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International Medical Case Reports... 2024In this case we report a rare presentation of a ruptured gastroduodenal artery aneurysm (GDA) accompanied by a duodenal perforation. It contributes to the scientific...
PURPOSE
In this case we report a rare presentation of a ruptured gastroduodenal artery aneurysm (GDA) accompanied by a duodenal perforation. It contributes to the scientific literature by discussing the management approach and results in a patient with dual complications and emphasizes the importance of early diagnosis and appropriate treatment.
CASE PRESENTATION
A 50-year-old male presented with severe abdominal pain, anemia, and signs of hemodynamic instability. Diagnostic imaging including CTA revealed a large, thrombosed gastroduodenal artery aneurysm with evidence of rupture. The patient underwent open surgical exploration and repair to address both the aneurysm and the duodenal perforation. The patient's recovery was satisfactory and was discharged home in stable condition.
CONCLUSION
Early diagnosis and appropriate management in gastroduodenal artery aneurysms is crucial. There is a need for individualized surgical interventions based on the patient's hemodynamic status and associated complications. Dual complications required open surgical exploration and repair, resulting in favorable outcomes.
PubMed: 38911607
DOI: 10.2147/IMCRJ.S468278 -
Journal of Scleroderma and Related... Jun 2024Systemic sclerosis is a rare disease with a high mortality rate. It is a multisystem connective tissue disease due to endothelial autoimmune activation along with tissue...
Systemic sclerosis is a rare disease with a high mortality rate. It is a multisystem connective tissue disease due to endothelial autoimmune activation along with tissue and vascular fibrosis, inducing vasculopathy, with an angiogenesis wasting. The endothelial damage provokes platelet activation and immune cell adhesion. The detachment of endothelial cells leads to the interaction of platelets and collagen present in the exposed subendothelial layer. This provokes the activation of several coagulative factors, inducing a pro-thrombotic condition by thrombin generation, which converts fibrinogen into fibrin. Moreover, thrombin has other functions, such as the induction of hyperplasia in smooth muscle cells and fibroblasts, thereby favouring fibrosis. An increased risk of venous thromboembolism has been found in systemic sclerosis, whereas pulmonary hypertension may be due to the obstruction of small pulmonary arteries. Pulmonary veno-occlusive disease may also occur. Warfarin showed inconsistent results, while the outcomes of a randomised, placebo-controlled clinical trial on apixaban versus placebo are still awaited. A new anticoagulation strategy based on anti-factor XI drugs is being developed, with the aim of achieving optimal anticoagulation along with a low risk of bleeding. The molecule types under investigation in this category include monoclonal antibodies, small molecules, natural inhibitors, antisense oligonucleotides, and aptamers. Patients with systemic sclerosis may be ideal candidates for clinical trials planned to analyse the efficacy and safety of these molecules.
PubMed: 38910594
DOI: 10.1177/23971983241256250 -
Journal of Zhejiang University.... Jun 2024Artificial vascular graft (AVG) fistula is widely used for hemodialysis treatment in patients with renal failure. However, it has poor elasticity and compliance, leading...
Artificial vascular graft (AVG) fistula is widely used for hemodialysis treatment in patients with renal failure. However, it has poor elasticity and compliance, leading to stenosis and thrombosis. The ideal artificial blood vessel for dialysis should replicate the structure and components of a real artery, which is primarily maintained by collagen in the extracellular matrix (ECM) of arterial cells. Studies have revealed that in hepatitis B virus (HBV)-induced liver fibrosis, hepatic stellate cells (HSCs) become hyperactive and produce excessive ECM fibers. Furthermore, mechanical stimulation can encourage ECM secretion and remodeling of a fiber structure. Based on the above factors, we transfected HSCs with the hepatitis B viral X () gene for simulating the process of HBV infection. Subsequently, these -HSCs were implanted into a polycaprolactone-polyurethane (PCL-PU) bilayer scaffold in which the inner layer is dense and the outer layer consists of pores, which was mechanically stimulated to promote the secretion of collagen nanofiber from the -HSCs and to facilitate crosslinking with the scaffold. We obtained an ECM-PCL-PU composite bionic blood vessel that could act as access for dialysis after decellularization. Then, the vessel scaffold was implanted into a rabbit's neck arteriovenous fistula model. It exhibited strong tensile strength and smooth blood flow and formed autologous blood vessels in the rabbit's body. Our study demonstrates the use of human cells to create biomimetic dialysis blood vessels, providing a novel approach for creating clinical vascular access for dialysis.
