Jonathan S. Deitch

Infected renal artery pseudoaneurysm and mycotic aortic aneurysm after percutaneous transluminal renal artery angioplasty and stent placement in a patient with a solitary kidney

Endovascular infections after percutaneous transluminal renal angioplasty with stenting (PTRAS) are rarely reported. Because strict longitudinal follow-up of patients undergoing PTRAS is lacking, the true incidence of such complications remains obscure. We report the first case of a patient with an infected renal artery pseudoaneurysm and de novo mycotic aortic aneurysm after PTRAS. This case serves to illustrate several important points, including (1) the retrieval of renal function in patients with renal artery occlusion, (2) the pathogenesis of infection after PTRAS, (3) the diagnosis and management of endovascular infection after percutaneous vascular intervention, and (4) recommendations for periprocedural antibiotic prophylaxis during PTRAS.

The F11 receptor (F11R/JAM-A) in atherothrombosis: Overexpression of F11R in atherosclerotic plaques

F11R is the gene name for an adhesion protein, called the F11-receptor, aka JAM-A, which under normal physiological conditions is expressed constitutively on the surface of platelets and localized within tight junctions of endothelial cells (EC). Previous studies of the interactions between human platelets and EC suggested that F11R/JAM-A plays a crucial role in inflammatory thrombosis and atherosclerosis. The study reported here obtained in-vivo confirmation of this conclusion by investigating F11R/JAM-A protein and mRNA in patients with aortic and peripheral vascular disease and in an animal model of atherosclerosis. Molecular and immunofluorescence determinations revealed very high levels of F11R/JAM-A mRNA and F11R/JAM-A protein in atherosclerotic plaques of cardiovascular patients. Similar results were obtained with 12-week-old atherosclerosis-prone apoE-/- mice, an age in which atherosclerotic plaques are well established. Enhanced expression of the F11R/JAM-A message in cultured EC from human aortic and venous vessels was observed following exposure of the cells to cytokines. Determinations of platelet adhesion to cultured EC inflamed by combined cytokine treatment in the presence of F11R/JAM-A - antagonists provided data indicating that de novo expression of F11R/JAM-A on the luminal surface of inflamed EC has an important role in the conversion of EC to a thrombogenic surface. Further studies of these interactions under flow conditions and under in-vivo settings could provide a final proof of a causal role for F11R/JAM-A in the initiation of thrombosis. Based on our in-vitro and in-vivo studies to date, we propose that therapeutic drugs which antagonize the function of F11R/JAM-A should be tested as novel means for the prevention and treatment of atherosclerosis, heart attacks and stroke.

Renal artery repair: consequence of operative failures.

OBJECTIVEnThis report examines the blood pressure and renal function response in 20 consecutive patients after secondary renal revascularization following failed operative repair.nnnSUMMARY BACKGROUND DATAnMost reports describing operative failure of renal artery (RA) repair emphasize the technical aspects of redo RA reconstruction and the immediate blood-pressure response to secondary operation. This report examines the eventual renal function and estimated survival after secondary intervention.nnnMETHODSnPrimary methods of RA reconstruction, primary blood pressure and renal function responses, and causes of failed RA repair were defined for 20 patients requiring reoperation for recurrent hypertension or renal insufficiency. These parameters were compared with secondary procedures and eventual blood pressure and renal function response. The eventual outcome for these 20 patients was compared with 514 patients managed by primary renal revascularization during the same period.nnnRESULTSnFailure of primary RA repair correlated with complex fibromuscular dysplasia requiring branch ex vivo reconstruction (p = 0.020). RA thrombosis frequently required nephrectomy (83%), whereas RA stenosis was successfully reconstructed (91 %; p = 0.001). Primary and secondary blood-pressure responses were equivalent (94% vs. 95% cured or improved); however, primary and eventual renal function responses differed significantly (p = 0.015), with seven patients dialysis-dependent on follow-up. Eventual dialysis dependence was associated with preoperative azotemia (p = 0.022), bilateral failure of primary RA repair (p = 0.007), and an increased risk of follow-up death (p = 0.002). Considering all 534 patients, failed RA repair demonstrated a significant and independent association with eventual dialysis dependence and decreased dialysis-free survival.nnnCONCLUSIONSnContemporary rates of reoperation after surgical RA repair are low. In properly selected patients, beneficial blood-pressure response is reliably observed after both primary and secondary operative procedures. However, secondary procedures are associated with a significant and independent risk of eventual dialysis dependence.

