Artery Coverage Research Articles

CXCL12 drives natural variation in coronary artery anatomy across diverse populations.

To efficiently distribute blood flow to cardiac muscle, the coronary artery tree must follow a specific branching pattern over the heart. How this pattern arises in humans is unknown due to the limitations of studying human heart development. Here, we leveraged a natural variation of coronary artery anatomy, known as coronary dominance, in genetic association studies to identify the first known driver of human coronary developmental patterning. Coronary dominance refers to whether the right, left, or both coronary arteries branch over the posterior left ventricle, but whether this variability is heritable and how it would be genetically regulated was completely unknown. By conducting the first large-scale, multi-ancestry genome-wide association study (GWAS) of coronary dominance in 61,043 participants of the VA Million Veteran Program, we observed moderate heritability (27.7%) with ten loci reaching genome wide significance. An exceptionally strong association mapped DNA variants to a non-coding region near the chemokine CXCL12 in both European and African ancestries, which overlapped with variants associated with coronary artery disease. Genomic analyses predicted these variants to impact CXCL12 levels, and imaging revealed dominance to develop during fetal life coincident with CXCL12 expression. Reducing Cxcl12 in mice to model the human genetics altered septal artery dominance patterns and caused coronary branches to develop away from Cxcl12 expression domains. Cxcl12 heterozygosity did not compromise overall artery coverage as seen with full deletion, but instead changed artery patterning, reminiscent of the human scenario. Together, our data support CXCL12 as a critical determinant of human coronary artery growth and patterning and lay a foundation for the utilization of developmental pathways to guide future precision 'medical revascularization' therapeutics.

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage

BackgroundClinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. MethodsThis single-center retrospective study included 812 open pancreaticoduodenectomies (2012–2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. ResultsThere were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12–0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1–20.3, P < .001) was predictive of this complication. ConclusionArterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.

Retromesenteric Omental Flap as Arterial Coverage in Pancreaticoduodenectomy: A Novel Technique to Prevent Post-pancreatectomy Hemorrhage

Retromesenteric Omental Flap as Arterial Coverage in Pancreaticoduodenectomy: A Novel Technique to Prevent Post-pancreatectomy Hemorrhage

Hospitalizations due to arterial hypertension and Family Health Strategy coverage: Brazil, 2010 to 2019

Enquadramento: A hipertensão arterial sistémica (HAS) é uma doença cardiovascular (DCV) que desencadeia internamento hospitalar. No Brasil, os internamentos por HAS são considerados sensíveis à atuação da Estratégia Saúde da Família (ESF), que organiza os seus processos de trabalho para o enfrentamento das condições crónicas, como a HAS. Objetivos: Analisar a tendência das taxas de internamento e verificar a relação entre as taxas de internamento e a cobertura da ESF no Brasil, de 2010 a 2019. Metodologia: Estudo ecológico de séries temporais, com dados do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS), de 2010 a 2019. Recorreu-se a regressão de Prais-Winsten e correlação de Pearson. Resultados: No período foram registados 793.198 internamentos. A taxa de internamento declinou de 58,7 para 29,6/100.000 habitantes, com variação anual de -16,3% (IC95% -21,8; -10,9). Conclusão: A correlação entre as taxas de internamento e a cobertura da ESF foi muito alta e inversamente proporcional (-0,98). As taxas de internamento seguiram tendência decrescente, o que pode refletir a melhoria do cuidado e do acesso aos serviços da ESF.

Spatial variation of hypertension treatment coverage in the municipality of Santiago, Chile

One of the tasks of primary health care is to achieve adequate treatment coverage for patients with arterial hypertension. The aim of this study was to analyze the spatial variation of hypertension treatment coverage in the municipality of Santiago de Chile in 2014, evaluating its relationship with the distance to primary health care establishments and socioeconomic factors using georeferencing techniques and global and geographically weighted Poisson regression models. According to the results, arterial hypertension treatment coverage shows spatial dependence, given that its relationship with the presence of older adults, the proportion of population enrolled, socioeconomic status and the distance to primary health care establishments varied spatially. It is concluded that in order to improve hypertension coverage it is necessary to consider different local realities, a process that can be facilitated by the application of spatial analysis techniques.

