Survival Comparison of Patients Undergoing Secondary Aortic Repair

Introduction. Infrarenal abdominal aortic aneurysm (AAA) repair warrants lifelong surveillance. Secondary aortic intervention (SAI) outcomes may be affected by the therapeutic approach. We compared short- and long-term mortality in patients who underwent SAIs after initial aortic repair, either endovascular (EVAR) or open. Methods. Patients who underwent AAA repair between 1986 and 2010 were retrospectively identified in a vascular surgery database as well as those who underwent SAIs. All-cause mortality and Kaplan-Meier survival curves were calculated. Results. We identified 149 patients who underwent either open AAA repair or EVAR followed by open or endovascular SAI. Seventy-seven patients (51.7%) underwent initial EVAR while 72 patients (48.3%) underwent open repair. Sixty (78%) initial EVAR patients underwent secondary EVAR while 17 (22%) patients had an open SAI. Initial open repair patients were evenly distributed between EVAR and open SAIs. Compared to EVAR, patients who underwent initial open repair had longer intervals between primary aortic interventions (PAIs) and SAIs. Multivariable-adjusted all-cause mortality was significantly higher for patients who underwent initial open AAA repair followed by EVAR when compared to patients who underwent endovascular PAI and SAI. Conclusion. Long-term mortality in patients with infrarenal aortic aneurysms who require SAI may be improved by an EVAR-first algorithm.

A Critical Evaluation of Carotid Duplex Scanning in the Diagnosis of Significant Carotid Artery Occlusive Disease

Carotid duplex (CD) scanning is the primary method of evaluating patients suspected of having extracranial carotid occlusive disease. It is incumbent on vascular laboratories (VL) to have internally validated criteria confirming overall accuracy, specificity (SP), sensitivity (SS), negative predictive value (NPV), and positive predictive value (PPV). Receiver operating characteristic (ROC) curves allow further analysis to update existing criteria. We correlated 127 internal carotid arteries studied by carotid duplex scanning and confirmatory modalities, which showed a SP of 83.3%, SS of 97.9%, NPV of 92.5%, PPV of 95%, and overall accuracy of 94.5% for >50% internal carotid artery stenosis. For >70% stenosis, SP was 88.8%, SS was 96.1%, NPV was 93.6%, PPV was 92.5%, and overall accuracy was 92.9%. ROC curves for the peak systolic velocities were used; for detecting a 50–69% stenosis range a sensitivity of 88%, specificity of 93%, NPV of 73%, and PPV of 97% were found. For detecting a 70–99% stenosis a sensitivity of 95%, specificity of 90%, NPV of 93%, and a PPV of 93% were found. All vascular laboratories must have a vigorous quality assurance program and must validate their own internal criteria or the recently promulgated consensus criteria for grading the severity of carotid stenosis by carotid duplex examination.

Unprotected Left-Main Coronary Angioplasty in the Elderly in a High Volume Catheterization Centre without On-Site Surgery Facilities: Immediate and Medium Term Outcome—The Old-Placet Registry

We aim to assess clinical feasibility and efficacy of unprotected left main (ULM) percutaneous coronary intervention (PCI) in patients older than 75 years over a 6-year period and with 2-year follow-up demonstrating that PCI is a feasible revascularization strategy even in absence of on-site cardiothoracic support. Nevertheless, the outcome of these high-risk patients is still hampered by a sensible in-hospital mortality rate. Older patients have a higher mortality at follow-up (10.0 versus 0.8%, P = 0.014), while younger patients have a low mortality after the acute phase (15.7 versus 8.4%, P = 0.15).

Perioperative Hemodynamic Management and Pharmacotherapeutics of Patients Undergoing Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) has become an attractive alternative treatment option for many patients with specific thoracic aortic disease. New devices and advanced image-guided procedures are continuously expanding the indications and improve neurological outcomes. Hemodynamic management of these patients is a critical aspect in reducing neurological deficit and it is different compared to patients undergoing open thoracic aortic operations. There are two different phases of blood pressure management for patients with thoracic aortic disease. Before and during the critical steps of TEVAR anti-impulsive therapy facilitates safe positioning and stent deployment. After stent grafts are deployed, controlled hypertensive blood pressure levels are achieved to avoid spinal cord ischemia. This precise blood pressure strategy is essential to ensure a safe procedure and good long-term results.

IVC Filters: Challenges and Future Directions

Since their introduction in 1973, inferior vena cava filters have evolved concurrent with advancing technology, and, therefore, their use has expanded due to broader indications for insertion. This paper focuses on the challenges and future directions of this trend, including a closer look at complications, retrieval rates, and cost-effectiveness.

