Maintain Blood Flow Research Articles

Contralateral Carotid Occlusion With Sufficient Circle of Willis is not Associated With A Higher Incidence of Neurologic Events During Carotid Endarterectomy Without Shunting

Introduction: Whereas large studies identified that contralateral carotid occlusion (CCO) has higher perioperative stroke risk in patients who underwent carotid endarterectomy (CEA), single-center studies have not confirmed this. Circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of the CCO in association with CoW on immediate neurological event (INE) after CEA without shunt protection. Methods: We reviewed the clinical data and outcomes of 114 patients (80 males mean age 65.9±8.7 years) who underwent CEA with CCO under general anesthesia between 01.01.2013 and 30.06.2018. Patients who had CEA with shunt (46) and with inadequate intracranial imaging (16) were excluded. Indications were asymptomatic (75%) and symptomatic (25%) carotid artery disease. CTAs were reviewed independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW. Segments were classified as normal, hypoplastic (diameter ˂ 1mm) or absent. CoW was assessed for short semicircle (ipsilateral P1 and Pcom) and long (from the contralateral P1 to the ipsiA1) semicircles considered as sufficient if there were normal segments between the basilar and the ipsilateral middle cerebral artery (MCA). INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. Results: Of the 52 included patients only two had a stroke (3.8%) in the postoperative period. From the two strokes one was immediate after the surgery. In addition of this stroke there were 3 immediate TIAs giving the 4 (7.7%) INE. Only one third of this study population (n=18; 34%) had normal, 17 patients (33%) had at least one hypoplastic segments and other 17 (33%) had missing segments between the clamped carotid and the basilar artery - short semicircle. There was no neurologic event with normal short semicircle. From the 4 INE two patients had hypoplastic and two had absent short semicircle. In all INE cases the other, long semicircle was insufficient as well. Conclusion: Contralateral carotid occlusion carries insignificant risk of INE or stroke after CEA with cross-clamping without shunt protection, when CoW collateral flow support is sufficient. In patients with CCO shunting is recommended when the collateral flow between the ipsilateral MCA and the basilar artery is compromised. Disclosure: Nothing to disclose

Extreme bradycardia and tachycardia in the world’s largest animal

The biology of the blue whale has long fascinated physiologists because of the animal's extreme size. Despite high energetic demands from a large body, low mass-specific metabolic rates are likely powered by low heart rates. Diving bradycardia should slow blood oxygen depletion and enhance dive time available for foraging at depth. However, blue whales exhibit a high-cost feeding mechanism, lunge feeding, whereby large volumes of prey-laden water are intermittently engulfed and filtered during dives. This paradox of such a large, slowly beating heart and the high cost of lunge feeding represents a unique test of our understanding of cardiac function, hemodynamics, and physiological limits to body size. Here, we used an electrocardiogram (ECG)-depth recorder tag to measure blue whale heart rates during foraging dives as deep as 184 m and as long as 16.5 min. Heart rates during dives were typically 4 to 8 beats min-1 (bpm) and as low as 2 bpm, while after-dive surface heart rates were 25 to 37 bpm, near the estimated maximum heart rate possible. Despite extreme bradycardia, we recorded a 2.5-fold increase above diving heart rate minima during the powered ascent phase of feeding lunges followed by a gradual decrease of heart rate during the prolonged glide as engulfed water is filtered. These heart rate dynamics explain the unique hemodynamic design in rorqual whales consisting of a large-diameter, highly compliant, elastic aortic arch that allows the aorta to accommodate blood ejected by the heart and maintain blood flow during the long and variable pauses between heartbeats.

ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow?

While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.

Acetyl-11-keto-β-boswellic acid (AKBA) Attenuates Oxidative Stress, Inflammation, Complement Activation and Cell Death in Brain Endothelial Cells Following OGD/Reperfusion.

