Eitan Heldenberg

Why Calls for More Routine Carotid Stenting Are Currently Inappropriate: An International, Multispecialty, Expert Review and Position Statement

Why Calls for More Routine Carotid Stenting Are Currently Inappropriate An International, Multispecialty, Expert Review and Position Statement

Terror Attacks Increase the Risk of Vascular Injuries

Objectives: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. Methods: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. Results: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. Conclusion: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.

A vasoactive intestinal peptide receptor analog alters the expression of homeobox genes

A lipophilic analog of vasoactive intestinal peptide (VIP), stearyl-Nle(17)-neurotensin(6-11)VIP(7-28) (SNH), that inhibited lung cancer growth, has been previously described. The mechanism of SNH inhibition of cancer growth is still being elucidated. The present study examined the effects of SNH on homeobox genes in the colon cancer cell line HT 29 that expresses VIP receptors. Homeobox genes contain a characteristic DNA sequence, coding for a stretch of 61 amino acid homeodomain that binds specific DNA motifs. While the HOX gene family contains a single homeodomain, the POU gene family contains an additional DNA binding homeodomain. HT 29 cells were incubated with SNH; RNA was extracted and subjected to reverse-transcription-polymerase chain reaction (RT-PCR) with primers that matched the conserved area of the various HOX or POU genes. The PCR products that were altered by SNH treatment were sequenced. Three candidate SNH-responsive genes, the HOX A4, the HOX B5 and the PUO V transcription factor I (Oct-3) were identified. Semi-quantitative RT-PCR with specific primers confirmed the increase in HOX A4 and the decrease in Oct-3 expression levels following SNH treatment. Thus, the HOX A4 and the Oct-3 homeobox genes may partially mediate SNH activity on cancer cells.

Clostridium septicum post-endovascular aneurysm repair stent-graft infection.

Endovascular aortic aneurysm repair (EVAR) is establishing its role as a valid alternative for the treatment of abdominal aortic aneurysm. Post-EVAR graft infection is a rare and devastating complication. The incidence of post-EVAR graft infection is yet to be defined, and available data at this stage consist of case reports and small series. Possible etiologies for aortic stent-graft infection include perioperative contamination and hematogenous seeding. To the best of our knowledge, this is the first report of post-EVAR stent graft infection with Clostridium septicum. The possible mechanisms of this unusual hematogenous seeding have been discussed.

Why the US Center for Medicare and Medicaid Services should not extend reimbursement indications for carotid artery angioplasty/stenting.

Why the US Center for Medicare and Medicaid Services Should Not Extend Reimbursement Indications for Carotid Artery Angioplasty/Stenting

Civilian casualties of terror-related explosions: the impact of vascular trauma on treatment and prognosis

Objectives A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non–terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. Methods A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. Results Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25–75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals’ resources were used—trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). Conclusions Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital’s resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level V.

Why the United States Center for Medicare and Medicaid Services should not extend reimbursement indications for carotid artery angioplasty/stenting

Why the United States Center for Medicare and Medicaid Services should not extend reimbursement indications for carotid artery angioplasty/stenting

Epithelioid hemangioendotheliomia as a rare cause of blue toe syndrome

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery

Background The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. Methods A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. Results The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months. Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. Conclusions In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Transiliac wing alternate route bypass for infected groin vascular graft.

Groin infection after vascular reconstruction is one of the most severe complications, necessitating aggressive surgical therapy. Maintaining limb perfusion along with removal of an infected graft sometimes requires an unorthodox surgical solution. We describe such an unorthodox surgical approach, in which a new graft was routed from the infrarenal aorta to the anterior tibial artery through the iliac bone wing.