Derek Mittleider

Retrograde Cannulation of the Thoracic Duct and Embolization of the Cisterna Chyli in the Treatment of Chylous Ascites

The authors offer a previously undescribed technique for cisterna chyli embolization in the treatment of chylous ascites. After the failure of conventional percutaneous direct cisterna chyli cannulation, the authors accessed the thoracic duct directly from the subclavian vein. Retrograde microcatheter access through the thoracic duct enabled embolization of the cisterna chyli. Embolization materials included fibered endovascular coils, gelatin sponge, and doxycycline. The patients symptoms returned 10 days after embolization. This technique provided short-term success in the treatment of the patients chylous ascites.

Sequence survey of the genome of the opportunistic microsporidian pathogen, Vittaforma corneae

Abstract The microsporidian Vittaforma corneae has been reported as a pathogen of the human stratum corneum, where it can cause keratitis, and is associated with systemic infections. In addition to this direct role as an infectious, etiologic agent of human disease, V. corneae has been used as a model organism for another microsporidian, Enterocytozoon bieneusi, a frequent and problematic pathogen of HIV-infected patients that, unlike V. corneae, is difficult to maintain and to study in vitro. Unfortunately, few molecular sequences are available for V. corneae. In this study, seventy-four genome survey sequences (GSS) were obtained from genomic DNA of spores of laboratory-cultured V. corneae. Approximately, 41 discontinuous kilobases of V. corneae were cloned and sequenced to generate these GSS. Putative identities were assigned to 44 of the V. corneae GSS based on BLASTX searches, representing 21 discrete proteins. Of these 21 deduced V. corneae proteins, only two had been reported previously from other microsporidia (until the recent report of the Encephalitozoon cuniculi genome). Two of the V. corneae proteins were of particular interest, reverse transcriptase and topoisomerase IV (parC). Since the existence of transposable elements in microsporidia is controversial, the presence of reverse transcriptase in V. corneae will contribute to resolution of this debate. The presence of topoisomerase IV was remarkable because this enzyme previously had been identified only from prokaryotes. The 74 GSS included 26.7 kilobases of unique sequences from which two statistics were generated: GC content and codon usage. The GC content of the unique GSS was 42%, lower than that of another microsporidian, E. cuniculi (48% for protein-encoding regions), and substantially higher than that predicted for a third microsporidian, Spraguea lophii (28%). A comparison using the Pearson correlation coefficient showed that codon usage in V. corneae was similar to that in the yeasts, Saccharomyces cerevisiae (r = 0.79) and Shizosaccharomyces pombe (r = 0.70), but was markedly dissimilar to E. cuniculi (r = 0.19).

Asymptomatic Isolated Celiac Artery Dissection After a Fall

Isolated injury to mesenteric vessels in blunt trauma is uncommon. Most patients with these injuries present with abdominal pain, shock, or laboratory evidence of bowel and/or liver ischemia. We report herein the case of a man with asymptomatic isolated celiac artery dissection after blunt trauma suspected by screening abdominal computed tomography and confirmed by catheter-based angiography. The patient was treated with 3 months of oral anticoagulation alone.

Methionine Aminopeptidase 2 Expression in Microsporidia

ELIZABETH s. DIDIER,” AARON D. MARTIN,” MARY E. STOVALL,” XAVIER ALVAREZ,~ DEREK MITTLEIDER; LINDA C. GREEN: LISA C. BOWERS,” ARDETH K. PLAUCHE,” PETER J. DIDIERb and PAUL J. BRINDLEY‘ “Divsion of Microbiology and Immunology, bDivision of Comparative Pathology, Tulane National Primate Research Centee Covington, LA 70433 U.S.A. “Department cf Tropical Medicine and Hygiene, Tulane Universitr; New Orleans, LA 70112 U.S.A., and dXavier University of Lauisiana, New Orleans, LA 70125, U.S.A.

Clinical Impact of Sacroplasty on Patient Mobility

PURPOSE To evaluate the effect of sacroplasty on patient mobility and pain when performed as a treatment for sacral insufficiency fractures. MATERIALS AND METHODS Imaging with computed tomography (CT), magnetic resonance imaging, or bone scan confirmed the diagnosis of sacral insufficiency fractures. Baseline clinical mobility scale (CMS) score and visual analog scale (VAS) pain score were recorded. Sacroplasty was performed under CT guidance. Follow-up CMS and VAS scores were assessed at 4, 24, and 48 weeks. RESULTS Eighteen elderly patients (age 80 y ± 8.5; 17 women) were treated. Repeated-measures analysis of variance was conducted to assess changes in CMS and VAS scores over time. Pairwise comparisons revealed a significant increase in average CMS score between baseline and all three follow-up points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in mobility over time. Pairwise comparisons revealed significant differences in mean VAS scores between baseline and all three follow-up time points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in overall pain level over time. CONCLUSIONS Treatment with CT-guided sacroplasty for sacral insufficiency fractures in this elderly population resulted in significant improvement in patient mobility.

