Cuff Placement Research Articles

Dorsolateral fibromuscular tissue preservation during artificial urinary sphincter cuff placement is associated with low infection and erosion rates.

To present a modified technique in artificial urinary sphincter (AUS) placement that is associated with low rates of erosion and infection in a high-risk population. After Institutional Review Board approval, we identified patients who underwent primary AUS placement using the modified technique between January 2007 and November 2015. Our modification consists of preserving the dorsolateral fibromuscular tissue surrounding the bulbar urethra and horizontally transecting the ventral bulbospongiosus muscle during urethral cuff placement. Preoperative variables such as radiotherapy (RT) and bladder neck contractures were recorded. Effectiveness and complications including infections, erosions, and re-operations were recorded at follow-up. The new technique was used on 208 patients: 40% had a history of RT, including 15% who had had a salvage radical prostatectomy; 26% had had previous bladder neck contractures. No patients developed infection. Overall, erosion occurred in six (2.9%) patients and spontaneous erosions occurred in two (0.9%) during the study period. In all, 21 patients underwent re-operation for device failure. The probability of re-operation for 'any' reason was 7% (95% confidence interval [CI] 4-12%) at 1 year. The 1-year social continence rate was 74% (95% CI 67-81%). Preservation of dorsolateral fibromuscular tissue during AUS placement is an effective means to achieve a low risk of erosions. Our modified technique is safe with low infection and erosion rates, whilst maintaining good functional outcomes despite a high-risk population.

Impact of Radiation and Transcorporeal Artificial Sphincter Placement in Patients with Prior Urethral Cuff Erosion: Results from a Retrospective Multicenter Analysis

Many providers elect to use a transcorporeal approach for artificial urinary sphincter placement in an attempt to minimize risks, given the increased risk of complications in revision cases. We present outcomes in a multicenter retrospective analysis of artificial urinary sphincter cuff reimplantation in patients with prior cuff erosion with special consideration given to the transcorporeal approach. We compiled a multi-institutional database of patients who underwent artificial urinary sphincter reimplantation after prior urethral erosion. Of the 34 identified patients 24 underwent transcorporeal cuff replacement. Patients with transcorporeal cuff replacement were further analyzed with specific stratification for radiation therapy. The rate of subsequent complications after eroded cuff reimplantation was 32.4% (11 of 34 patients). The most frequent complication was recurrent erosion, which developed in 9 of the 34 patients (26.4%). Repeat artificial urinary sphincter complications developed more frequently in patients with history of radiation compared to nonirradiated patients (8 of 16 or 50% vs 3 of 18 or 16.7%). However, this difference was not statistically significant (p = 0.066). The transcorporeal technique was applied in 24 of 33 patients (70.5%) and relative to the nontranscorporeal group there was no difference in the complication rate (p= 0.438). On subgroup analysis of the transcorporeal group there was a higher rate of repeat complications in irradiated patients (p = 0.006). These data suggest that transcorporeal cuff reimplantation may not decrease the incidence of repeat complications after prior cuff erosion. However, radiation therapy is associated with a worse outcome even when transcorporeal cuff placement is performed.

Re: Low Serum Testosterone is Present in Nearly Half of Men Undergoing Artificial Urinary Sphincter Placement.

Objectives To report the prevalence of low serum testosterone (LST) in men undergoing artificial urinary sphincter (AUS) placement at a single high-volume institution. Methods We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from January 2015 to January 2018 to identify men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. Patients with only posttreatment testosterone levels were excluded. Demographic characteristics and clinical outcomes were compared between men with and without LST. Results Among 113 patients who underwent AUS with pretreatment serum testosterone levels drawn an average of 2.2 months before AUS surgery, 45.1% (51 of 113) met criteria for LST, including 18 patients on androgen deprivation therapy. The rate of primary LST was 34.7% (33 of 95). The median total serum testosterone level among men with LST was 118 ng/dL (interquartile range 6-211), and 413 mg/dL (interquartile range 333-550) in the normal serum testosterone group. There were no differences in patient age, history of radiation, erectile dysfunction, or other comorbidities between the groups. Body mass index was higher in the LST group compared to normal serum testosterone (30 vs 27 kg/m2, P = .001). Cuff size and rates of transcorporal cuff placement were similar between groups. Conclusion Nearly one-half of men with stress urinary incontinence undergoing AUS placement present with LST. While AUS cuff erosion appears to be more common in men with LST, further study is needed to determine if treating LST will reduce cuff erosion rates.

