Arterial Infiltration Research Articles

Association of T-cell subtypes with macrophage-specific arterial infiltration in people with HIV.

People with human immunodeficiency virus (HIV, PWH) face an increased risk of cardiovascular disease (CVD) compared to the general population. We previously demonstrated that people with (versus without) HIV have higher macrophage-specific arterial infiltration in relation to systemic monocyte activation. We now show that select T lymphocyte subpopulations (naïve CD4 + , effector memory CD4 + , and central memory CD8 + ) are differentially associated with macrophage-specific arterial infiltration among participants with versus without HIV, with evidence of interaction by HIV status. Our results suggest that among PWH, circulating T lymphocytes associate with macrophage-specific arterial infiltration, of relevance to atherogenesis and CVD risk.

Preoperative predictors for non-resectability in perihilar cholangiocarcinoma

IntroductionExplorative laparotomy without subsequent curative-intent liver resection remains a major clinical problem in the treatment of perihilar cholangiocarcinoma (pCCA). Thus, we aimed to identify preoperative risk factors for non-resectability of pCCA patients.Material and methodsPatients undergoing surgical exploration between 2010 and 2022 were eligible for the analysis. Separate binary logistic regressions analyses were used to determine risk factors for non-resectability after explorative laparotomy due to technical (tumor extent, vessel infiltration) and oncological (peritoneal carcinomatosis, distant nodal or liver metastases)/liver function reasons.ResultsThis monocentric cohort comprised 318 patients with 209 (65.7%) being surgically resected and 109 (34.3%) being surgically explored [explorative laparotomy: 87 (27.4%), laparoscopic exploration: 22 (6.9%)]. The median age in the cohort was 69 years (range 60–75) and a majority had significant comorbidities with ASA-Score ≥ 3 (202/318, 63.5%). Statistically significant (p < 0.05) risk factors for non-resectability were age above 70 years (HR = 3.76, p = 0.003), portal vein embolization (PVE, HR = 5.73, p = 0.007), and arterial infiltration > 180° (HR = 8.05 p < 0.001) for technical non-resectability and PVE (HR = 4.67, p = 0.018), arterial infiltration > 180° (HR = 3.24, p = 0.015), and elevated CA 19–9 (HR = 3.2, p = 0.009) for oncological/liver-functional non-resectability.ConclusionAdvanced age, PVE, arterial infiltration, and elevated CA19-9 are major risk factors for non-resectability in pCCA. Preoperative assessment of those factors is crucial for better therapeutical pathways. Diagnostic laparoscopy, especially in high-risk situations, should be used to reduce the amount of explorative laparotomies without subsequent liver resection.

Myocardial perfusion in cardiac amyloidosis.

Cardiac involvement is the main driver of clinical outcomes in systemic amyloidosis and preliminary studies support the hypothesis that myocardial ischaemia contributes to cellular damage. The aims of this study were to assess the presence and mechanisms of myocardial ischaemia using cardiovascular magnetic resonance (CMR) with multiparametric mapping and histopathological assessment. Ninety-three patients with cardiac amyloidosis (CA) (light-chain amyloidosis n = 42, transthyretin amyloidosis n = 51) and 97 without CA (three-vessel coronary disease [3VD] n = 47, unobstructed coronary arteries n = 26, healthy volunteers [HV] n = 24) underwent quantitative stress perfusion CMR with myocardial blood flow (MBF) mapping. Twenty-four myocardial biopsies and three explanted hearts with CA were analysed histopathologically. Stress MBF was severely reduced in patients with CA with lower values than patients with 3VD, unobstructed coronary arteries and HV (CA: 1.04 ± 0.51 ml/min/g, 3VD: 1.35 ± 0.50 ml/min/g, unobstructed coronary arteries: 2.92 ± 0.52 ml/min/g, HV: 2.91 ± 0.73 ml/min/g; CA vs. 3VD p = 0.011, CA vs. unobstructed coronary arteries p < 0.001, CA vs. HV p < 0.001). Myocardial perfusion abnormalities correlated with amyloid burden, systolic and diastolic function, structural parameters and blood biomarkers (p < 0.05). Biopsies demonstrated abnormal vascular endothelial growth factor staining in cardiomyocytes and endothelial cells, which may be related to hypoxia conditions. Amyloid infiltration in intramural arteries was associated with severe lumen reduction and severe reduction in capillary density. Cardiac amyloidosis is associated with severe inducible myocardial ischaemia demonstrable by histology and CMR stress perfusion mapping. Histological evaluation indicates a complex pathophysiology, where in addition to systolic and diastolic dysfunction, amyloid infiltration of the epicardial arteries and disruption and rarefaction of the capillaries play a role in contributing to myocardial ischaemia.