Topics: Rabbits; Animals; Hepatic Stellate Cells; Renal Dialysis; Polyesters; Viral Regulatory and Accessory Proteins; Tissue Scaffolds; Transfection; Bionics; Polyurethanes; Blood Vessel Prosthesis; Extracellular Matrix; Humans; Hepatitis B virus; Collagen; Tissue Engineering; Trans-Activators
PubMed: 38910495
DOI: 10.1631/jzus.B2300479 -
Journal of Vascular Surgery Jun 2024Hemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the...
OBJECTIVE
Hemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients.
METHODS
This is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI.
RESULTS
Of the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively.
CONCLUSIONS
Our study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.
PubMed: 38909917
DOI: 10.1016/j.jvs.2024.05.045 -
International Journal of Cardiology Jun 2024
PubMed: 38908551
DOI: 10.1016/j.ijcard.2024.132284 -
Journal of Hepatology Jun 2024Mechanisms and clinical impact of portal microthrombosis featuring severe COVID-19 are unknown. Intrapulmonary vascular dilation (IPVD)-related hypoxia has been...
BACKGROUND & AIMS
Mechanisms and clinical impact of portal microthrombosis featuring severe COVID-19 are unknown. Intrapulmonary vascular dilation (IPVD)-related hypoxia has been described in severe liver diseases. We hypothesized that portal microthrombosis is associated with IPVD and fatal respiratory failure in COVID-19.
METHODS
Ninety-three patients who died from COVID-19, were analysed for portal microvascular damage (histology), IPVD (histology and chest-computed tomography, CT), and hypoxemia (arterial blood gas). Seventeen patients who died from COVID-19-unrelated pneumonia served as controls. Vascular lesions and microthrombi were phenotyped for endothelial (vWF) and pericyte (αSMA/PDGFR-β) markers, tissue factor (TF), viral spike-protein and nucleoprotein (SP, NP), fibrinogen, platelets (CD41a). Viral particles in vascular cells were assessed by transmission electron microscopy (TEM). Cultured pericytes were infected with SARS-CoV-2 to measure TF expression and tubulisation of human pulmonary microvascular endothelial cells (HPMEC) was assessed upon vWF treatment.
RESULTS
IPVD was present in 16/66 COVID-19 patients with both liver and lung histology, with a younger age (62 vs 78yo), longer illness (25 vs 14 days), worsening hypoxemia (PaO/FiO from 209 to 89), and more ventilatory support (63 vs 22%) compared to COVID-19/Non-IPVD. IPVD, absent in controls, were confirmed by chest-CT. COVID-19/IPVD liver histology showed portal microthrombosis in >82.5% of portal areas, with a thicker wall of αSMA/PDGFR-β/ SP/NP pericytes compared with COVID-19/Non-IPVD. Thrombosed portal venules correlated with αSMA area, whereas infected SP/NP pericytes expressed TF. SARS-CoV-2 viral particles were observed in portal pericytes. In-vitro SARS-CoV-2 infection of pericytes up-regulated TF and induced endothelial cells to overexpress vWF, which expanded HPMEC tubules.
CONCLUSIONS
SARS-CoV-2 infection of liver pericytes elicits a local procoagulant response associated with extensive portal microthrombosis, IPVD and worsening respiratory failure in fatal COVID-19.