Brain endothelial cells play an important role in maintaining blood flow homeostasis in the brain. Cerebral ischemia is a major cause of endothelial dysfunction which can disrupt the blood-brain barrier (BBB). Oxygen-glucose deprivation (OGD)/reperfusion promote cell death and BBB breakdown in brain endothelial cells. Acetyl-11-keto-β-boswellic acid (AKBA), a biologically active phytoconstituent of the medicinal plant Boswellia serrata, has been shown to be protective against various inflammatory diseases as well as ischemic brain injury. The molecular mechanisms underlying these beneficial characteristics of AKBA are poorly understood. We subjected bEND.3 cells to OGD/reperfusion to investigate the protective role of AKBA in this model. We found that AKBA treatment attenuated endothelial cell death and oxidative stress assessed by means of TUNEL assay, cleaved-caspase-3, and dihydroethidium (DHE) staining. Furthermore, OGD downregulated tight junction proteins ZO-1 and Occludin levels, and increased the expressions of inflammatory cytokines TNF-α, ICAM-1, and complement C3a receptor (C3aR). We also noticed the increased phosphorylation of ERK 1/2 in bEND.3 cells in OGD group. AKBA treatment significantly attenuated expression levels of these inflammatory proteins and prevented the degradation of ZO-1 and Occludin following OGD. In conclusion, AKBA treatment provides protection against endothelial cell dysfunction following OGD by attenuating oxidative stress and inflammation.

Abstract P1120: Opioids Induce Proliferation in Vascular Smooth Muscle Cells Leading to an Increase in Myogenic Tone in Resistance Arteries

The United States of America is currently undergoing an opioid crisis. According to the 2018 CDC Annual Surveillance Report of Drug Related Risks and Outcomes there were 78,840 hospitalizations and an estimated 140,077 emergency room visits for opioid related poisonings in 2015 alone. It has been shown that opioid exposure increases vascular age relative to chronological age. Further, long-term abuse of opioids leads to changes in regional cerebral blood flow. However, there is a lack of understanding about acute and chronic opioid abuse and how it affects microvasculature structure and function; specifically on myogenic tone, a fundamental mechanism to maintain blood flow to important tissues including the brain, kidneys, and more. We hypothesize that opioids cause an increase in proliferation of vascular smooth muscle cells (VSMC) leading to an increase in myogenic tone in mesenteric resistance arteries. To test this hypothesis, aortic vascular smooth muscle cells were cultured and treated with the endogenous opioid (ENO) beta-endorphin or the exogenous opioid (EXO) morphine. ENO treatment increased cellular proliferation with chronic exposure (greater than 72 hours). We measured a maximum proliferation at 120 hours and performed 2 way ANOVA with Bonferroni posttests [confluence (%): DMSO vehicle 20.4 ± 4.8, 1 nM 34.9 ± 7.4*, and 1 μM 29.9 ± 7.0; * p<0.05]. Increased proliferation was also demonstrated in cells treated with EXO. We measured a maximum proliferation at 120 hours and performed 2 way ANOVA with Bonferroni posttests [confluence (%): DMSO vehicle 20.4 ± 4.8, 1 nM 32.6 ± 9.0, 1μM 33.3 ± 10.2*, and 10 μM 29.7 ± 4.4; * p<0.05]. We also observed that when acutely exposing mesenteric resistance arteries to EXO (1.0 μM) there was a left shift in myogenic tone to 80 mmHg as opposed to 100 mmHg in the in absence of EXO. In conclusion, our results suggest that chronic exposure to ENO and EXO increase VSMC proliferation. Further, acute exposure to EXO was able to increase myogenic tone in resistance arteries. This suggests that opioid dependence could contribute to the development of peripheral vascular disorders such as hypertension.

Stent graft fenestration for establishing and maintaining blood flow in the side branch

Stent graft fenestration for establishing and maintaining blood flow in the side branch

Effect of Baduanjin exercise on patients with chronic heart failure: protocol for a systematic review and meta-analysis

IntroductionChronic heart failure (CHF) is defined when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs, and it is caused by various cardiopulmonary...