Low Serum Testosterone is Present in Nearly Half of Men Undergoing Artificial Urinary Sphincter Placement

To report the prevalence of low serum testosterone (LST) in men undergoing artificial urinary sphincter (AUS) placement at a single high-volume institution. We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from January 2015 to January 2018 to identify men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. Patients with only posttreatment testosterone levels were excluded. Demographic characteristics and clinical outcomes were compared between men with and without LST. Among 113 patients who underwent AUS with pretreatment serum testosterone levels drawn an average of 2.2 months before AUS surgery, 45.1% (51 of 113) met criteria for LST, including 18 patients on androgen deprivation therapy. The rate of primary LST was 34.7% (33 of 95). The median total serum testosterone level among men with LST was 118 ng/dL (interquartile range 6-211), and 413 mg/dL (interquartile range 333-550) in the normal serum testosterone group. There were no differences in patient age, history of radiation, erectile dysfunction, or other comorbidities between the groups. Body mass index was higher in the LST group compared to normal serum testosterone (30 vs 27 kg/m2, P = .001). Cuff size and rates of transcorporal cuff placement were similar between groups. Nearly one-half of men with stress urinary incontinence undergoing AUS placement present with LST. While AUS cuff erosion appears to be more common in men with LST, further study is needed to determine if treating LST will reduce cuff erosion rates.

Histopathologic Correlates of Irreversible Renal Injury in Renal Artery Stenosis

AimThe aim of this study was to define the functional correlates of reversibilitiy following restoration of blood flow in the murine 2K1C model of renovascular hypertension.Method: Renal artery stenosis surgery (RAS) was performed by placement of a polytetrafluoroethylene cuff on the right renal artery (N=18). Sham surgery was performed without cuff placement (N=6). In two groups the cuff was removed at 7 days (7D cuff‐off, N=6) and 14 days (14D cuff‐off, N=6) after surgery. In the RAS group, cuff was left in place for 28 days (28D RAS, N=6). Kidneys were harvested at 28 days for assessment of histology and microvessel density (MVD). Renal blood perfusion and oxygenation were measured using 16.4T MRI. Blood pressure measurements were done using tail cuff method.ResultsIn 7D cuff‐off group, baseline intra‐renal perfusion (891±142.8 ml/100g/min) was significantly reduced (311±73.4 ml/100g/min, p<0.0001) following cuff placement. Perfusion was restored to normal level (810±81.2 ml/100g/min) at 28 days following cuff removal at 7 days after RAS. In 14D cuff‐off group, baseline intra‐renal perfusion (846±74.5 ml/100g/min) was also significantly reduced (304±45.9 ml/100g/min, p=0.0002) following cuff placement with non‐significant improvement (579±112.9 ml/100g/min) at 28 days after cuff removal at 14 days after RAS. Baseline intra‐renal perfusion (905±54.9 ml/100g/min) in the 28D RAS group was significantly reduced (455±56.4 ml/100g/min, p<0.0034) following cuff placement and the reduction was maintained throughout the study period (478±22.2 ml/100g/min).7D cuff‐off group (142±8.2 mg) showed no significant difference in kidney weights measured at 28 days compared to the sham group (154±4.8 mg), but was significantly higher compared to the 28D RAS group (67±10.5 mg, p=0.0010). The kidney weights of the 14D cuff‐off group (86±18.3 mg) measured at 28 days was not significantly different from the 28D RAS group. The 7D cuff‐off group had a significantly lower % atrophy (7±2.2%, p=0.0042) and higher MVD count (152±6.5, p=0.0045) compared to 28D RAS group (% atrophy 66±13%, MVD count 78±15.2). The 14D cuff‐off group had severe atrophy (56±16.6%) and reduced MVD count (94±20.1) similar to that seen in 28D RAS group. 50% of mice that developed hypoxia at day 3 had an improvement in their oxygenation after cuff removal at day 7, whereas, mice undergoing cuff removal at day 14 and 28 day ras mice remained hypoxic.ConclusionBased on these results, we conclude that the renal architecture and microvessel density are preserved when the cuff is removed no longer than 7 days post surgery. We Identified that 2 weeks after cuff placement is the “point of no return” in the renal injury in murine RAS model due to their reduction in microvessel density. Studies to identify biomarkers associated with irreversible renal injury in this model are currently being performed.Support or Funding InformationNIH AI 100911This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