Abstract 12393: Pexidartinib Ameliorates Monocrotaline-Induced Pulmonary Arterial Hypertension in Rats

Background: Pulmonary arterial hypertension (PAH) is a life-threatening disease caused by pulmonary artery remodeling, inflammation, and altered immune responses. Lungs from PAH patients show that accumulation of perivascular macrophages is a key factor for the development of pulmonary artery remodeling, which leads to right ventricular failure. However, pharmacological inhibition of this pathway for treating PAH has not been thoroughly examined. Pexidartinib inhibits macrophage proliferation and polarization, thus can be a candidate for treating PAH. Objective: To investigate the effect of pexidartinib in PAH. Methods: Male Sprague-Dawley rats were divided into 4 groups: control, pexidartinib treated, monocrotaline (MCT)-exposed, pexidartinib treated and MCT-exposed rats. Right ventricular hemodynamic changes, right ventricular hypertrophy, and pulmonary artery morphological features were examined. Pulmonary artery perivascular macrophage infiltration was determined by immunofluorescence of CD68 and arginase-1 (M2 macrophage marker). Results: Immunofluorescence of lungs from MCT-exposed PAH rats showed perivascular CD68- and arginase-1-positive macrophage infiltration (P &lt; 0.05, each) and muscularization of pulmonary arteries (P &lt; 0.05) compared to controls. Treatment of pexidartinib inhibited perivascular CD68- and arginase-1-positive macrophage infiltration (P &lt; 0.05, each) and attenuated right ventricular systolic pressure and the right ventricle to the left ventricle plus septum ratio (RV/LV+IVS) in MCT-exposed PAH rats (Figure 1). Conclusion: Pexidartinib treatment prevented MCT-induced PAH and right ventricular hypertrophy by inhibiting perivascular macrophage infiltration and M2 macrophage polarization in rat pulmonary arteries. Therefore, pexidartinib may be a promising drug for the treatment of PAH.

Respect the Middle Lobe: Perioperative Risk of Bilobectomy Compared With Lobectomy and Pneumonectomy

BackgroundIn some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration may necessitate bilobectomy. Although the middle lobe is believed to represent a fraction of total lung function, the morbidity and mortality associated with bilobectomy is not well described. MethodsWe retrospectively identified patients in The Society of Thoracic Surgeons Database who underwent lobectomy, bilobectomy, or pneumonectomy for lung cancer from 2009 to 2017. The primary outcome was 30-day perioperative mortality. We performed propensity matching by patient demographics, comorbidities, and perioperative variables for each surgical type against bilobectomy and ran Cox proportional hazard models. Secondary outcomes of 30-day morbidity and mortality of upper vs lower bilobectomy were also compared. ResultsWithin the study period 2911 bilobectomy, 65,506 lobectomy, and 3370 pneumonectomy patients met the inclusion criteria. Patients undergoing pneumonectomy and bilobectomy had fewer comorbidities than lobectomy patients. After propensity matching 30-day mortality of bilobectomy was comparable with left pneumonectomy (hazard ratio [HR], 1.35; 95% CI, 0.95-1.91; P = .09) and significantly worse than left (HR, 0.40; 95% CI, 0.29-0.56; P < .0001) or right (HR, 0.43; 95% CI, 0.31-0.59; P < .0001) lobectomy. Bilobectomy was associated with a survival advantage compared with right pneumonectomy (HR, 2.54; 95% CI, 1.72-3.74; P < .0001). Thirty-day morbidity was higher for bilobectomy compared with lobectomy, and upper bilobectomy had a significant unadjusted 30-day mortality advantage compared with lower bilobectomy (98.3% vs 97%, P = .04). ConclusionsThe morbidity and mortality of bilobectomy is significantly worse than lobectomy and is comparable with left pneumonectomy. The addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during preoperative risk stratification.

Arterial Resection for Pancreatic Cancer: Feasibility and Current Standing in a High-Volume Center.