Comparison of nitric oxide levels in patients undergoing surgery in absence and deliverance of blood transfusion in association with hemoglobin

Blood transfusion has an important role in patients undergoing surgery. However, besides providing sufficient amounts of oxygen, blood transfusion should protect the safety of blood recipients too. Hemoglobin (Hb) is the most abundant intra-erythrocytic protein and reacts rapidly with nitic oxide (NO), the endothelium-derived relaxing factor that maintains blood flow and oxygen transport to tissues. The interaction of NO and Hb have been found to have unavoidable consequences. Clinical factors play an important role in the decision of transfusion if otherwise avoidable. Keywords: Blood transfusion, Nitric oxide, Hemoglobin.

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. Part 2: how to perform BASILICA.

Coronary obstruction is a life-threatening complication of transcatheter aortic valve replacement. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) seems to be an effective approach for preventing coronary obstruction by maintaining blood flow towards the coronary artery by an intentionally created leaflet laceration. In this report, we aimed to provide step-by-step guidance on how to perform a BASILICA procedure. The technique includes several steps that can be challenging without proper guidance. Assistance by operators who have already performed BASILICA seems to be crucial, and formal proctorship during initial procedures can ensure good clinical outcomes.

Functional Interaction among KCa and TRP Channels for Cardiovascular Physiology: Modern Perspectives on Aging and Chronic Disease.

Effective delivery of oxygen and essential nutrients to vital organs and tissues throughout the body requires adequate blood flow supplied through resistance vessels. The intimate relationship between intracellular calcium ([Ca2+]i) and regulation of membrane potential (Vm) is indispensable for maintaining blood flow regulation. In particular, Ca2+-activated K+ (KCa) channels were ascertained as transducers of elevated [Ca2+]i signals into hyperpolarization of Vm as a pathway for decreasing vascular resistance, thereby enhancing blood flow. Recent evidence also supports the reverse role for KCa channels, in which they facilitate Ca2+ influx into the cell interior through open non-selective cation (e.g., transient receptor potential; TRP) channels in accord with robust electrical (hyperpolarization) and concentration (~20,000-fold) transmembrane gradients for Ca2+. Such an arrangement supports a feed-forward activation of Vm hyperpolarization while potentially boosting production of nitric oxide. Furthermore, in vascular types expressing TRP channels but deficient in functional KCa channels (e.g., collecting lymphatic endothelium), there are profound alterations such as downstream depolarizing ionic fluxes and the absence of dynamic hyperpolarizing events. Altogether, this review is a refined set of evidence-based perspectives focused on the role of the endothelial KCa and TRP channels throughout multiple experimental animal models and vascular types. We discuss the diverse interactions among KCa and TRP channels to integrate Ca2+, oxidative, and electrical signaling in the context of cardiovascular physiology and pathology. Building from a foundation of cellular biophysical data throughout a wide and diverse compilation of significant discoveries, a translational narrative is provided for readers toward the treatment and prevention of chronic, age-related cardiovascular disease.

Heterogeneity and Variability in Pressure Autoregulation of Organ Blood Flow: Lessons Learned Over 100+ Years.

Pressure autoregulation is an organ's intrinsic ability to maintain blood flow despite changes in perfusion pressure. The purpose of this review is to discuss autoregulation's heterogeneity among different organs and variability under different conditions, a very clinically relevant topic. Systematic search of Ovid MEDLINE; nonsystematic search of PubMed, Google Scholar, and reference lists. Animal or human studies investigating the potency or variation of pressure autoregulation of any organs or the association between autoregulation and outcomes. Two authors screened the identified studies independently then collectively agreed upon articles to be used as the basis for this review. Study details, including subjects, organ investigated, methods of blood pressure intervention and blood flow measurement, and values of the lower limit, upper limit, and plateau were examined. Comparative canine studies were used to demonstrate the heterogeneity of pressure autoregulation among different organs and validate the proposed scale for organ categorization by autoregulatory capacity. Autoregulatory variability is discussed per organ. The association between cerebral autoregulation and outcome is summarized. The organs with robust autoregulation are the brain, spinal cord, heart, and kidney. Skeletal muscle has moderate autoregulation. Nearly all splanchnic organs including the stomach, small intestine, colon, liver, and pancreas possess weak autoregulation. Autoregulation can be readily affected by a variety of clinically relevant factors. Organs with weak or weakened autoregulation are at a greater risk of suboptimal perfusion when blood pressure fluctuates. Cerebral autoregulation and outcomes are closely related. These lessons learned over 100+ years are instructive in clinical care.