PD39-02 EROSION RATES OF 3.5 CM ARTIFICIAL URINARY SPHINCTER CUFFS ARE SIMILAR TO LARGER CUFFS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy II1 Apr 2018PD39-02 EROSION RATES OF 3.5 CM ARTIFICIAL URINARY SPHINCTER CUFFS ARE SIMILAR TO LARGER CUFFS Nabeel Shakir, Maxim McKibben, Joceline Fuchs, Jeremy Scott, and Allen Morey Nabeel ShakirNabeel Shakir More articles by this author , Maxim McKibbenMaxim McKibben More articles by this author , Joceline FuchsJoceline Fuchs More articles by this author , Jeremy ScottJeremy Scott More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1914AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since the launch of 3.5 cm artificial urinary sphincter (AUS) cuffs in the US market in 2009, the possible increased risk of erosion has been a concern. We sought to compare the outcomes of 3.5 cm AUS cuffs versus larger cuffs for men having stress urinary incontinence (SUI) with and without a history of pelvic radiation after 8 years of experience. METHODS We reviewed the records of all men who underwent AUS placement by a single surgeon between 2009 and 2017 collected in a large, tertiary male SUI database. A uniform perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement. Patients were stratified by cuff size and radiation status, and patient demographics and surgical outcomes were analyzed. Success was defined as patient-reported use of ≤1 pad per day. RESULTS Among 400 AUS cases included in the analysis, the 3.5 cm cuff was used in 164 (41‰) cases, while 236 (59‰) patients received 4.0 cm or larger cuffs. AUS cuff erosion was seen 34 patients, who suffered a total of 44 cuff erosions over a median follow-up of 45 months. Rate of cuff erosion was similar in the 3.5 cm cuff group (12‰, 19/164), compared to the 4+ cm group (11‰, 25/236, p=0.7) (FIGURE). On multivariate logistic regression, predictors of AUS cuff erosion include history of pelvic radiation (OR 7.27, IQR 3.19-16.6, p<0.0001), history of IPP placement (OR 3.63, IQR 1.69-7.81, p=0.0009), and coronary artery disease (OR 4.05, IQR 1.86-8.81, p=0.0005). Patient demographics were similar between the two cuff size groups, including age, BMI, comorbidities, smoking history, radiation history, prior AUS, prior inflatable penile prosthesis (IPP), and proportion of patients with prior erosions. In patients receiving larger cuffs, 19‰ (45/236) were placed using a transcorporal approach, compared to 2‰ (4/164) of those undergoing 3.5 cm cuff placement (p<0.0001). Continence rates were high among all AUS patients, with similar success in both groups (89‰ for 3.5 cm, 82‰ for 4+ cm, p=0.1). CONCLUSIONS After eight years of experience and follow-up, the 3.5 cm AUS cuff behaves similarly to 4+ cm cuffs with respect to efficacy and rates of urethral erosion. Use of any cuff in radiated patients should be approached cautiously, as risk of erosion is substantial. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e798 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Nabeel Shakir More articles by this author Maxim McKibben More articles by this author Joceline Fuchs More articles by this author Jeremy Scott More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1190 - Artificial urinary sphincter in male patients with spina bifida: Comparison of perioperative and functional outcomes between bulbar urethra and bladder neck cuff placement

