Tomasz Zubilewicz

Bioengineered human acellular vessels for dialysis access in patients with end-stage renal disease: two phase 2 single-arm trials

BACKGROUND For patients with end-stage renal disease who are not candidates for fistula, dialysis access grafts are the best option for chronic haemodialysis. However, polytetrafluoroethylene arteriovenous grafts are prone to thrombosis, infection, and intimal hyperplasia at the venous anastomosis. We developed and tested a bioengineered human acellular vessel as a potential solution to these limitations in dialysis access. METHODS We did two single-arm phase 2 trials at six centres in the USA and Poland. We enrolled adults with end-stage renal disease. A novel bioengineered human acellular vessel was implanted into the arms of patients for haemodialysis access. Primary endpoints were safety (freedom from immune response or infection, aneurysm, or mechanical failure, and incidence of adverse events), and efficacy as assessed by primary, primary assisted, and secondary patencies at 6 months. All patients were followed up for at least 1 year, or had a censoring event. These trials are registered with ClinicalTrials.gov, NCT01744418 and NCT01840956. FINDINGS Human acellular vessels were implanted into 60 patients. Mean follow-up was 16 months (SD 7·6). One vessel became infected during 82 patient-years of follow-up. The vessels had no dilatation and rarely had post-cannulation bleeding. At 6 months, 63% (95% CI 47-72) of patients had primary patency, 73% (57-81) had primary assisted patency, and 97% (85-98) had secondary patency, with most loss of primary patency because of thrombosis. At 12 months, 28% (17-40) had primary patency, 38% (26-51) had primary assisted patency, and 89% (74-93) had secondary patency. INTERPRETATION Bioengineered human acellular vessels seem to provide safe and functional haemodialysis access, and warrant further study in randomised controlled trials. FUNDING Humacyte and US National Institutes of Health.

Role of 18F-FDG PET/CT in the diagnosis of inflammatory and infectious vascular disease

This review article discusses the utility of 18F-FDG PET/CT in diagnosis and management of vascular disease. We stress usefulness of this method in large vessel inflammation and infection. In our work we based on the literature analysis and clinical cases diagnosed in our institution by use of 18F-FDG PET/CT. The literature exploration was focusing on vascular inflammation and infections and 18-FDG PET. The search was performed on PubMed database and cross referencing. We present the practical review with several images of vascular diseases like: Takayasu arteritis, giant cell arteritis, vascular graft infections, abdominal aortic aneurysm infections and cases of aortitis and periaortitis. From this work inflammation associated with atheromatic process and vulnerable atherosclerotic plaque we excluded. 18F-FGD PET/CT is a sensitive metabolic, reliable, non-invasive imaging modality suitable for diagnosis and follow-up of inflammation and infections in vascular system.

Carotid surgery affects plasma kynurenic acid concentration: a pilot study.

Background An increase in plasma kynurenic acid (KYNA) concentration has been observed following surgery, inflammation, and cerebral pathologies. The aim of the present study was to analyze the changes in plasma KYNA concentration in patients undergoing carotid surgery (CS). Material/Methods Adult patients undergoing elective carotid endarterectomy (CEA) or carotid angioplasty with stent placement (CAS) were studied. Plasma KYNA concentrations were analyzed before surgery and at 4 time points after CS. The amount of inflammation was measured as neutrophil-lymphocyte ratio (NLR). Results Forty patients (10 female and 30 male) aged 55–86 years of age were evaluated in this study. In patients with unstable carotid plaque, the plasma KYNA concentration was higher than in patients with stable carotid plaque. Moreover, the NLR was significantly higher in patients with unstable carotid plaque undergoing CEA than in patients undergoing CAS. Plasma KYNA concentration increased after surgery in patients undergoing CEA and CAS. There was a strong correlation between plasma KYNA concentration and NLR in patients with postoperative neurological disorders. Conclusions CS increases plasma KYNA concentration, and changes in plasma KYNA concentration can indicate neurologic outcomes in patients undergoing CS.

The changes of plasma thrombin-antithrombin complex in the patients with peripheral arterial disease undergoing surgical revascularization.

UNLABELLED In patients with severe lower limb ischemia the coagulation and fibrinolytic systems have been found to be activated preoperatively. The aim of the study was to evaluate the changes of TAT level as a selected coagulation factor, before, during and after surgical revascularization and the analysis of the impact of coexisting diseases on the coagulation during the procedure. MATERIAL AND METHODS 50 patients with PAOD, in Fontaine stages IIb to IV (29 men and 21 women; median age 65.8 years, ASA II/III) undergoing elective surgical revascularization were studied. Two groups of patients were compared: 20 undergoing reconstruction on aorto-femoral and 30 on femoropopliteal level. Blood samples were collected 5 times: 24 hours before the operation; intraoperatively after artery exposure; after heparin administration and clamping; after reperfusion and -24 hours postoperatively. RESULTS Elevated values of TAT (10.5 g/l ±7.1) were found before the operation. The elevated value of TAT increased intraoperatively (25.1 g/l ±44.58; p<0.001) (norm 1-4.1 g/l) and maintaining higher levels after the surgery. The significant correlations between plasma level of TAT and ischemia degree were found. Also the correlation between intraoperative increase of TAT and the duration of surgery was noticed. No significant differences between two analysed groups were observed. CONCLUSIONS The results indicate the activation of coagulation and prothrombotic state in the patients with advanced arteriosclerosis. During the surgical revascularisation permanent increase of activation of blood coagulation was observed. This activation depends on duration of the procedure and maintains increased one-day after the operation. Our findings may explain the unexpected occurrence of early thrombotic complications after technically successful vascular reconstructions.