Carotid Endarterectomy: The Need for In vivo Optical Spectroscopy in the Decision-Making on Intraoperative Shunt Usage - A Technical Note.

Background:Carotid endarterectomy (CEA) is the surgical excision of the atherosclerotic plaque in patients with severe carotid artery stenosis. It is a common surgical technique required by neurosurgeons that should be mastered. In this article, we provide an outline of the technique and multimodality adjuncts involved in performing an effective CEA with a better surgical outcome.Materials and Methods:We have operated a total of 14 patients in our institute from 2015 to 2018. The male to female ratio is 13:1. Four (28.5%) patients were symptomatic and 10 (71.5%) were asymptomatic; with an average percentage of carotid stenosis being 81.2% in symptomatic and 76.6% in asymptomatic patients. Two patients have undergone bilateral CEA. Intraoperative monitoring was done with continuous in vivo optical spectroscopy (INVOS). Furui's double balloon shunt system was used to maintain blood flow from common carotid artery to the internal carotid artery, thus preventing cerebral ischemia in selected cases with significantly lateralized cerebral oximetry (CO) recordings.Results:Of the 14 patients with 16 CEA procedures, continuous INVOS monitoring was used in 12 CEA procedures. Of the 12 cases, only 5 (41.6%) needed a shunt. Furui's shunt was not used in 7 (58.3%) CEA procedures, where there were no changes in the intraoperative CO and these patients had an uneventful postoperative period. INVOS monitoring not only reduced the use of routine intraoperative shunt but also reduced the total surgical time and thus aided in preventing neurological complications.Conclusion:CEA should be strongly considered for symptomatic patients with >70% of carotid stenosis and in patients with 50%–69% stenosis if no other etiological basis for the ischemic symptoms can be identified. Continuous INVOS monitoring is mandatory for the decision of the use of intraoperative shunt, which reduces the perioperative morbidity and mortality significantly.

Comparison between intracranial collaterals and cerebral hemodynamics in patients with extracranial carotid stenosis versus combined extra- and intracranial stenosis using transcranial duplex

BackgroundIn acute ischemic stroke, collateral circulation plays an important role in maintaining blood flow to the tissue that is at risk of progressing into ischemia, and in increasing the successful recanalization rate without hemorrhagic transformation.ObjectivesTo compare between collaterals in patients with extracranial carotid stenosis alone and in patients having both extracranial and intracranial carotid stenosis and therefore the difference in prognosis between them.Materials and methodsA total of 30 patients of acute ischemic stroke were enrolled. The extracranial part of the carotid artery was assessed with color-coded duplex. Transcranial color-coded duplex was done to assess cerebral hemodynamics and collaterals to differentiate between extracranial significant carotid stenosis alone versus combined extra- and intracranial significant carotid stenosis.ResultsOut of 15 patients with significant extracranial stenosis, 3 of them obtained reversed flow in the ophthalmic artery and 3 patients of them showed change of flow in the anterior cerebral artery(ACA), whereas the other 15 patients of combined stenosis did not show any reversed blood flow in the same arteries which considered nonsignificant. The residual deficit of patients with extracranial stenosis alone was better when compared to that of the other group.ConclusionOur study concluded that transcranial duplex provides useful information about cerebral reserve and status of collaterals which show nonsignificant difference between two studied groups regarding intracranial collaterals. Furthermore, patients with combined extra- and intracranial stenosis were found to have more deficit and worse prognosis than patients with internal carotid stenosis only.