Abstract TP354: Trends in Stroke Severity and Incidence After Endovascular Repair for Descending Thoracic Aorta Diseases

Background: Perioperative stroke is a devastating complication after treatment of descending thoracic aorta disease (DTAD). As to whether developments in Thoracic Endovascular repair (TEVAR) influenced the overall stroke burden of patients with DTAD remains to be defined. This study investigated the current incidence and severity of procedure-related stroke in patients undergoing elective or emergency TEVAR. Methods: Patients with DTAD treated by TEVAR were questioned for perioperative stroke. Multivariable logistic regression models with backward variable selection were applied to investigate independent associations with perioperative stroke. Results: Between 2003-2015, 141 consecutive TEVAR (71.6% men;mean age 67.3+16.7years) were performed for DTAD: 58 (41.4%) were emergency procedures. The 30-day mortality was 9.2% (13/141) and 10 patients experienced procedure-related stroke. 30-day mortality was increased in patients with stroke: 23% vs. 5.5% (OR 5.2; 95%CI1.16-23.2;P=0.05). Stroke fatality was even more evident in elective repairs (P=0.049). Procedure-related stroke incidence was higher in emergency (13.3% vs. 2.6%;P=0-02), in procedures with left subclavian artery (LSA) coverage (21.4% vs. 3.5%;P=0.004) and in TEVAR performed before 2007 (15.6% vs 3.1%;P= 0.01). The relationship between increased stroke incidence and LSA coverage (35.7% vs. 6.5%;P=0.01) or procedure before 2007 (26.6% vs.5.1%;P=0.02) was particularly evident in TEVAR performed in emergency, while disappeared in elective repairs. Type of disease and age did not affect stroke risk. In multivariable regression, emergency of repair (OR,10.9; 95%CI,1.56-76.5; P=0.0.2), LSA coverage (OR,10.8; 95%CI 1.8-65.6;P=0.009) and procedure after 2007(OR 0.15; 95%CI 0.03-0.88;P=0.04) were confirmed as independently associated with procedure-related stroke as well as female sex (P=0.034). Conclusions: With developed technology the incidence of procedure-related stroke after TEVAR has declined. This trend was particularly achieved in emergency procedures where the prompt treatment may not allow for accurate planning. Nevertheless, stroke remains a devastating complication at high fatality risk for patients with DTAD even after elective TEVAR.

Mid-term results of endovascular treatment with the Gore TAG device for degenerative descending thoracic aortic aneurysms.

To confirm the validity of using Gore TAG for degenerative descending thoracic aneurysm repair, we evaluated the mid-term clinical outcomes in our single-center experience. From May 2008 to April 2011, elective thoracic endovascular aortic repair (TEVAR) with Gore TAG without left subclavian artery (LSA) coverage for a degenerative descending thoracic aneurysm was performed in 36 consecutive cases. The procedural success rate was 100%, and no patient died within 30 days of the operation. We observed no cases of paraplegia or stroke. The mean follow-up was 33.2 ± 13.0 months (the maximum follow-up was 58.0 months). The actuarial survival rate was 100, 97.2 and 94.4% at 1, 2 and 3 years. There was no aorta-related death at 3 years. Two (5.6%) late distal Type I endoleaks were observed. Freedom form aortic events rate was 97.2, 97.2, and 97.2% at 1, 2, and 3 years respectively. In six cases with bird-beak configurations at the 2-year follow-up, the bird-beak length and angle had increased gradually. Elective TEVAR using the Gore TAG for degenerative descending thoracic aortic aneurysms without LSA coverage is effective and provides satisfactory early and mid-term outcomes. However, since the bird-beak configurations progressed, a conformable and flexible device for the next generation of procedures will be needed.

Management of a Complicated Ruptured Infected Pseudoaneurysm of the Femoral Artery in a Drug Addict

Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed.