The Impact of Warfarin on Patients with End Stage Renal Disease

Introduction. A deficiency in vitamin K through the utilization of warfarin may result in increased vascular calcification and complications. This study aimed to determine the impact of warfarin administration on patients with end stage renal disease (ESRD) in a large, national sample. Methods. A retrospective analysis using the 2005–2010 National Inpatient Sample (NIS), a part of the Health Care Utilization Project (HCUP), was completed using ICD-9 diagnosis codes to capture patients with ESRD prescribed and not prescribed warfarin. Statistical analysis was through ANOVA and chi-squared testing. Results. From 2005–2010, 927,814 patients with ESRD were identified nationally. 3.5% (32,737) were prescribed warfarin. Patients prescribed warfarin had an average age of 64 years and 51% were male. For every comorbid condition (amputation, congestive heart failure, chronic obstructive pulmonary disorder, cerebrovascular accident, diabetes, hypertension, myocardial infarction, peripheral vascular diasese, and valvular disease) patients prescribed Warfarin had significantly higher rates of disease as compared to their nonwarfarin ESRD counterparts. ESRD patients prescribed warfarin had significantly shorter length of stay but increased hospital charges. They were more likely to be discharged to home and had significantly decreased in-hospital mortality. Conclusion. Patients with ESRD taking warfarin are more likely to have comorbidities and/or complications but have a decreased LOS and in-hospital mortality compared to their ESRD counterparts not administered warfarin.

Vascular Aging across the Menopause Transition in Healthy Women

Vascular aging, featuring endothelial dysfunction and large artery stiffening, is a major risk factor for developing cardiovascular disease (CVD). In women, vascular aging appears to be accelerated during the menopause transition, particularly around the late perimenopausal period, presumably related to declines in ovarian function and estrogen levels. The mechanisms underlying endothelial dysfunction and large artery stiffening with the menopause transition are not completely understood. Oxidative stress and the proinflammatory cytokine tumor necrosis factor-α contribute to endothelial dysfunction and large artery stiffening in estrogen-deficient postmenopausal women. Habitual endurance exercise attenuates the age-related increase in large artery stiffness in estrogen-deficient postmenopausal women and can reverse arterial stiffening to premenopausal levels in estrogen-replete postmenopausal women. In contrast, estrogen status appears to play a key permissive role in the adaptive response of the endothelium to habitual endurance exercise in that endothelial improvements are absent in estrogen-deficient women but present in estrogen-replete women. We review here the current state of knowledge on the biological defects underlying vascular aging across the menopause transition, with particular focus on potential mechanisms, the role of habitual exercise in preserving vascular health, and key areas for future research.

Diverse Functions of Secretory Phospholipases A2

Phospholipase A2 enzymes (PLA2s) catalyze the hydrolysis of glycerophospholipids at their sn-2 position releasing free fatty acids and lysophospholipids. Mammalian PLA2s are classified into several categories of which important groups include secreted PLA2s (sPLA2s) and cytosolic PLA2s (cPLA2s) that are calcium-dependent for their catalytic activity and calcium-independent cytosolic PLA2s (iPLA2s). Platelet-activating factor acetylhydrolases (PAF-AHs), lysosomal PLA2s, and adipose-specific PLA2 also belong to the class of PLA2s. Generally, cPLA2 enzymes are believed to play a major role in the metabolism of arachidonic acid, the iPLA2 family to membrane homeostasis and energy metabolism, and the sPLA2 family to various biological processes. The focus of this review is on recent research developments in the sPLA2 field. sPLA2s are secreted enzymes with low molecular weight (with the exception of GIII sPLA2), Ca2+-requiring enzymes with a His-Asp catalytic dyad. Ten enzymatically active sPLA2s and one devoid of enzymatic activity have been identified in mammals. Some of these sPLA2s are potent in arachidonic acid release from cellular phospholipids for the biosynthesis of eicosanoids, especially during inflammation. Individual sPLA2 enzymes exhibit unique tissue and cellular localizations and specific enzymatic properties, suggesting their distinct biological roles. Recent studies indicate that sPLA2s are involved in diverse pathophysiological functions and for most part act nonredundantly.

Vascular Functions and Brain Integrity in Midlife: Effects of Obesity and Metabolic Syndrome

Intact cognitive function is the best predictor of quality of life and functional ability in older age. Thus, preventing cognitive decline is central to any effort to guarantee successful aging for our growing population of elderly. The purpose of the work discussed in this outlook paper is to bridge knowledge from basic and clinical neuroscience with the aim of improving how we understand, predict, and treat age- and disease-related cognitive impairment. Over the past six years, our research team has focused on intermediate neuroimaging phenotypes of brain vulnerability in midlife and isolating the underlying physiological mechanisms. The ultimate goal of this work was to pave the road for the development of early interventions to enhance cognitive function and preserve brain integrity throughout the lifespan.