TRANSAORTIC MESENTERIC ENDARTERECTOMY

Although a number of methods for mesenteric artery reconstruction have been suggested, we believe that patients with atherosclerotic stenosis and occlusion of mesenteric vessels presenting with either acute or chronic visceral ischemia are best managed by either antegrade aortomesenteric bypass or transaortic mesenteric endarterectomy. Antegrade bypass is the most versatile technique and is therefore best adapted to extensive mesenteric disease. Transaortic mesenteric endarterectomy lends itself well to simultaneous renal artery endarterectomy when clinically significant osteal atherosclerosis is present at both sites. With any method of reconstruction, the technical adequacy of repair should be defined intraoperatively. In this regard, intraoperative duplex sonography provides both anatomic and hemodynamic data necessary to ensure technical success and late patency.

Renal artery repair in African-Americans

Abstract Purpose: This retrospective review examines the results of atherosclerotic renal artery (RA) repair in consecutive hypertensive African-Americans treated at our center and compares these results with Caucasians treated during the same period. Methods: From Jan. 1987 through Sep. 1996, a total of 485 patients underwent operative RA repair. Of these, 28 African-Americans and 370 Caucasians were managed for atherosclerotic renovascular disease. These cohorts were compared on the basis of preoperative blood pressure and renal function, extent of renal disease, extrarenal atherosclerosis, response to operation, and estimated survival. Results: The African-American cohort included nine men and 19 women (mean age, 62 years) with hypertension (mean blood pressure, 204 ± 31/109 ± 20 mm Hg) for an average of 10.2 ± 7.5 years. Ischemic nephropathy (serum creatinine level, >1.3 mg/dl) was present in 82% (n = 23) of the African-American group. RA reconstructions were unilateral in nine patients and bilateral in 19 patients (including repair to two solitary kidneys), for a total of 45 RA reconstructions (30 RA bypass procedures; eight transrenal/transaortic RA endarterectomy procedures; two RA reimplantations; five nephrectomies). Nine patients underwent combined aortic procedures (four abdominal aortic aneurysm; five occlusive disease). There was one perioperative death in the African-American group as a result of sepsis and multiple organ failure. Among surgical survivors, 20 African-American patients (74%) had a beneficial hypertension response (7% cured, 67% improved). Mean estimated glomerular filtration rate improved significantly from 34 to 42 ml/min/1.73 m 2 ( p p = 0.03) and tended toward more severe renal dysfunction (mean serum creatinine level, 2.5 vs 2.1 mg/dl; p = 0.25). However, African-Americans demonstrated a beneficial blood pressure and renal function response after operation, similar to Caucasians. Conclusions: Our results indicate that the majority of selected African-Americans have a favorable blood pressure and renal function response to operative renal artery repair. This beneficial clinical response appears equivalent to the response observed in Caucasian patients and supports the search for RA disease in hypertensive African-Americans.

Expression of a recombinant protein of the platelet F11 receptor (F11R) (JAM-1/JAM-A) in insect cells: F11R is naturally phosphorylated in the extracellular domain

The F11 receptor (F11R/JAM) is a member of the immunoglobulin superfamily localized on the membrane surface of human platelets and a component of tight junctions of endothelial and epithelial cells. F11R was demonstrated to participate in the adhesion of human platelets to cytokine-inflamed endothelial cells (EC), indicating an important role for F11R in inflammatory thrombosis and atherosclerosis. Domains responsible for the formation of tight junctions, the adhesion of platelets to EC, activation of platelets resulting in granule release, the activation of αIIb/β3 integrin and platelet aggregation, were identified in the external portion of F11R. To further examine critical sites of F11R, we utilized the baculovirus system to generate the F11R recombinant protein with the sequence of the extracellular domain, in two types of insect cells, Sf9 and H5. The F11R recombinant protein was detected in the cytoplasm of both infected Sf9 and H5 insect cells, but only infected H5 cells secreted a soluble F11R protein. The purified recombinant F11R proteins, obtained from both types of insect cells, were recognizeable by a conformation-dependent monoclonal antibody, M.Ab.F11, directed against domains within the N-terminus and the first Ig-like fold of F11R. Assessment of the phosphorylation state in the recombinant F11R protein revealed phosphorylation of serine, threonine and tyrosine amino acid residues within the external domain. Real-time biomolecular interaction analysis, performed to assess kinetic constants associated with the binding of active molecules to the purified recombinant F11R protein revealed high affinity binding of the phosphorylated recombinant protein by M.Ab.F11 with Ka of 5.47u2009×u2009106 and Kd of 1.83u2009×u200910−7, comparable to values measured with intact human platelets. The findings reported here provide new information on specific domains of F11R that can lead to the generation of therapeutic agents expected to be useful in the treatment of cardiovascular diseases.

IP141. Endovascular Treatment of Chronic Common Femoral Arteriovenous Fistulas

reports describe removal by femoral arteriotomy, so the severity of this IABP rupture was rare in the need for aortotomy to remove the IABP secondary to the abundance of dense clot material within the balloon. Recommendation for removal at the first sign of rupture as well as avoidance of larger balloons than are needed will reduce the incidence of this problem. A review of the literature and subsequent recommendations for the surgical management of IABP entrapment are discussed in the context of our case.