasting insulin, and study-specific covariates. RESULTS: Nine SNPs at eight loci were associated with proinsulin levels (P < 5 × 10(-8)). Two loci (LARP6 and SGSM2) have not been previously related to metabolic traits, one (MADD) has been associated with fasting glucose, one (PCSK1) has been implicated in obesity, and four (TCF7L2, SLC30A8, VPS13C/C2CD4A/B, and ARAP1, formerly CENTD2) increase T2D risk. The proinsulin-raising allele of ARAP1 was associated with a lower fasting glucose (P = 1.7 × 10(-4)), improved β-cell function (P = 1.1 × 10(-5)), and lower risk of T2D (odds ratio 0.88; P = 7.8 × 10(-6)). Notably, PCSK1 encodes the protein prohormone convertase 1/3, the first enzyme in the insulin processing pathway. A genotype score composed of the nine proinsulin-raising alleles was not associated with coronary disease in two large case-control datasets. CONCLUSIONS: We have identified nine genetic variants associated with fasting proinsulin. Our findings illuminate the biology underlying glucose homeostasis and T2D development in humans and argue against a direct role of proinsulin in coronary artery disease pathogenesis

Endovaskulärer Entryverschluss bei chronischen Typ B Aortendissektionen --- Perioperatives Outcome, Re-Interventionen und Veränderungen des wahren und falschen Lumens

Einleitung: Die chronische Aortendissektion vom Typ B nach Stanford bedarf bei einer Expansion im thorakalen Bereich von über 6 cm oder einer raschen Progredienz von mehr als 1 cm pro Jahr einen thorakalen, endovaskulären Entryverschluss um eine drohende Ruptur zu verhindern und die Perfusion im wahren Lumen zu sichern. Material und Methodik: Die vorliegende retrospektive Studie beleuchtet das Patientengut, das klinische Outcome mit dem Langzeitverlauf und Re-Interventionen sowie die Veränderung des wahren und falschen Lumens nach endovaskulärem Entryverschluss der 27 von 99 Patienten, die im Zeitraum vom 09/1999 bis 04/2013 an der Universitätsklinik Ulm einem endovaskulärem Entryverschluss im Rahmen einer chronischen Typ B-Dissektion zugeführt wurden. Ergebnisse: Der primäre technische Erfolg lag bei 92,5 %. Die „In-Hospital Mortalität“ lag bei 0 %. Es konnte gezeigt werden, dass es im Bereich der thorakalen Aorta zu einer Vergrößerung des wahren Lumens nach Stentgraft-Implantation kommt. Für die infrarenale Aorta konnte eine Abnahme der Querschnittsfläche des falschen Lumens verzeichnet werden. Die Falschlumen-Thromboserate im gestenteten Anteil der thorakalen Aorta lag bei 81,5 %. Bei einem Follow-Up von bis zu 149 Monaten lag die Re-Interventionsrate bei beachtlichen 51,8 %. Zusammenfassung: Zusammengefasst kann somit konstatiert werden, dass es sich bei dem endovaskulären Entryverschluss im Rahmen einer chronischen Typ B-Dissektion um ein sicheres Verfahren mit hohem primären technischen Erfolg handelt. Nach einer Stentimplantation kommt es umgehend zu einer verbesserten Perfusion im wahren Lumen bei gleichzeitig hoher Falschlumen-Thromboserate. Die Re-Interventionsrate im Langzeitverlauf lag jedoch bei über 50 %

In vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens of acute cholangitis

AIM: To analyze the in vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens isolated from patients with acute cholangitis