1190 - Artificial urinary sphincter in male patients with spina bifida: Comparison of perioperative and functional outcomes between bulbar urethra and bladder neck cuff placement

Increasing Use of Open Conversion for Late Complications After Endovascular Aortic Aneurysm Repair

Open procedures are often required for late complications after endovascular aortic aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to identify factors that can predict mortality after open conversion. We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality. There were 81 patients who underwent open conversion 3.9 ± 3.3 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016 (Fig); 44.7% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 66 patients (81.5%) and infection in 13 (16.1%). One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 21.0% and was highest in 17 ruptures (41.2%) and 13 infections (46.2%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.16; 95% confidence interval [CI], 1.41-26.98; P = .02), endograft infection (OR, 11.64; 95% CI, 2.38-56.90; P = .002), and use of a supraceliac clamp (OR, 4.70; 95% CI, 1.26-17.49; P = .02). Transient acute kidney injury (15.6%) and prolonged intubation (11.7%) were the most common postoperative complications. In 49 patients treated for endoleak without rupture, 31 underwent endograft explantation; 18 had a limited intervention (branch vessel ligation for type II endoleak in 16, external banding of the aneurysm neck for type Ia endoleak in 7). Mortality was 6.5% when the endograft was explanted and 5.6% when it was not (P = 1.00). During 2.3 ± 2.9 years of follow-up, only one reintervention was required (proximal cuff placement for new type Ia endoleak after branch vessel ligation). Survival was 91.0% at 1 year and 81.7% at 5 years. Open conversion is playing an increasing role in the management of late EVAR complications. In patients without rupture or infection, both limited conversions and total explantation have a low mortality and good long-term durability.

Endogenous Interleukin-1β Is Implicated in Intraplaque Hemorrhage in Apolipoprotein E Gene Null Mice.

Intraplaque hemorrhage (IPH) has been implicated in plaque instability and rupture in atherosclerotic lesions, although the mechanisms by which IPH progresses remain largely unknown. In this study, apolipoprotein E-deficient mice with carotid artery ligation and cuff placement around the artery were used, and pro-inflammatory cytokines that are implicated in IPH were analyzed.Methods and Results:The expression of interleukin-1β (IL-1β) increased significantly following cuff placement compared with mice with carotid artery ligation alone. IPH occurred in the cuff-placed carotid artery following treatment with the negative control (NC) small interfering RNA (siRNA). However, the occurrence was significantly reduced in the cuff-placed carotid artery following treatment with an IL-1β siRNA. Neovessel formation was significantly reduced in the carotid artery treated with the NC siRNA compared with that treated with IL-1β siRNA. IL-1β significantly inhibited the tube formation and wound healing capacities of vascular endothelial cells in vitro. Furthermore, immunostaining of matrix metalloproteinase-9 (MMP-9) significantly increased in the carotid artery treated with the NC siRNA compared with that treated with IL-1β siRNA. These results suggest that endogenous IL-1β is implicated in the progression of IPH via the inhibition of physiological angiogenesis in the atherosclerotic plaque, leading to the formation of leaky neovessels. Furthermore, the stimulation of MMP-9 expression may also contribute to the formation of leaky neovessels.

Endoleak after an Open Abdominal Aortic Aneurysm Repair

Although endoleaks have been well described after endovascular abdominal aortic aneurysm (AAA) repair, their occurrence after open repair is much less common. This case report describes a patient who had a leak at the proximal anastomotic site of the graft after open AAA repair. The patient was a 78 year old male patient who presented to our facility with bright red blood from the rectum at approximately 3 months after an open AAA repair at an outside facility. On computed tomographic angiography, a leak was detected at the proximal anastomotic site and resembled a type I endoleak that may occur after endovascular repair. The patient was treated through endovascular technique with the placement of two proximal extension cuffs. The endoleak was not observed on follow-up imaging, and the patient has been asymptomatic since treatment. Endoleaks after open AAA repair are rare, but they can be treated through an endovascular approach, with proximal extension cuff placement to seal the leak.

Tongue motion variability with changes of upper airway stimulation electrode configuration and effects on treatment outcomes.

