Rachael Nicholson

RIZ1 is epigenetically inactivated by promoter hypermethylation in thyroid carcinoma

Allelotype studies have suggested that chromosome 1p is frequently lost in thyroid cancers, thus suggesting that there is an important tumor suppressor at this location. RIZ1 (PRDM2), located on 1p36, is a recently described tumor suppressor gene and is a member of the protein methyltransferase superfamily. RIZ1 expression is lost in a variety of tumors, primarily by means of epigenetic mechanisms that involve promoter hypermethylation.

Endovascular recanalization of total occlusions of the mesenteric and celiac arteries

OBJECTIVE To evaluate our experience with the endovascular treatment of total occlusions of the mesenteric and celiac arteries. METHODS We performed a retrospective review of endovascular stenting of 27 nonembolic total occlusions of the superior mesenteric artery (SMA) and celiac artery (CA) between July 2004 and July 2011 (26 patients, 16 females; mean age, 62 ± 13 years). A variety of demographic, lesion-related and procedure-related variables were evaluated for potential impact of technical success and patency. The follow-up protocol included clinical assessment, and color and spectral Doppler evaluation of the stented vessel(s). RESULTS The clinical presentation was chronic mesenteric ischemia in 12 patients, acute mesenteric vascular syndromes in 10 patients, foregut ischemia/ischemic pancreatitis in three patients, and prior to endovascular repair of aortic aneurysm in one patient. The treated vessel was SMA in 22 procedures, CA in three, and both SMA and CA in one. Technical success was achieved in 23 of the 27 attempted recanalizations (85%). Three patients who failed the attempt underwent open bypass, and another one underwent retrograde recanalization and stenting of the SMA. Procedure success was only significantly related to patient age <70 years or procedure performance after the year 2006. Notably, the presence of a stump, ostial plaque, extensive vascular calcification, recanalization route (intraluminal vs subintimal), occlusion length, and vessel diameter had no significant impact on procedure success. Traditional duplex criteria proved unreliable in predicting restenosis. Life table analysis of freedom from symptom recurrence showed a primary and assisted rates of 58% and 80% at 1 year, and 33% and 60% at 2 years, respectively. Clinical recurrences developed in six patients (four presented with abdominal angina and weight loss, two presented with abdominal catastrophe). There were six access-related complications and no procedural deaths. Four delayed deaths occurred during follow-up (two cardiac causes, two due to abdominal sepsis). CONCLUSIONS Endovascular recanalization of mesenteric artery occlusion is both feasible and successful, provided careful planning is used.

Suprarenal Clamping Is a Safe Method of Aortic Control when Infrarenal Clamping Is not Desirable

We evaluated the safety of suprarenal aortic clamping in patients with abdominal aortic aneurysm (AAA) treated by open aortic replacement by retrospectively reviewing all patients who underwent elective AAA replacement at a university hospital from 1993 until 2003. We reviewed 249 patient charts and divided them into three groups according to the clamp location during aortic replacement: group 1, infrarenal clamp group (n = 185); group 2, suprarenal clamp group (n = 52); and group 3, supraceliac clamp group (n = 12). Groups 1 and 2 were compared with respect to risk factors, intraoperative events, and postoperative events. Statistical analysis was done using Wilcoxons rank-sum test, chi-squared test, and Fishers exact test. Risk factors were comparable in groups 1 and 2 except for weight, which was higher in group 1. Intraoperative urine output, hypotensive episodes, and use of renal protective drugs were comparable in the two groups. Operation time, blood loss, and use of IV fluids were all significantly higher in group 2, while total aortic clamp time was higher in group 1. Postoperative events were comparable except for postoperative peak creatinine, intensive care unit length of stay, and postoperative length of stay, which were higher in group 2; however, discharge creatinine was comparable without a significant difference. Suprarenal clamping is a safe method of aortic control during open AAA replacement surgery. The selection of clamping site should be individualized according to the intraoperative anatomy. Supraceliac clamping is not necessarily the preferable method of aortic control when the infrarenal location is not suitable for clamping.

Impact of Aggressive Endovascular Recanalization Techniques on Success Rate in Chronic Total Arterial Occlusions (CTOs)

Purpose: To report experience with aggressive recanalization approaches in chronic total arterial occlusion (CTO). Methods: Chronic total arterial occlusion recanalization was attempted on 112 limbs in 99 consecutive patients between January 1999 and December 2006. Results: There were 63 iliac arteries, 45 femoropopliteal arteries, and 4 occluded stents. Mean occlusion length was 8.7 ± 4.7 cm. Conventional recanalization was attempted first and was successful in 71 limbs (70%). Probing with the guidewire’s stiff end was attempted in 33 of the 41 procedures where conventional techniques failed and was successful in 18 (54%), improving the overall procedural success rate to 80%. For the remaining 15 limbs, home-made directional sharp needle recanalization was attempted in 11 and was successful in 9 (82%), further improving the overall recanalization success to 88%. Procedural complications were self-limited or managed nonoperatively. Conclusions: Aggressive recanalization techniques in CTO following failure of traditional means are safe and can substantially improve procedural success rates.