IMPACT AND IMPLICATIONS
Vascular involvement of the liver represents a serious complication of COVID-19 infection that must be considered in the work-up of patients with long-lasting and progressively worsening respiratory failure, as it may associate with the development of intrapulmonary vascular dilations. This clinical picture is associated with a pro-coagulant phenotype of portal venule pericytes, which is induced by SARS-CoV-2 infection of pericytes. Both observations provide a model that may apply, at least in part, to other vascular disorders of the liver, featuring obliterative portal venopathy, similarly characterized at the clinical level by development of hypoxemia and at the histological level, by phlebosclerosis and reduced caliber of the portal vein branches in the absence of cirrhosis. Moreover, our findings bring light to an as yet overlooked player of thrombosis pathophysiology, i.e. pericytes, which may provide novel therapeutic tools to halt prothrombotic mechanisms.
PubMed: 38908437
DOI: 10.1016/j.jhep.2024.06.014 -
Clinical & Translational Oncology :... Jun 2024Both venous and arterial thrombotic events (VTE/AT) can be associated with Immune Checkpoint Inhibitors (ICI). However, there is a paucity of information apropos...
Immune checkpoint inhibitors-associated thrombosis in patients with head and neck cancer: a study of the Spanish society of medical oncology (SEOM) thrombosis and cancer group.
PURPOSE
Both venous and arterial thrombotic events (VTE/AT) can be associated with Immune Checkpoint Inhibitors (ICI). However, there is a paucity of information apropos patients in routine clinical practice.
METHODS
/Patients. This retrospective, multicenter study was promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Individuals with head and neck cancer who initiated ICI between 01/01/2015 and 31/12/2021 were recruited. Minimum follow-up was 6 months (except in cases of demise). The primary objective was to calculate the incidence of ICI-associated VTE/AT, with secondary objectives including the analysis of their impact on survival and the identification of variables predictive of VTE/AT.
RESULTS
A total of 143 patients with head and neck cancer were enrolled. The incidence of VTE/AT during follow-up (median 8.6 months) was 2.8%. Survival analysis showed no significant differences (p = 0.644) between the group that developed VTE/AT (median 7.13 months, 95% CI 0-22.9) and the group that did not (median 9.86 months, 95% CI 6.3-13.4). The presence of liver metastases was predictive of VTE/AT (p < 0.05).
CONCLUSIONS
Thromboembolic disease associated with immunotherapy in patients with head and neck neoplasia does not significantly impact survival. The presence of liver metastases can predict these events.
PubMed: 38907096
DOI: 10.1007/s12094-024-03570-w -
Journal of Neurointerventional Surgery Jun 2024Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk-benefit is not well...
BACKGROUND
Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk-benefit is not well known.
OBJECTIVE
To investigate the efficacy and safety of tirofiban compared with aspirin in patients with acute ischemic stroke undergoing eCAS.
METHODS
We conducted a retrospective single-center study of the prospective ARTISTA Registry, including patients with atherosclerotic internal carotid artery occlusion treated with eCAS. Two groups, according to antiplatelet drug, were studied: aspirin (250-500 mg single-dose) versus tirofiban (500 μg bolus+200 μg/h). Primary outcomes were the rate of in-stent thrombosis and symptomatic intracranial hemorrhage (sICH) within the first 24 hours.
RESULTS
During the period 2019-2023, 181 patients were included, 103 received aspirin, 78 tirofiban; 149 (82.3%) had tandem lesions. The primary efficacy outcome occurred in 9 (9.4%) in the aspirin group, as compared with 1 (1.3%) in the tirofiban group (adjusted odds ratio (aOR)=0.11, 95% CI 0.01 to 0.98; P=0.048). The primary safety outcome was detected in 12 (11.7%) in the aspirin group, as compared with 2 (2.6%) in the tirofiban group (aOR=0.16, 95% CI 0.03 to 0.87; P=0.034). The tirofiban group presented a lower risk of parenchymal hemorrhage (18 (17.4%) vs 4 (5.2%), aOR=0.27, 95% CI 0.09 to 0.88; P=0.029) and an increased rate of excellent recanalization (expanded Treatment in Cerebral Infarction (eTICI) 2c-3) (50 (48.5%) vs 54 (69.2%); aOR=2.15, 95% CI 1.12 to 4.13; P=0.02). There were no differences in functional outcomes or mortality at 3 months.