Percutaneous Thrombin Injection of a Femoral Artery Pseudoaneurysm with Simultaneous Venous Balloon Occlusion of a Communicating Arteriovenous Fistula

An 82-year-old woman developed acute occlusion of her right coronary artery. She underwent percutaneous coronary stent placement and aortic balloon pump installation. In the postprocedural period, she developed a common femoral artery pseudoaneurysm (PSA) that communicated with the common femoral vein via an arteriovenous fistula (AVF). After unsuccessful ultrasound-guided compression, ultrasound-guided thrombin injection of the PSA was performed, with simultaneous balloon occlusion of the common femoral vein at the level of the AVF. There was complete thrombosis of the PSA and AVF.

Peripheral Atherectomy: Applications and Techniques

Peripheral atherectomy is a class of procedures that is rapidly increasing in volume. Multiple classes of devices exist, and newer variants are added to the market annually. The devices see wide application for de novo lesions, in-stent restenosis, and adjunctive therapy for drug-coated balloons. The body of evidence supporting atherectomy is less robust than for many other peripheral therapies. The frequency and severity of complications from atherectomy can be significant compared with angioplasty and stenting, and familiarity with preventative and bailout techniques is essential for the interventionalist.

Renal cell carcinoma initially presenting as an arteriovenous malformation: a case presentation and a review of the literature.

We describe a case of a patient who presented with hematuria and was diagnosed with a renal arteriovenous malformation (AVM). Transcatheter arterial embolization subsequently was performed on this lesion multiple times. Follow-up imaging demonstrated that the AVM was masking an underlying, rapidly growing renal cell carcinoma (RCC). We describe the pathological and radiographic characteristics of AVMs and RCC. We describe the strengths and weaknesses of computed tomography (CT) and magnetic resonance imaging (MRI) to detect and characterize RCC and AVM. We recommend initial and follow-up MR imaging in patients with an AVM to establish a baseline, monitor treatment response, and survey lesions for underlying and obscured malignancy.

Retrograde Tibiopedal Access for the Treatment of Critical Limb Ischemia

Critical limb ischemia (CLI) is associated with high rates of morbidity and mortality. Many patients with CLI are poor surgical candidates. Endovascular therapy has been shown to be an effective technique to improve arterial perfusion for patients with CLI. In patients with isolated infrapopliteal occlusive disease, endovascular therapy may be more effective than conventional bypass surgery. When antegrade endovascular revascularization fails, an understanding of tibiopedal access and retrograde crossing techniques is essential to re-establish flow to aid in tissue healing, provide symptomatic relief, and avoid amputation.

Safety and Efficacy of Angio-Seal Closure in Antegrade Superficial Femoral Artery Access

Objective: Arterial access for endovascular revascularization in patients with debilitating peripheral arterial disease is commonly achieved through retrograde common femoral artery (CFA) approach. However, retrograde access presents multiple technical challenges, including long distance from the access site to the target lesion, and mechanical disadvantage of working over the aortic bifurcation and often tortuous iliac vessels. Antegrade CFA access avoids these challenges but has been fraught with its own difficulties, particularly in obese patients. Antegrade superficial femoral artery (SFA) access provides the same mechanical advantages while avoiding the difficulties of antegrade CFA access, but a vascular closure device is required due to distance from the femoral head. This single-center study evaluates the safety and efficacy of the Angio-Seal device (St. Jude Medical, St. Paul, MN) in SFA punctures. Materials and Methods: From May 2011 to January 2015, 140 antegrade SFA punctures were performed on 110 limbs in 88 patients for endovascular revascularization, all with ultrasound guidance. Complications and patient data including age, sex, body mass index, Fontaine stage, sheath size, and intraoperative heparin doses were analyzed. Results: In 140 antegrade SFA punctures, there were 11 access-related complications (7.9%). The majority were hematomas or pseudoaneurysms requiring nominal or no therapy. There were 3 major complications: Two delayed access stenoses ultimately resulted in toe amputations and one hemorrhage required extended hospitalization and transfusion. Patient data analysis showed a statistically significantly increased complication rate in females (20.7%) versus males (4.5%) (p = 0.0105). Conclusions: Antegrade SFA access with Angio-Seal closure is safe and effective. An increased complication rate in females warrants cautious post-procedural follow-up.