Hemodynamic analysis of a novel stent graft design with slit perforations in thoracic aortic aneurysm

Thoracic endovascular aortic repair (TEVAR) has been introduced as a less invasive approach to the treatment of thoracic aortic aneurysm (TAA). However, the effectiveness of TEVAR in the treatment of TAA is often limited due to the complex anatomy of aortic arch. Flow preservation at the three supra-aortic branches further increases the overall technical difficulty. This study proposes a novel stent graft design with slit perforations that can positively alter the hemodynamics at the aortic arch while maintaining blood flow to supra-aortic branches. We carried out a computational fluid dynamic (CFD) analysis to evaluate flow characteristics near stented aortic arch in simplified TAA models, followed by in-vitro experiments using particle image velocimetry (PIV) in a mock circulatory loop. The hemodynamics result was studied in terms of time-averaged wall shear stress (TAWSS), oscillating shear index (OSI), and endothelial cell action potential (ECAP). The results showed that the stent graft with slit perforations can reduce the disturbed flow region considerably. Furthermore, the effect of the slits on flow preservation to the supra-aortic branches was simulated and compared with experimental results. The effectiveness of the stent graft with slit perforations in preserving flow to the branches was demonstrated by both simulated and experimental results. Low TAWSS and elevated ECAP were observed in the aortic arch aneurysm after the placement of the stent graft with slits, implying the potential of thrombus formation in the aneurysm. On the other hand, the effects of the stent grafts with full-slit design and half-slit design on the shear stress did not differ significantly. The present analysis indicated that not only could the stent graft with slit perforations shield the aneurysm from rupture, but also it resulted in a favorable environment for thrombus that can contribute to the shrinkage of the aneurysm.

Effect of increased inspiratory muscle work on blood flow to inactive and active limbs during submaximal dynamic exercise.

What is the central question of this study? Increased respiratory muscle activation is associated with neural and cardiovascular consequences via the respiratory muscle metaboreflex. Does increased sympathetic vasoconstriction originating from the respiratory musculature elicit a reduction in blood flow to an inactive limb in order to maintain blood flow to an active limb? What is the main finding and its importance? Arm blood flow was reduced whereas leg blood flow was preserved during mild leg exercise with inspiratory resistance. Blood flow to the active limb is maintained via sympathetic control of blood flow redistribution when the respiratory muscle-induced metaboreflex is activated. The purpose of this study was to elucidate the effect of increasing inspiratory muscle work on blood flow to inactive and active limbs. Healthy young men (n=10, 20±2years of age) performed two bilateral dynamic knee-extension and knee-flexion exercise tests at 40% peak oxygen uptake for 10min. The trials consisted of spontaneous breathing for 5min followed by voluntary hyperventilation either with or without inspiratory resistance for 5min (40% of maximal inspiratory mouth pressure, inspiratory duty cycle of 50% and a breathing frequency of 40 breathsmin-1 ). Mean arterial blood pressure was acquired using finger photoplethysmography. Blood flow in the brachial artery (inactive limb) and in the femoral artery (active limb) were monitored using Doppler ultrasound. Mean arterial blood pressure during exercise was higher (P<0.05) with inspiratory resistance (121±7mmHg) than without resistance (99±5mmHg). Brachial artery blood flow increased during exercise without inspiratory resistance (120±31mlmin-1 ) compared with the resting level, whereas it was attenuated with inspiratory resistance (65±43mlmin-1 ). Femoral artery blood flow increased at the onset of exercise and was maintained throughout exercise without inspiratory resistance (2576±640mlmin-1 ) and was unchanged when inspiratory resistance was added (2634±659mlmin-1 ; P>0.05). These results suggest that sympathetic control of blood redistribution to active limbs is facilitated, in part, by the respiratory muscle-induced metaboreflex.