Axial splitting of the medial antebrachial cutaneous nerve facilitates second-stage elevation of basilic or brachial vein in patients with arteriovenous fistula

We describe a novel surgical technique to facilitate the second-stage elevation of the basilic or brachial vein in patients with first-stage brachial-basilic or autogenous brachial-brachial arteriovenous fistula by axial splitting of the medial antebrachial cutaneous nerve (MABCN). Filaments of the MABCN typically traverse the anterior aspect of the basilic and brachial veins. The second-stage elevation/shelf superficialization of the basilic or brachial vein, so as not to cause an injury to the MABCN, requires division of these veins with transposition over the nerve branches and subsequent reanastomosis. Our method of axial splitting of the MABCN enables elevation and shelf superficialization of the basilic or brachial vein without the division and reanastomosis of the vein. Twenty-eight patients underwent this simplified elevation. The nerve perineurium was incised longitudinally, nerve fibers were divided intrafascicularly, and cutaneous nerve branches were retracted aside. The vein was elevated between the divided nerves. On discharge and at 1-month follow-up, only one patient complained of localized patch hypoesthesia as reported in a simplified neurologic assessment questionnaire and neurologic examination.

The evaluation of the effectiveness of Tachosil in the treatment of lymphorrhea of the postoperative wound in the selected group of patients, after vascular reconstructive surgeries--preliminary report.

UNLABELLED Lymphorrhea of a postoperative wound after vascular reconstructive surgeries does not occur frequently but it accounts for a major complication. It should be brought to attention that during the intraoperative period it is impossible to diagnose any damages within the lymphatic system of the operated area. Additionally, the treatment of lymphorrhea with thermal abrasion does not usually bring the desired outcome. Therefore, the extended time of the postoperative wound treatment with the lymphatic drainage constitutes a standard method in such cases. The aim of the study was to evaluate the effectiveness of Tachosil surgical patch in the treatment of lymphorrhea of the postoperative wound in a selected group of patients who have undergone vascular reconstructive surgeries. Additionally, the aim of the study was to analyze the results and draw conclusions pertaining to the validity and effectiveness of the treatment with the use of Tachosil surgical patch. MATERIAL AND METHODS The observed group included 10 patients with lymphorrhea developed during the postoperative period. 6 of the observed patients have undergone the vascular reconstructive surgery with the implantation of the vascular prosthesis (distal femoropopliteal reconstruction bridge - 3 patients; iliofemoral reconstruction bridge - 1 patient; angioplasty of the common femoral artery (CFA) with the use of the prosthetic patch - 1 patient; the implantation of the bifurcated (type Y) aortofemoral prosthesis - 1 patient). The remaining patients in the observed group have undergone the restoration of patency of the CFA. Additionally, 1 patient has undergone the resection of the pseudo aneurysm in the distal part of the iliofemoral prosthesis. The vascular reconstructive surgery required the denudation and isolation of the common femoral artery from the surrounding tissue as a step 1. The persisting lymphorrhea of the postoperative wound, in the volume of more than 200 ml per day during the first 3 postoperative days, indicated the necessity for the inguinal wound revision. In addition, Tachosil surgical patch was applied at that time. The drain was placed over Tachosil patch. RESULTS Complete stop of lymphorrhea was shorter by 4.87 days in patients treated with the use of Tachosil in comparison to control group. These patients also had an average hospitalization time shorter by 3.88 days than patients in the control group. CONCLUSIONS Early intervention in the cases of lymphorrhea of the postoperative wound allows planning and conducting successful treatment. The use of Tachosil surgical patch in the treatment of lymphorrhea of the postoperative wound shortens the treatment and hospitalization periods. The use of Tachosil in the treatment of postoperative lymphorrhea appeared to be significantly more effective than the standard drainage method of treatment. Results obtained through this study pave the way for the research on other possible applications of Tachosil in the cases of lymphorrhea after vascular reconstructive surgeries.