Arterial resection (AR) during pancreatectomy for curative R0 resection of pancreatic ductal adenocarcinoma (PDAC) remains a controversial procedure with high morbidity. To investigate the feasibility and oncological outcomes of pancreatectomy combined with AR at a high-volume center for pancreatic surgery. We retrospectively analyzed our experience in PDAC patients, who underwent pancreatic resection with AR and/or venous resection (VR) between 2007 and 2021. In total 259 PDAC patients with borderline resectable (n = 138) or locally advanced (n = 121) PDAC underwent vascular resection during tumor resection. From these, 23 patients had AR (n = 4 due to intraoperative injury, n = 19 due to suspected arterial infiltration). However, 12 out of 23 patients (52.2%) underwent simultaneous VR including 1 case with intraoperative arterial injury. In comparison, 11 patients (47.8%) underwent AR only including 3 intraoperative arterial injury patients. Although the operation time and bleeding rate of patients with AR were respectively longer and higher than in VR, no significant difference was detected in postoperative complications between VR and AR (P = 0.11). The final histopathological findings of PDAC patients were similar, including M stage, regional lymph node metastases, and R0 margin resection. The mortality of the entire cohort was 6.2% (16/259), with a tendency to increase mortality in the AR cohort, yet without statistical significance (VR: 5% vs AR: 21.1%; P = 0.05). Although 19 (82.6%) patients had PDAC in the final histopathology, only 6 were confirmed to have infiltrated arteria. The microscopic distribution of PDAC in these infiltrated arterial walls on hematoxylin-eosin staining was classified into 3 patterns. Strikingly, the perivascular nerves frequently exhibited perineural invasion. AR can be performed in high-volume centers for pancreatic surgery with an acceptable morbidity, which is comparable to that of VR. However, the likelihood of arterial infiltration seems to be rather overestimated, and as such, AR might be avoidable or replaced by less invasive techniques such as divestment during PDAC surgery.

Characteristics of Renal Intravascular Large B-cell Lymphoma

Renal intravascular large B-cell lymphoma (IVLBCL) is a rare, aggressive B-cell lymphoma with neoplastic cells occupying the vascular lumina with only 53 patients reported to date. Here, we present the largest case series to characterize this rare disease. We performed a multi-institutional, retrospective review of kidney biopsies and autopsies with a diagnosis of kidney IVLBCL and report our findings. We identified 20 patients with an average age of 65.7 ± 7.8 years (55% males) with IVLBCL on kidney biopsy. The most common clinical presentation was fever and anemia. Acute kidney injury (AKI) was noted in 70% to 90%, proteinuria in 70% to 84.1%, hematuria in 45%, and nephrotic-range proteinuria in 10% to 26.1% of cases. The median (interquartile range) of serum creatinine was 1.75 (1.14, 3.3) mg/dl. Neoplastic lymphoid cells were present in glomeruli, peritubular capillaries, and arteries or veins. Of the patients, 44.3% showed extrarenal infiltration into bone marrow, liver, spleen, central vervous system, lung and skin. Neoplastic cells express CD20, CD79a, PAX-5, and MUM1+, and were CD10-negative. Available follow-up data showed a median survival of 21 months after diagnosis. Extrarenal involvement is a significant and independent predictor of mortality with a hazard ratio of 4.975 (95% confidence interval:1.38, 17.88) after controlling for age and gender. Serum creatinine, age, sex, and infiltration of intrarenal arteries or veins did not affect survival. Kidney IVLBCL is a rare disease that is unexpectedly diagnosed by kidney biopsy, presenting with fever, anemia, mild AKI, and proteinuria. Median survival is 21 months and extrarenal involvement is associated with worse outcome.