Upper airway stimulation (UAS) is an effective treatment for obstructive sleep apnea (OSA). Previous data have demonstrated a correlation between the phenotype of tongue motion and therapy response. Closed loop hypoglossal nerve stimulation implant offers five different electrode configuration settings which may result in different tongue motion. Two-center, prospective consecutive trial in a university hospital setting. Clinical outcomes of 35 patients were analyzed after at least 12 months of device use. Tongue motion was assessed at various electrode configuration settings. Correlation between the tongue motion and treatment response was evaluated. OSA severity was significantly reduced with the use of UAS therapy (P < .001). Changes in tongue motion patterns were frequently observed (58.8%) with different electrode configuration settings. Most of the patients alternated between right and bilateral protrusion (73.5%), which are considered to be the optimal phenotypes for selective UAS responses. Different voltage settings were required to achieve functional stimulation levels when changing between the electrode settings. UAS is highly effective for OSA treatment in selected patients with an apnea-hypopnea index between 15 and 65 events per hour and higher body mass index. Attention should be given to patients with shifting tongue movement in response to change of electrode configuration. The intraoperative cuff placement should be reassessed when tongue movement shifting is observed. 4 Laryngoscope, 1970-1976, 2018.

Select early type IA endoleaks after endovascular aneurysm repair will resolve without secondary intervention

ObjectiveAlthough it is traditionally considered ominous, the natural history of early proximal attachment site endoleaks (IA) after endovascular aneurysm repair (EVAR) is not well known. Our aim was to identify risk factors for persistent type IA endoleaks and to determine their effect on long-term outcomes after EVAR. MethodsAll patients who underwent infrarenal EVAR at a single institution between 1998 and 2015 were identified. Preoperative axial imaging and intraoperative arteriograms were reviewed, and those patients with a type IA endoleak were further studied. Aneurysm features were characterized by two reviewers and were studied for predictors of persistent endoleaks at the conclusion of the case. Patient records and the Social Security Death Index were used to record 1-year and overall survival. ResultsWe identified 1484 EVARs, 122 (8%) of which were complicated by a type IA endoleak on arteriography after graft deployment, with a median follow-up of 4 years. The majority of patients underwent additional ballooning of the proximal site (52 [43%]) or placement of an aortic cuff (47 [39%]); 30 patients (25%) received a Palmaz stent, and four patients were treated with coils or anchors. At case end, only 43 (35%) of the type IA endoleaks remained; at 1 month, only 16 endoleaks persisted (13%), and only six persisted at 1 year (6%). In multivariable analysis, the only independent predictor of persistence of type IA endoleak at the conclusion of the case was the presence of extensive neck calcifications (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.4-67.9; P = .02). Thirteen patients (11%) underwent reintervention for type IA endoleaks, with a time frame ranging from 3 days postoperatively to 11 years. There were three patients (2.4%) who experienced aneurysm rupture. Postoperative type IA endoleak was associated with lower survival at 1 year (79% vs 91%; relative risk, 2.5; 95% CI, 1.1-5.4; P = .02), but it did not affect long-term survival (log-rank, P = .45). Both an increase in aneurysm sac size and failure of the endoleak to resolve by case end were independent predictors of a need for reintervention (growth: OR, 8.3; 95% CI, 2.2-31.6; P < .01; persistent endoleak: OR, 7.6; 95% CI, 1.8-31.5; P < .01). A persistent type IA endoleak was not independently associated with an increase in sac size on surveillance imaging (P = .28). ConclusionsAneurysm rupture secondary to persistent type IA endoleak is rare, and most will resolve within 1 year. Extensive neck calcification is the only independent predictor of persistent type IA endoleak, and an increase in sac size warrants reintervention. These data suggest that select early persistent type IA endoleaks can be safely observed.

Improving surgical results in complex nerve anatomy during implantation of selective upper airway stimulation

The following report presents a case of two late embedded hypoglossus branches during implantation of an upper airway stimulation device that caused a mixed activation of the tongue when included in the stimulation cuff. In the end, correct cuff placement could be achieved by careful examination of the hypoglossal nerve anatomy, precise nerve dissection, tongue motion analysis and intraoperative nerve monitoring.