Preservation of Anterior Choroidal Artery Blood Flow During Trapping of the Internal Carotid Artery for a Ruptured Blood Blister-Like Aneurysm with High-Flow Bypass

The ideal surgery for a blood blister-like aneurysm (BBA) in the internal carotid artery (ICA) involves complete termination of blood flow into the BBA by trapping of the ICA at sites both proximal and distal to the BBA. In the present report, we describe a clipping method with ICA trapping for prevention of anterior choroidal artery ischemia, a major problem in ICA trapping with reconstruction surgery using external carotid artery-middle cerebral artery high-flow bypass (HFB). The data from patients with a ruptured BBA treated by the combination of ICA trapping and blood flow reconstruction from 2008 to 2018 were retrospectively evaluated. Fifteen patients had been treated with the combination surgery. Clip placement for ICA trapping depended on the relationship between the distal neck of the BBA and the posterior communicating artery. In the case of the BBA distal neck located at the same level or distal to the posterior communicating artery, oblique placement of a distal clip to the ICA was mandatory to maintain blood flow of the anterior choroidal artery. No patients developed recurrence of the BBA after trapping. The outcomes were assessed using the modified Rankin scale score, with a score of 0 or 1 in 12 of the 15 patients (80%). A complete shutdown of blood flow to the BBA by ICA trapping is essential for the permanent prevention of BBA recurrence. In cases of a BBA distal neck located distal to the posterior communicating artery, the oblique clipping technique applied to the ICA is useful to prevent ischemic complications of the anterior choroidal artery.

Age-related changes in gingival blood flow parameters measured using laser speckle flowmetry

Previous studies have suggested a possible relationship between age-related changes to human gingival hemodynamics and periodontal disease. However, firmly establishing this has been difficult because of a lack of suitable tools. Our study investigated whether a non-invasive laser speckle flowgraphy (LSFG)-based 2-dimensional technique could be used to assess maxillary anterior gingival blood flow under resting conditions. In total, 124 healthy male volunteers aged between 22 and 69 years were included in the study and delineated into young (Y; 22-37 years, n = 45), middle-aged (M; 38-53 years, n = 43), and elderly groups (E; 54-69 years, n = 36). The differences in gingival hemodynamics were compared among age groups and pulse waveform analysis performed to calculate blood flow indices, mean blur rate (MBR), gingival vascular conductance (MBR/mean blood pressure [MBP]), and three pulse waveform parameters (acceleration time index [ATI], falling rate, and blowout time [BOT]). Although no statistically significant differences were observed in the MBR of the three age groups, vascular conductance (MBR/MBP) was lower in groups M and E compared to group Y and correlated negatively with age. ATI and falling rates were also significantly higher in group E relative to group Y, whereas average BOT was significantly lower. All of the assessed parameters correlated with age. These data suggest that there are age-related decreases in the ability to maintain blood flow in the human maxillary anterior gingiva under resting conditions which may impact the likelihood of periodontal disease.

Assessing the institutional learning curve for pararenal aortic repair using the fenestrated Anaconda endograft.

Custom-made fenestrated aortic endografts allow exclusion of pararenal aortic aneurysms while maintaining blood flow to aortic branches. Meticulous device planning and precise deployment of the main body are essential to allow successful cannulation of the fenestrations. This study investigates whether a learning curve can be observed with more reliable cannulation and connection of fenestrations over time at a single department of vascular and endovascular surgery with multiple surgeons trained to use the device. A retrospective analysis of data from all patients undergoing primary fenestrated endovascular aneurysm repair during the study period was performed. Outcome measures included case volume and average number of fenestrations over time, average fluoroscopy dose area product per calendar year and primary unconnected fenestration and 30-day mortality rates. Between 1 January 2013 and 31 December 2016, 89 patients with no history of endovascular aneurysm repair underwent fenestrated endovascular aneurysm repair at our institution. The number of fenestrations per case increased over time, averaging 2.6 in 2013 and 3.3 in 2016. Primary unconnected fenestration and 30-day mortality rates were 5.6%. Primary-assisted technical success was 93.3%, secondary-assisted technical success was 94.4%. Fluoroscopy dose area product declined over the study period. Thirty-day mortality and primary unconnected fenestration rates did not significantly change over the study period. Albeit the reduction in lethal complications and primary technical success rates were not statistically significant, a lower percentage of unconnected fenestrations and 30-day mortality per calendar year were observed over time. At the same time, an increasing complexity of performed cases, as reflected by an increasing number of fenestrations per case, was observed. Complications associated with this complex endovascular procedure are potentially lethal and remain an unfortunate reality and may not be entirely dependent on overcoming a learning curve. A higher volume of cases performed over the study period and a reduction in fluoroscopy use can be considered a representation of the institutional development and learning curve for the Anaconda fenestrated endograft at a department with prior complex endovascular aortic repair experience, but due to limitations of the current retrospective observation, deserve further consideration in future trials, ideally designed in a prospective fashion.