Outcome of Arterial Reconstruction and Free-Flap Coverage in Diabetic Foot Ulcers: Long-Term Results

Outcome of Arterial Reconstruction and Free-Flap Coverage in Diabetic Foot Ulcers: Long-Term Results

Does Clopidogrel Each Day Keep Stent Thrombosis Away?

THE POLYMER-BASED ELUTION OF ANTIPROLIFERATIVE medications from a metal stent prosthesis has been demonstrated to suppress neointimal proliferative response to stent-vessel injury and to reduce consequent late arterial lumen loss and restenosis. In randomized controlled trials, drug-eluting stents compared with bare-metal stents caused a 70% to 80% reduction in binary ( 50%) angiographic restenosis and a 50% to 70% reduction in repeat target lesion or vessel revascularization. Furthermore, comprehensive follow-up to 1 year demonstrated no evidence for any excess in the incidence of death, myocardial infarction (MI), or stent thrombosis for either treatment strategy. Thus, based on pivotal clinical trial evidence for both the relative safety and efficacy of drug-eluting stents, the US Food and Drug Administration approved both Cypher, the sirolimus-eluting stent, in 2002, as well as TAXUS, the paclitaxel-eluting stent device, in 2004. Subsequently, multiple other drug-eluting stent platforms have become available outside of the United States. Following approval of the sirolimus-eluting stent, sweeping adoption of this promising new technology into clinical practice occurred as it appeared that restenosis, the Achilles heel of bare-metal stenting, had finally been cured. Indeed, the pace of drug-eluting stent utilization outstripped any available clinical trial–based evidence for support, and drug-eluting stent deployment “off label” soon accounted for up to half of all use. However, some leaders questioned, “Should standard practice patterns undergo marked immediate changes when fewer than 2000 patients have been studied in 3 clinical trials?” In the initial US Food and Drug Administration panel discussionsprecedingapprovalof the sirolimus-elutingstent,however, a probing question was posed by a panel member, “What is the error level for a 1000 patient randomized study? Could we miss a 1% adverse outcome?” Indeed, with longer duration clinical follow-up in larger numbers of patients, an important observation has been made. The aggregate follow-up ofmultiple randomizedcomparative trialsofdrug-eluting stents vs bare-metal stents demonstrates a low frequency (approximately 0.5% absolute) relative increase in the incidence of very late stent thrombosis, which becomes evident only after 9 to 12 months and appears to extend to 3 to 4 years. The relative incremental risk approximates 0.2% per year (total increment 0.46%-0.57% through 3 years) for the types of patients included in these trials and appears similar for both drugeluting stent devices. Several postulates regarding pathogenesis of late stent thrombosis were proposed, with the most plausible being that the same drug/polymer combinations that effectively reduce instent smooth muscle cell hyperplasia may also cause slower, less complete arterial healing and endothelial coverage, as has been noted on both angioscopic and pathological examination. Beyond this, delayed endothelialization and healing due to polymer-related hypersensitivity, inflammation, or both, as well as acquired late incomplete stent apposition due to vessel positive remodeling in the stented arterial segment, have all been incriminated as potential causes of late drug-eluting stent thrombosis, particularly once combination antiplatelet therapy (aspirin plus thienopyridine) is discontinued. Indeed, discontinuation of clopidogrel within 30 days and even within 6 months following drug-eluting stent deployment has been associated with stent thrombosis, death, or both. The benefit of extending clopidogrel therapy beyond 6 months has been debated. News media reports have increased public awareness and generated serious concern about late drugeluting stent thrombosis. In this issue of JAMA, the article by Eisenstein and colleagues provides constructive information valuable to current and future patients treated with drug-eluting stents by examining the optimal duration of clopidogrel therapy following implantation of drug-eluting and bare-metal stents. The authors provide observations from consecutive patients who received either bare-metal stents (n=3165) or drug-eluting stents (n=1501) between January 1, 2000, and July 31, 2005, at Duke Heart Center. Landmark analyses were performed among patients who were event-free (no death,