Cardiovascular phenotype in Smad3 deficient mice with renovascular hypertension.

Renovascular hypertension (RVH) has deleterious effects on both the kidney and the heart. TGF-β signaling through Smad3 directs tissue fibrosis in chronic injury models. In the 2-kidney 1-clip (2K1C) model of RVH, employing mice on the 129 genetic background, Smad3 deficiency (KO) protects the stenotic kidney (STK) from development of interstitial fibrosis. However, these mice have an increased incidence of sudden cardiac death following 2K1C surgery. The purpose of this study was to characterize the cardiovascular phenotype of these mice. Renal artery stenosis (RAS) was established in Wild-type (WT) and Smad3 KO mice (129 genetic background) by placement of a polytetrafluoroethylene cuff on the right renal artery. Mortality was 25.5% for KO mice with RAS, 4.1% for KO sham mice, 1.2% for WT with RAS, and 1.8% for WT sham mice. Myocardial tissue of mice studied at 3 days following surgery showed extensive myocyte necrosis in KO but not WT mice. Myocyte necrosis was associated with a rapid induction of Ccl2 expression, macrophage influx, and increased MMP-9 activity. At later time points, both KO and WT mice developed myocardial fibrosis. No aortic aneurysms or dissections were observed at any time point. Smad3 KO mice were backcrossed to the C57BL/6J strain and subjected to RAS. Sudden death was observed at 10–14 days following surgery in 62.5% of mice; necropsy revealed aortic dissections as the cause of death. As observed in the 129 mice, the STK of Smad3 KO mice on the C57BL/6J background did not develop significant chronic renal damage. We conclude that the cardiovascular manifestations of Smad3 deficient mice are strain-specific, with myocyte necrosis in 129 mice and aortic rupture in C57BL/6J mice. Future studies will define mechanisms underlying this strain-specific effect on the cardiovascular system.

Artificial Urinary Sphincter in Male Patients with Spina Bifida: Comparison of Perioperative and Functional Outcomes between Bulbar Urethra and Bladder Neck Cuff Placement

We evaluated the perioperative and long-term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism. We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation-free and revision-free device survival was estimated by the Kaplan-Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure. A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision-free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation-free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75). In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

The epigenetic factor PCAF regulates vascular inflammation and is essential for intimal hyperplasia development.

ObjectiveGenetic P300/CBP-associated factor (PCAF) variation affects restenosis-risk in patients. PCAF has lysine acetyltransferase activity and promotes nuclear factor kappa-beta (NFκB)-mediated inflammation, which drives post-interventional intimal hyperplasia development. We studied the contributing role of PCAF in post-interventional intimal hyperplasia.Methods and resultsPCAF contribution to inflammation and intimal hyperplasia was assessed in leukocytes, macrophages and vascular smooth muscle cells (vSMCs) in vitro and in a mouse model for intimal hyperplasia, in which a cuff is placed around the femoral artery. PCAF deficiency downregulate CCL2, IL-6 and TNF-alpha expression, as demonstrated on cultured vSMCs, leukocytes and macrophages. PCAF KO mice showed a 71.8% reduction of vSMC-rich intimal hyperplasia, a 73.4% reduction of intima/media ratio and a 63.7% reduction of luminal stenosis after femoral artery cuff placement compared to wild type (WT) mice. The association of PCAF and vascular inflammation was further investigated using the potent natural PCAF inhibitor garcinol. Garcinol treatment reduced CCL2 and TNF-alpha expression, as demonstrated on cultured vSMCs and leukocytes.To assess the effect of garcinol treatment on vascular inflammation we used hypercholesterolemic ApoE*3-Leiden mice. After cuff placement, garcinol treatment resulted in reduced arterial leukocyte and macrophage adherence and infiltration after three days compared to untreated animals.ConclusionsThese results identify a vital role for the lysine acetyltransferase PCAF in the regulation of local inflammation after arterial injury and likely the subsequent vSMC proliferation, responsible for intimal hyperplasia.