Penile Size Restoration With Nondegloving Approach for Peyronie’s Disease: Initial Experience

The sliding technique (ST), commonly done with a subcoronal circumcising incision with penile degloving, has been used to restore penile size in patients with severe Peyronie's disease (PD) and erectile dysfunction, but with a potential risk of ischemic injury to the glans penis. To provide detailed surgical techniques regarding the nondegloving ventral incision and report our initial experience with this approach to perform the ST and penile prosthesis placement in patients with severe PD. This was a retrospective review of patient outcomes after penile prosthesis placement with penoplasty for severe PD and erectile dysfunction from January 2015 to December2017. Primary outcomes included straightening rates, penile measurement, along with immediate and late complications. Secondary outcomes include operative time and overall patient satisfaction. 12 Patients had significant penile atrophy and/or curvature >60 degrees and underwent inflatable penile prosthesis placement with grafting procedure. Significant penile atrophy was determined by a combination of the patient's subjective report and the surgeon's objective assessment through stretched penile length. 7 (58.3%) of those patients underwent ST, of which the last 5 had the procedure performed through a nondegloving ventral incision. Mean degree of curvature prior to ST was 66 degrees (45-90 degrees). Mean penile length gain was 2.6 cm (2.0-3.0 cm). At a mean follow-up of 15.5 months (3-31 months), only 1 patient had minimal residual curvature of 15 degrees. There were no vascular complications. This nondegloving technique theoretically maintains blood flow continuity to the glans penis by preserving the continuity of the skin, dartos fascia, and neurovascular bundle. Strengths of this study include the novel nature of this approach, no incidence of vascular complications, and adaptability to other grafting procedures during penile prosthesis placement. Limitations include the use of 5-item International Index of Erectile Function scores to assess preoperative erectile function on PD, small population, longer incision, and a possible steep learning curve. While ischemic complications of ST and penile prosthesis implantation are rare, there are reports of ischemic injury in patients undergoing a subcoronal circumcising incision with penile degloving. The non-degloving technique with ventral incision provides for an alternative method for ST and penile prosthesis placement to maintain dartos and skin continuity to the glans penis while still allowing for adequate surgical exposure. Clavell-Hernández J, Wang R. Penile Size Restoration With Nondegloving Approach for Peyronie's Disease: Initial Experience. J Sex Med 2018;15:1506-1513.

Isoproterenol-induced cardiac ischemia and fibrosis: Plant-based approaches for intervention.

Heart is the most active and incumbent organ of the body, which maintains blood flow, but due to various pathological reasons, several acute and chronic cardiac complications arise out of which myocardial infarction is one of the teething problems. Isoproterenol (ISP)-induced myocardial ischemia is a classical model to screen the cardioprotective effects of various pharmacological interventions. Phytochemicals present a novel option for treating various human maladies including those of the heart. A large number of plant products and their active ingredients have been screened for efficacy in ameliorating ISP-induced myocardial ischemia including coriander, curcumin, Momordica, quercetin, and Withania somnifera. These phytochemicals constituents may play key role in preventing disease and help in cardiac remodeling. Reactive oxygen species scavenging, antiinflammatory, and modulation of various molecular pathways such as Nrf2, NFкB, p-21 activated kinase 1 (PAK1), and p-smad2/3 signaling modulation have been implicated behind the claimed protection. In this review, we have provided a focused overview on the utility of ISP-induced cardiotoxicity, myocardial ischemia, and cardiac fibrosis for preclinical research. In addition, we have also surveyed molecular mechanism of various plant-based interventions screened for cardioprotective effect in ISP-induced cardiotoxicity, and their probable mechanistic profile is summarized.