CONCLUSIONS
Periprocedural antithrombotic therapy with tirofiban was associated with a lower risk of in-stent thrombosis and sICH at 24 hours from eCAS compared with aspirin. Prospective randomized clinical trials are needed to confirm our results.
PubMed: 38906690
DOI: 10.1136/jnis-2024-021845 -
Medicine Jun 2024Extracorporeal membrane oxygenation (ECMO) is used for severe cardiopulmonary failure, with veno-arterial ECMO for cardiogenic shock and veno-venous ECMO for acute... (Observational Study)
Observational Study
BACKGROUND
Extracorporeal membrane oxygenation (ECMO) is used for severe cardiopulmonary failure, with veno-arterial ECMO for cardiogenic shock and veno-venous ECMO for acute respiratory failure. ECMO's application has expanded to ICUs, emergency departments, and operating rooms. ECMO patients are at high risk for complications, including acute kidney injury (AKI), often requiring renal replacement therapy (RRT), posing significant management challenges.
METHODS
From August 2015 to June 2022, 120 patients were cured with veno-venous ECMO (n = 60) or veno-arterial ECMO (VA-ECMO, n = 60) combined with CRRT in our hospital. In the control group (n = 60), the input end (arterial end) of CRRT was connected to the ECMO oxygenator. The reinfusion end (venous end) of CRRT was connected to the oxygenator of ECMO for CRRT + ECMO treatment. In the experimental group (n = 60), the input end (arterial end) of CRRT was connected to the oxygenator of ECMO, and an additional pressure regulating device was installed on the connection of the 2 lines. The observation indexes including clinical therapeutic effect, clinical therapeutic effect, the incidence of complications, and the incidence of complications were compared.
RESULTS
There was a notable decrease in serum creatinine, and the differences in blood urea nitrogen, procalcitonin, and C-reactive protein after operation were statistically significant (P < .05). The filter use time in the study group was notably longer (P < .01). There exhibited no remarkable difference in the incidences of bleeding, thrombosis, numbness of hands and feet, metabolic alkalosis, disseminated intravascular coagulation, organ dysfunction syndrome, hyperbilirubinemia, and infection.
CONCLUSION
This study demonstrates that additional pressure regulation devices are installed at the line connection between the CRRT input end and the CRRT return end to ensure that the flow rate of ECMO does not affect the CRRT treatment. ECMO and CRRT provide a safe pressure range so that the ECMO line can be safely connected to the CRRT machine at physiological pressure, reducing the occurrence of complications related to CRRT machine interruption and improving the efficiency of CRRT without affecting the efficiency of ECMO, ensuring patient safety.
Topics: Humans; Extracorporeal Membrane Oxygenation; Female; Male; Middle Aged; Acute Kidney Injury; Renal Replacement Therapy; Aged; Incidence; Adult
PubMed: 38905421
DOI: 10.1097/MD.0000000000038580 -
Frontiers in Cardiovascular Medicine 2024Behcet's disease (BD) is a systematic vasculitis that affects vessels with various sizes, presenting as venous thrombosis and arterial pseudoaneurysms. The most severe...
BACKGROUND
Behcet's disease (BD) is a systematic vasculitis that affects vessels with various sizes, presenting as venous thrombosis and arterial pseudoaneurysms. The most severe manifestation in BD is ascending aortic pseudoaneurysm, which is associated with high risks of rupture and mortality.
CASE PRESENTATION
We present a case of ascending aortic pseudoaneurysm in a 50-year-old patient with BD. After preoperative evaluation, coil embolization was successfully performed to treat the pseudoaneurysm, resulting in a satisfactory outcome at the 1-year follow-up.
CONCLUSION
Coil embolization serves as an effective treatment option for ascending aortic pseudoaneurysm in BD when open surgical repair and stent graft placement are unsuitable.
PubMed: 38903968
DOI: 10.3389/fcvm.2024.1392236