Non-invasive blood pressure measurement in ferrets (Mustela putorius furo) using high definition oscillometry

This study was conducted to validate the use of high definition oscillometry (HDO) for non-invasive blood pressure (NIBP) measurements in ferrets and to establish reference ranges for NIBP in minimally sedated, healthy, young adult ferrets (<4years of age). The bias, limits of agreement and correlation for HDO compared to direct arterial blood pressure (DABP) measurement were established in 14 anaesthetised ferrets. Measurements were performed at the forelimb, hind limb and tail under hypo- (<110mmHg), normo- (110–170mmHg) and hypertensive (>170mmHg) conditions. Although HDO correlated well with DABP (r>0.90), it showed significant proportional bias, whereby HDO generally underestimated DABP with hyper- and normotensive conditions, and overestimated DABP with hypotensive conditions. Measurements obtained from the hind limb showed higher bias than those obtained from the tail or forelimb (P<0.001). Based on the above, and for practical reasons, the tail was selected as the preferred site of cuff placement in ferrets. Subsequently, a cross-over study was performed in 10 ferrets to establish the minimum dose of butorphanol and midazolam needed to successfully obtain NIBP in 100% of cases. Using this dose (0.2mg/kg IM, each), reference intervals for NIBP from 63 healthy, young adult ferrets were established at 95–155mmHg (systolic), 69–109mmHg (mean) and 51–87mmHg (diastolic) arterial pressures.

Surgical anatomy of the hypoglossal nerve: A new classification system for selective upper airway stimulation.

Selective upper airway stimulation (UAS) has shown effectiveness in treating patients with obstructive sleep apnea (OSA). The terminating branches of the hypoglossal nerve show a wide complexity, requiring careful discernment of a functional breakpoint between branches for inclusion and exclusion from the stimulation cuff electrode. The purpose of this study was to describe and categorize the topographic phenotypes of these branches. Thirty patients who received an implant with selective UAS from July 2015 to June 2016 were included. All implantations were recorded using a microscope and resultant tongue motions were captured perioperatively for comparison. Eight different variations of the branches were encountered and described, both in a tabular numeric fashion and in pictorial schema. The examinations showed the complex phenotypic surgical anatomy of the hypoglossal nerve. A schematic classification system has been developed to help surgeons identify the optimal location for cuff placement in UAS.

Effects of remote ischemic preconditioning in patients with concentric myocardial hypertrophy: A randomized, controlled trial with molecular insights

BackgroundEfficacy of remote ischemic preconditioning (RIPC) for cardioprotection in cardiac surgery is controversial. We aimed to evaluate the clinical and molecular effects of RIPC on the concentrically hypertrophied myocardium. MethodsSeventy-two aortic stenosis patients receiving aortic valve replacement (AVR) under sevoflurane anesthesia were randomly allocated to RIPC (3cycles of 5-min inflation [300mmHg] and deflation on the left arm) or control (deflated cuff placement) group. The primary endpoints were 24-h area under the curve (AUC) for serum creatine kinase (CK)-MB and troponin (Tn)-T levels. The secondary endpoints were myocardial activation of cell signaling pathways, including reperfusion injury salvage kinases (RISK), signal transducer and activator of transcription (STAT), nitric oxide synthase (NOS), and apoptosis related molecules, obtained from right atrial tissue before and after cardiopulmonary bypass (CPB). ResultsThere were no intergroup differences in 24-h AUCs of CK-MB and Tn-T. Phosphorylations of RISK pathway molecules were not enhanced by RIPC before and after CPB. Phosphorylation of STAT5 was significantly lower in the RIPC group before and after CPB. Phosphorylations of STAT3 and endothelial NOS were not enhanced by RIPC before and after CPB. Expression level of cleaved caspases-3/caspase-3 was significantly higher in the RIPC group before CPB. ConclusionsRIPC did not provide clinical benefits or activate protective signaling in patients with concentric left ventricular hypertrophy undergoing AVR.

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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.