Psoriatic erythroderma coexisting with erythema multiforme‐like lesions induced by retinoids or retinoids combined with an antibiotic: case report

Psoriasis is currently considered a multifactorial disease, which can coexist with many somatic and psychological disorders. We present the case of a 50‐year‐old woman referred to our department due to erythroderma with concomitant peculiar violaceous, polycyclic lesions most likely induced by medications. Past medical history revealed numerous systemic disorders, including metabolic syndrome, hypertension, cardiac insufficiency, obesity, and depression. Additional examinations and consultations demonstrated dyslipidemia, xanthelasma, incomplete block of the right branch of His bundle, thyreocardiac syndrome, benign adrenal tumor, and delusions. Recently, psoriasis has been intensively studied. We present the case in which erythroderma was most likely triggered by acitretin combined with ceftriaxone. Treatment of many diseases and psychiatric disturbances coexisting with psoriasis is extremely difficult and requires cooperation of various specialists.

Serumska razina za neuron specifične enolaze kao biljeg ishemijsko-reperfuzijskog oštećenja u bolesnika podvrgnutih karotidnoj endarterektomiji

In patients with atherosclerotic stenosis of the extracranial segment of internal carotid artery, surgical intervention is an effective method to prevent cerebral ischemic stroke. However, this surgical procedure may cause vascular brain damage. The aim of the study was to investigate consequential brain ischemia-reperfusion injury by measuring the cerebral specific marker, neuron-specific (NSE), in serum of patients having undergone internal carotid endarterectomy (CEA). The study involved 25 patients that underwent CEA due to internal carotid artery stenosis. Blood samples were obtained from each patient on three occasions: within 24 h prior to surgery, 12 h after surgery, and 48 h after surgery. Serum NSE levels were measured by a commercially available enzyme-linked immunosorbent assay. The study showed that serum NSE level was statistically significantly increased 48 h after CEA as compared with the level 12 h after surgery and the level before surgery (p<0.05). Difference in serum NSE between the level before surgery and 12 h after CEA was not statistically significant (p>0.05). Data from our study showed CEA to affect serum NSE in patients with significant internal carotid artery stenosis. Thus, serum NSE may be used as a biochemical marker of brain ischemia-reperfusion injury following CEA.

Cide-A Gene Expression in Patients with Obesity Qualified for Endovascular Treatment of Abdominal Aorta Aneurysm

UNLABELLED CIDE-A gene and the genes of LRP group play a key role in the regulation of the body weight and lipid metabolism in mammals. CIDE-A is defined as a potential human obesity gene and the LRP1 gene is associated with the development of abdominal aortic aneurysm (AAA). The aim of the study was to define the role of CIDE-A gene in patients with dyslipidemia and asymptomatic AAA. MATERIAL AND METHODS The study group consisted of 38 subjects, including 27 men and 11 women qualified for endovascular aneurysm repair (EVAR). The subjects with abdominal aortic aneurysm were enrolled in the study group, depending on the body mass index (BMI); in obese patients (BMI > 30). The control group (n = 16) included subjects without lipid disorders. One-step isolation of RNA from lymphocytes and adipose tissue cells was performed using the modified TRI method by Chomc-zynski and Sacchi, and then the gene expression was tested by real-time PCR. RESULTS The highest mean relative of the gene expression for CIDE-A was reported in subjects with the normal body weight. The lowest mean relative of the gene expression for CIDE-A was observed in the group of obese patients with aortic aneurysm and lipid disorders. A high negative correlation (r = -0.7101) in the gene expression for CIDE-A was observed in the group of obese patients with aortic aneurysm, depending on the BMI. CONCLUSIONS Due to the important role of the CIDE-A gene and Cide-A protein in the development of metabolic syndrome, obesity and the accompanying vascular lesions such as abdominal aortic an-eurysm, seen in this context, the tested gene and protein Cide-A represent a potential therapeutic target in these diseases.

Antioxidative mechanism in the course of varicose veins

Objective Our objective was to evaluate the state of oxidative stress in the great saphenous varicose vein wall and blood of varicose vein patients taken from the antecubital vein. Methods The superoxide dismutase, reduced glutathione (GSH) and total antioxidant status were measured with commercially available colorimetric kits in erythrocytes, plasma and varicose vein wall of 65 patients (second degree of clinical state classification, etiology, anatomy and pathophysiology) aged 22–70 (49 women, 16 men) in comparison to normal great saphenous vein walls collected from 10 patients who underwent coronary artery bypass graft and blood collected from 20 healthy individuals. Results A statistically significant decrease (p < 0.001) in superoxide dismutase activity in erythrocytes and the increase (p < 0.05) in superoxide dismutase activity in varicose vein has been observed. There have been no significant changes in the concentration of GSH in plasma and in varicose vein. The decreased concentration of total antioxidant status in plasma (p < 0.001) and in varicose vein wall (p < 0.05) in comparison to the control has been noticed. Conclusion The varicose vein patients are affected by oxidative stress. Our results indicate impaired antioxidant defense mechanism in the blood of varicose vein patients. In contrast to the blood, an increased process of antioxidant defense in the varicose vein wall was noticed.