Myocardial ischaemia in cardiac amyloidosis: a change of perspective

Abstract Introduction Cardiac involvement is the main driver of clinical outcomes in systemic amyloidosis; however many clinical observations are not explained by the concept of replacement of the interstitium by amyloid material. Preliminary studies support the hypothesis that myocardial ischaemia contributes to cellular damage. Purpose This study assesses the presence and mechanisms of myocardial ischaemia using cardiovascular magnetic resonance (CMR) with multiparametric mapping and histopathological assessment. Methods Ninety-two patients with cardiac amyloidosis (CA) (AL = 41, ATTR = 51) and 97 without CA (3-vessel coronary disease (3VD) = 47, unobstructed coronary arteries = 26, healthy volunteers (HV) = 24) underwent quantitative stress perfusion CMR with myocardial blood flow (MBF) mapping. Twenty-six myocardial biopsies and 3 explanted hearts with CA were analysed histopathologically. Results Stress MBF was severely reduced in patients with CA with lower values than patients with 3VD, unobstructed coronary arteries and HV (CA = 1.03±0.51 ml/min/g, 3VD = 1.35±0.50 ml/min/g, Unobstructed coronaries = 2.92±0.52 ml/min/g, HV = 3.14±0.69 ml/min/g; CA vs 3VD p=0.008, CA vs Unobstructed coronaries p&amp;lt;0.001, CA vs HV p&amp;lt;0.001). After adjustment for intracellular volume the MBF in patients with CA remained significantly lower than in HV (stress MBF/ICV: AL = 2.24±1.12, ATTR = 2.22±0.93, HV = 4.38±1.06; AL vs. ATTR p=1.000, AL vs HV p&amp;lt;0.001, ATTR vs. HV p&amp;lt;0.001). Myocardial perfusion reserve (MPR) was severely reduced in CA patients, compared to HV and patients with unobstructed coronary arteries, with the degree of reduction being comparable only to patients with 3VD (CA = 1.55±0.60, 3VD = 1.54±0.51, unobstructed coronaries = 2.78±0.70, HV = 4.08±0.86; CA vs 3VD p=1.000, CA vs unobstructed coronary arteries p&amp;lt;0.001, CA vs. HV p&amp;lt;0.001). Myocardial perfusion abnormalities correlated with amyloid burden, systolic and diastolic function, structural parameters and blood biomarkers (p&amp;lt;0.05). Biopsies demonstrated diffuse hypoxia with abnormal VEGF staining in cardiomyocytes and endothelial cells. Amyloid infiltration in intramural arteries was associated with severe lumen reduction in 20% of vessels, and severe reduction in capillary density. Conclusion CA is associated with severe myocardial ischaemia demonstrable by histology and CMR stress perfusion mapping. Histological evaluation indicates a complex pathophysiology, where systolic and diastolic dysfunction, amyloid infiltration of the epicardial arteries and disruption and rarefaction of the capillaries play a role in contributing to myocardial ischaemia. Funding Acknowledgement Type of funding sources: None.

Increased Macrophage-Specific Arterial Infiltration Relates to Noncalcified Plaque and Systemic Immune Activation in People With Human Immunodeficiency Virus.

Persistent immune activation is thought to contribute to heightened atherosclerotic cardiovascular disease (ASCVD) risk among people with human immunodeficiency virus (PWH). Participants (≥18 years) with or without human immunodeficiency virus (HIV) and without history of clinical ASCVD were enrolled. We hypothesized that increased macrophage-specific arterial infiltration would relate to plaque composition and systemic immune activation among PWH. We applied a novel targeted molecular imaging approach (technetium-99m [99mTc]-tilmanocept single photon emission computed tomography [SPECT]/CT) and comprehensive immune phenotyping. Aortic 99mTc-tilmanocept uptake was significantly higher among PWH (n = 20) than participants without HIV (n = 10) with similar 10-year ASCVD risk (P = .02). Among PWH, but not among participants without HIV, noncalcified aortic plaque volume related directly to aortic 99mTc-tilmanocept uptake at different uptake thresholds. An interaction (P = .001) was seen between HIV status and noncalcified plaque volume, but not calcified plaque (P = .83). Systemic levels of caspase-1 (P = .004), CD14-CD16+ (nonclassical/patrolling/homing) monocytes (P = .0004) and CD8+ T cells (P = .005) related positively and CD4+/CD8+ T-cell ratio (P = .02) inversely to aortic 99mTc-tilmanocept uptake volume. Macrophage-specific arterial infiltration was higher among PWH and related to noncalcified aortic plaque volume only among PWH. Key systemic markers of immune activation relating to macrophage-specific arterial infiltration may contribute to heightened ASCVD risk among PWH. NCT02542371.