ECM1 Expression in Thyroid Tumors : A Comparison of Real-Time RT-PCR and IHC

BACKGROUND Increased extracellular matrix 1 (ECM1) expression, as determined by real-time reverse transcriptase-polymerase chain reaction (RT-PCR), has been recently proposed as a novel and independent diagnostic marker for malignant thyroid nodules. However ECM1 protein expression has not been previously evaluated in thyroid tumors. Real-time RT-PCR is not widely available and this has important implications for the widespread use of the expression of this gene for diagnosis. The purpose of the current study is to evaluate and compare ECM1 expression by real-time RT-PCR with immunohistochemistry (IHC) as diagnostic aids in thyroid neoplasms. MATERIALS AND METHODS ECM1 expression was studied in normal thyroid tissues (n = 14) and primary thyroid tumors (19 benign, 30 malignant) using both techniques. The performance characteristics of ECM1 expression were examined with receiver operating characteristic curves and the resulting area under the curve. RESULTS ECM1 was highly expressed in thyroid carcinomas, compared with benign thyroid tissues, both at the mRNA (P < 0.01) and protein (P = 0.06) levels. However, ECM1 mRNA expression appeared to be a more sensitive marker of thyroid malignancy than IHC (AUC = 0.77 and 0.65, respectively). ECM1 expression by both methods was useful in identifying malignant follicular, but not Hürthle cell neoplasms. CONCLUSIONS We confirm that ECM1 expression has potential utility as an independent diagnostic marker for thyroid cancer, although, performance characteristics were lower than previously published. Furthermore, IHC was not as sensitive as real-time RT-PCR in identifying malignant lesions. Prospective studies are needed to further clarify the role of ECM1 expression as a diagnostic marker.

Endovascular Treatment of a Traumatic Thoracic Aortic Injury in an Eight-Year Old Patient: Case Report and Review of Literature

Traumatic aortic injuries in children and adolescents are rare. Although endovascular repair has become the preferred approach for such injuries in adults, open repair has endured as the gold standard in children owing mainly to the smaller aortic and access vessel diameter and the scarcity of long-term follow-up data. We report a successful endovascular repair of a traumatic thoracic aortic injury in an 8-year-old girl using a Zenith Alpha thoracic endograft (Cook Medical, Bloomington, IN). We also review the literature on endovascular treatment of traumatic aortic injuries in the pediatric population.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Results: Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Femoropopliteal Endovascular Interventions

The treatment of peripheral arterial disease (PAD) has witnessed a remarkable evolution in the past two decades. While endovascular therapy has become well established as a primary treatment modality in aortoiliac occlusive disease, transcatheter treatment of infrainguinal occlusive disease remains controversial. The availability of a wide range of therapeutic options and devices applicable to infrainguinal interventions has resulted in a dramatic increase in the number of peripheral endovascular procedures over the past decade, with a staggering reported 979 % growth in peripheral vascular interventions reported since 1995. Despite this remarkable growth and increasing acceptance, many questions remain unanswered regarding the indications, choice of device/technique, clinical efficacy, long-term outcome, and cost-effectiveness of the available competing modalities. These decisions are also compounded by intense and often conflicting marketing efforts by the industry in the current competitive market. With the scarcity of randomized controlled trials, much of the published reports for newer endovascular technologies rely primarily on immediate angiographic outcomes and target limb revascularization (TLR) data. The following text is meant to provide an overview over current treatment options, technologies, and devices based on available evidence and the experience and opinions of the authors. The endovascular surgeon must be familiar with all the available treatments for PAD in order to continue to manage these patients amidst the increasingly complex health-care environment.

A natural history of aortic aneurysm hygroma

A 56-year-old man with a family history of aortic aneurysm underwent routine repair in 2003. A postoperative computed tomography scan showed a 6-cm perigraft hygroma. Sudden onset of abdominal pain 12 months later revealed a larger hygroma, with an additional anterior fluid collection suggestive of contained rupture. The bilobed hygroma remained stable until 2010, when he presented with chills and severe abdominal pain. A computed tomography scan demonstrated free rupture of the sister hygroma, with air pockets observed within the sac. Conservative management was elected. Air pockets as well as the hygroma eventually resolved, and the patient remains well.

Choice of Approach for Laparoscopic Common Duct Exploration

When laparoscopic cholecystectomy is undertaken in the presence of known common duct stones, laparoscopic common duct exploration is generally part of the planned procedure. Chapters 5 and 6 explored alternatives in the management of choledocholithiasis, including the role of endoscopic retrograde cholangiopancreatography (ERCP). This chapter deals specifi cally with the relative merits of the transcystic duct approach versus laparoscopic choledochotomy (a procedure that more nearly mimics what was done during open surgery for this problem).