109MO Respect the middle lobe: Perioperative survival of bilobectomy compared to lobectomy and pneumonectomy

In some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration may necessitate bilobectomy. Although the middle lobe is thought to represent only a small fraction of the total right lung function, the morbidity and mortality associated with bilobectomy in comparison to other pulmonary resections is not well described. We retrospectively identified patients in the Society for Thoracic Surgeons General Thoracic Surgery Database who underwent elective lobectomy, bilobectomy, or pneumonectomy for lung cancer from 2009 to 2017, excluding reoperations. The primary outcome was 30-day perioperative mortality. Cox proportional hazards were calculated after adjusting for patient demographics, comorbidities, and perioperative variables. Secondary outcomes included 30-day morbidity, mortality of upper versus lower bilobectomy, and rate of nodal upstaging or downstaging. Within the study period, 2,911 bilobectomy, 65,506 lobectomy, and 3,024 pneumonectomy patients met inclusion criteria. Patients undergoing pneumonectomy and bilobectomy had fewer comorbidities than lobectomy patients. Both unadjusted and adjusted 30-day mortality of bilobectomy were comparable to a left pneumonectomy, which was worse than left or right lobectomy but better than right pneumonectomy (Table). Bilobectomy had consistently worse 30-day morbidity than lobectomy. Upper bilobectomy had a small but significant unadjusted 30-day survival advantage compared to lower bilobectomy (98.3% vs 97%, log-rank p=0.04). Nodal upstaging of bilobectomy (22.8%) fell between that of lobectomy and pneumonectomy.Table: 109MOAdjusted 30-day Cox proportional hazards and absolute mortalityCox proportional hazardHR95% CIpAbsolute mortalityBilobectomyref--2.6%Left lobectomy0.440.34-0.56<0.00011.0%Right lobectomy0.470.36-0.60<0.00011.1%Left pneumonectomy1.320.95-1.850.103.5%Right pneumonectomy2.762.01-3.81<0.00017.0% Open table in a new tab The morbidity and mortality of bilobectomy is significantly worse than lobectomy and is comparable to the outcomes of left pneumonectomy. The addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during pre-operative risk stratification.

Can local ablative techniques replace surgery for locally advanced pancreatic cancer?

In the treatment of pancreatic ductal adenocarcinoma (PDAC) the best chance at long term survival or cure has to date always included the complete surgical removal of the tumor. However, locally advanced pancreatic cancer (LAPC), about 25% of all newly diagnosed PDAC, is defined by its primary technical unresectability due to infiltration of visceral arteries and absence of metastasis. Induction therapies, especially FOLFIRINOX treatment, together with technical surgical advancement have increased the numbers for conversion to secondary resectability. Recent data on resections after induction therapy show promising, almost doubled survival compared to palliative treatment. Yet, around 70% of LAPC remain unresectable after induction therapy, often due to persistent local invasion. As locally ablative techniques are becoming more widely available this review examines their possible applicability to substitute for surgery in these cases which we propose to group under the new term "Inconvertible LAPC". The need for defining this novel subgroup who might benefit from ablative treatment is based on the findings in our review that high-level evidence on ablative techniques for PDAC is largely lacking and the latest effective, harmonized treatment guidelines for LAPC are not often incorporated in these studies. The "inconvertible LAPC" label requires persistent unresectability after staging and induction therapy of LAPC according to current guidelines followed by liberal indication for aggressive surgical exploration at a center equipped for extended pancreatic resections. Ideally, this specification of a new, distinct patient group will also put it in the spotlight more, hopefully prompt more trials designed to generate robust evidence and optimize transferability of study results.

Investigating the forensic pathological characteristics of systemic vasculitis: A retrospective study of 20 deaths caused by systemic vasculitis

Systemic vasculitis (SV) is a condition characterized by vascular inflammatory disease that often involves the medium and small arteries of various organs throughout the body. SV is difficult to diagnose due to the diversity of clinical symptoms and manifestations, and only tissue biopsy is of great significance. Even so, complications or secondary lesions of SV can also lead to death. In forensic medicine, we can often observe multiple vasculitis in histological observations, which is easily overlooked as a primary cause of death in the final diagnosis. Twenty SV cases were registered in our institution from a total of 1088 completed autopsies, which represents 1.83% of the total autopsies. The ages of these 20 SV patients ranged from 16 to 73 years, and the mean age was 41.1 ± 15.9 years. SV usually involves multiple organs, such as the heart, lung, liver, kidney, gastrointestinal system and brain, simultaneously. The intensity of the lesions in the heart and kidney seemed to be more severe than the lesion intensity in other organs in most cases. The causes of death were identified as acute myocarditis (8 cases), acute heart failure (3 cases), cerebral artery rupture (3 cases), cardiovascular artery rupture (2 cases), acute interstitial pneumonia (2 cases), aortic aneurysm rupture (1 case) and acute renal failure (1 case). The typical histopathological changes (smooth muscle degeneration, fibrinoid necrosis, inflammatory cell infiltration and microthrombosis) of arteries observed in this study were of great significance for diagnosing SV. In this article, we try to analyse and summarize the lesion characteristics in cases of death caused by SV in order to provide some help for forensic workers in identifying such cases.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

BackgroundPancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.Case presentationA 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m2) plus nab-paclitaxel (125 mg/m2) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m2/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).ConclusionFor locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

Pancreatectomy Combined with Arterial Resection for Pancreatic Carcinoma with Arterial Infiltration: A Meta-analysis

Pancreatic carcinoma (PC) easily invades the peripancreatic arteries, which is the main reason for the poor prognosis. This meta-analysis aimed to investigate the perioperative outcomes and long-term survival of pancreatectomy combined with arterial resection (AR) in PC patients with arterial infiltration. We searched the Medline, EMbase, and Cochrane Library and used the Review Manager 5.3. A total of 11 studies were reviewed, including 1829 patients who underwent pancreatectomy or palliative therapies, of whom 205 received AR. The results showed that AR was associated with a longer operation time (MD = 87.05, P < 0.00001), higher blood loss (MD = 422.73, P < 0.00001), and an increased risk for overall complication (OR = 2.10, P < 0.0001), postpancreatectomy hemorrhage (PPH) (OR = 3.32, P = 0.003), and reoperation (OR = 2.38, P = 0.001). The occurrence of postoperative pancreatic fistula (POPF) (OR = 1.66, P = 0.05), delayed gastric emptying (DGE) (OR = 2.15, P = 0.13), and perioperative mortality (OR = 1.94, P = 0.06) seemed higher in AR group. Pancreatectomy with AR showed a better survival at 1 year (OR = 1.55, P = 0.05), 3 years (OR = 1.78, P = 0.04), and 5 years (OR = 3.24, P = 0.03). Therefore, we concluded that pancreatectomy with AR could be conducted under the comprehensive consideration of patients’ conditions, and it may be especially beneficial for those who have the probability to achieve R0 resection.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

The surgical outcomes of borderline resectable or locally advanced pancreatic cancer.

691 Background: Advances in multidisciplinary treatment for pancreatic cancer (PC) have increased surgical opportunities for initially unresectable locally advanced (UR-LA) or borderline resectable PC. In order to obtain a high rate of R0 resection, it is important to select an appropriate approach according to the infiltration site of the artery that can determine whether curative surgery is possible or not at early phase of the operation. Methods: From April 2012 to December 2018, 81 patients who were scheduled for curative resection for UR-LA or borderline resectable PC that contact the main artery (BR-A). In our institution, if a tumor is in contact with the superior mesenteric artery (SMA), we select the mesenteric approach. And if a tumor is in contact with the common hepatic artery (CHA) and/or celiac artery (CA), we open the lesser omentum and then dissect from the cranial side of pancreas to the diaphragm leg to judge the resectability before dividing the stomach. When arterial plexus infiltration is observed during surgery, we abandoned curative surgery or we performed combined resection of CHA and reconstruction if possible. Results: There were 69 BR-A and 12 UR-LA patients. Macroscopic curative resection was performed in 67 (83%) of 81 patients, and 14 patients were unresectable. Pancreatoduodenectomy was performed in 54 patients, distal pancreatectomy (DP) in 8, and DP with celiac axis resection in 7. There were 67 patients with vascular resection / reconstruction. R0 resection was obtained in 64 of 67 patients among curative resection. The median blood loss, operation time, and length of hospital stay were 714 mL, 439 minutes, and 19 days, respectively. The complications of Clavien-Dindo grade 3a or higher were observed in 18 patients (27%). There were no post-operative deaths. The 3-year survival rate after surgery was 70.3%, and there was no significant difference between BR-A and UR-LA (P = 0.701). The 3-year recurrence-free survival rate after surgery was 34.4%, which was not significantly different between the two groups (P = 0.816). Conclusions: A high R0 resection rate (96%) was obtained by an appropriate approach that can determine the resectability at early stage of operation, and high R0 rate leads to good outcomes.

Uterus transplant graft's arterial atherosclerotic remodeling veracity.

Background:Uterus transplantation is a complex, multi-step experimental procedure used for the treatment of uterus absence or uterus anomaly that prevents embryo implantation or pregnancy completion.Method:To date, only 51 uterus transplants worldwide had been performed. When simplified, it is vascularized composite allograft transplantation. While it is still an experimental procedure with encouraging results for the future, there are still many issues that have to be clarified. The most serious complications of uterus transplantation are graft rejection or grafts vascular failure.Results:So far, no reference to the atherosclerotic arterial infiltration of the uterus arteries was suggested and studied as one of the main causes of graft's failure.Conclusion:In this review we summarized current knowledge and possible role of uterus arterial damage, including atherosclerotic changes on the graft's survival.

Pathomorphology of cats with myocardial infectious peritonitis

The article presents the results of macroscopic and microscopic examinations of myocardial cats in wet and mixed forms of FIP. A pathoanatomical study of 19 cat carcasses, aged from 3 months to 7 years, was diagnosed with infectious peritonitis during life (on the basis of anamnesis, clinical features, morphological and biochemical blood test, ultrasound, Rivalt test and FCVetx rapid test VetE.) All animals were kept at home. For the microstructural study, samples of cats' hearts were selected, which were fixed in 10% aqueous formalin neutral solution, Carnua, Buen solutions and 96 ° ethyl alcohol. Histogram sections were stained with hematoxylin and eosin staining, picrofuxin (Van Gizon), PAS reaction (McManus), methyl green pyronin (Brache), Malory, and examined under a microscope. Histological examination of the cardiac muscle of cats in various forms of infectious peritonitis revealed changes of non-inflammatory and inflammatory nature. In the exudative form, non-inflammatory processes prevailed. In the myocardium, the most severe changes occurred in the capillaries, the walls of the arterial vessels and the stroma, which were characterized by diapedic hemorrhage, mucoid and fibrinoid swelling and necrosis of the walls of the arterioles. Disorganization of connective tissue was accompanied by stratification of connective tissue fibers and impregnation of weakly oxyphilic, PAS-positive compounds of the intermuscular lumen, which was combined with dystrophic changes in cardiomyocytes. In the mixed form, proliferative-destructive vasculitis, diffuse or focal lymphoid-histiocytic infiltrates in the myocardium prevail. The revealed optical changes in the structural elements of the heart indicated a sharp weakening of the contractile function of cardiomyocytes and heart failure. In addition, it should be noted that the characteristic morphological manifestation for immunocomplex diseases is the development of vasculitis, which is preceded by fibrinoid necrosis of the walls of the arterial vessels and intensive infiltration of their circulatory elements, and these changes occurred in infectious peritonitis of cats.

Endovascular Catheter Biopsy for the Diagnosis of Pulmonary Artery Sarcoma.

The diagnosis of pulmonary artery sarcoma (PAS) is challenging, and its definitive diagnosis is mainly confirmed using specimens obtained during surgery or autopsy. Endovascular catheter biopsy was performed in five patients with suspected PAS to establish a definitive diagnosis. Aspiration biopsy was performed in all patients, and forceps biopsy was performed in one patient. Three patients were diagnosed with PAS, and no definitive diagnosis was obtained in two patients with squamous cell lung carcinoma with pulmonary artery infiltration. Endovascular catheter biopsy is helpful in the diagnosis of PAS and should be performed when a tumor is suspected.

Pancreatic cancer surgery with vascular resection: current concepts and perspectives

Abstract Pancreatic cancer is a devastating disease and resection at an early disease stage is the best chance of cure. Less than 20% of all patients present with a resectable tumor, while another 20% to 30% have locally advanced pancreatic cancer and the majority of the patient suffer from metastatic disease. Recently, it has been recognized that there is a 4th group of patients with so-called borderline resectable disease. Here, the tumor approaches or infiltrates the vascular axis (superior mesenteric vein/portal vein and/or superior mesenteric/hepatic artery/celiac trunk). While a large number of tumors with suspected venous infiltration can be resected with concomitant venous resection and reconstruction, arterial infiltration has been considered a contraindication to resection. Neoadjuvant treatment with combination chemotherapy protocols with or without radiotherapy has allowed for higher resection rates even in patients with arterial invasion. Here, we review the contemporary literature on extensive pancreatic cancer surgery with vascular resection and reconstruction.