Sac Size Research Articles

Umbilical Hernia Mesh Repair: Overview on its Safety, Efficacy, and Techniques

Adult umbilical hernias make up about 6 to 14% of all abdominal wall hernias. Surgical intervention is usually indicated when the umbilical hernia becomes symptomatic and poses a risk of incarceration. The hernia contains a stable, fibrotic hernia void that does not enlarge, rather a hernia sac that enlarges In most patients. Because the hernia sac neck is usually small compared to the hernia sac size, confinement and suffocation are ordinary. As a result, after diagnosis, an elective repair is

Predictive factors of treatment success in two-dose methotrexate regimen in ectopic tubal pregnancy: A retrospective study

Objectives:To investigate the predictive factors of success or failure in treating ectopic tubal pregnancies with two-dose methotrexate (MTX).Methods:The records of patients treated for tubal EP with two-dose MTX were retrospectively reviewed. Patients were divided into two groups; the Group-I (failure) consisted of patients who did not respond to MTX therapy and the Group-II (success) included patients who were successfully treated with MTX. Parameters, including the week of gestation, presence or absence of fetal cardiac activity, gestational sac size, serum β-hCG levels, and adverse effects were compared.Results:Fifty patients were included in this study, 8 (16%) were in Group-I and 42 (84%) were in Group-II. Patients in Group-I required surgery after a mean duration of 6.7±3 days after administering the initial dose of MTX. There was no difference between the groups in terms of the week of gestation, presence or absence of fetal cardiac activity, gestational sac size, serum β-hCG levels, and adverse effects. The average time to β-hCG negativization was 31 days in Group-II.Conclusions:The two-dose MTX protocol has a reasonable success rate, which seems to be dependent on serum β-hCG levels.

Prospective study of yolk sac size and shape as a predictor in first trimester pregnancy outcome at a tertiary hospital

Prospective study of yolk sac size and shape as a predictor in first trimester pregnancy outcome at a tertiary hospital

Morphometric effects of various weathered and virgin/pure microplastics on sac fry zebrafish (<i>Danio rerio)</i>

<abstract> Microplastics (5 mm to1 nm) and plasticizers are ubiquitous worldwide in waterways, beaches, sediments, and biota. Ingestion of microplastics by various marine species and bioaccumulation of plasticizers continues to be of concern. Additionally, microplastics act as a carrier for the transport of persistent organic pollutants and some harmful microorganisms, increasing the hazard to aquatic species. Microplastics vary in composition based on their monomeric component and the specific plasticizer(s). There is a large data gap in our understanding of the biological toxicity of the different plastic polymers. The results presented here examine gross morphological alterations in sac fry zebrafish as a result of exposure to weathered microplastics and virgin/pure plastic polymers. Embryos were exposed from 3 hours post fertilization (hpf) to 96 hpf with samples of weathered microplastics from estuaries in Newark Bay, NJ, as well as commercially available virgin/pure plastics at concentrations of 1 µg/mL or 10 µg/mL. The Newark Bay microplastics were chemically identified using pyrolysis GC-MS. The three field samples were composed primarily of polyethylene (FPE), polypropylene (FPP) and polyvinyl chloride vinyl acetate mixture (FVA). Significant morphometric changes (<italic>P</italic> &lt; 0.05) were noted between the control zebrafish and the treated groups in the embryonic zebrafish samples for the Newark Bay, weathered samples following statistical analysis of morphometric data. The commercial microplastics tested included: low density polyethylene (LDPE), medium density polyethylene (MDPE), high density polyethylene (HDPE), polypropylene (PP), polystyrene (PS), polyvinyl chloride (PVC), sodium polyacrylate (SPA), polyethylene terephthalate (PET), polyurethane (PUR), poly methyl-methacrylate (PMMA), polyethylene (co-vinyl-acetate) (PEVA), and polystyrene (co-acrylonitrile) (PSAN). Significant changes were seen in total body length in all three Newark Bay field sample microplastics, as well as virgin/pure microplastic treatment groups PET, PUR, PMMA. The pericardial sac size was found significantly altered in FPP 10 µg/mL sample plastic as well as pure microplastic treatment groups HDPE, SPA, PET, PUR, PMMA, PP, and PEVA. The interocular distance was found to be significantly changed in the pure microplastic treatment groups HDPE and PET. The pericardial sac size was the most sensitive endpoint measured followed by total body length. The least sensitive endpoint was interocular distance. These results highlight the associated toxicity with both weathered and lab standard grade microplastics exposure to treated zebrafish developing embryos. The laboratory induced cardiac and growth alterations following laboratory microplastic exposure could be examined in field populations exposed to high microplastic concentrations. </abstract>

Outcomes of chimney and fenestrated endografting using Viabahn VBX and atrium iCAST stents.

The Atrium iCAST balloon expandable stent is the traditional choice of stent for chimney and fenestrated endovascular aneurysm repair (ChEVAR and FEVAR respectively). Due to the iCAST's lack of flexibility, the Gore Viabahn balloon-expandable stent (VBX; W. L. Gore & Associates, Inc., Newark, DE, USA) has arisen as a flexible alternative for parallel or branch graft placement during complex EVAR. Our purpose was to analyze patients' outcomes after undergoing ChEVAR or FEVAR using VBX or iCAST stents with the major outcome of assessing stent graft patency. The secondary outcome was residual aneurysm sac behavior. We retrospectively reviewed patients who were treated by ChEVAR or FEVAR with placement of iCAST or VBX stents from July 2012 to August 2018. Patients received follow-up CT scan and/or aortic duplex imaging. We examined 53 cases (70% ChEVAR and 30% FEVAR) with 15.6 months (0-76.5 months) mean follow-up period. Placement of stents included renal (65 iCAST and 38 VBX), superior mesenteric (12 iCAST and 13 VBX), celiac (4 iCAST and 5 VBX), and iliac arteries (1 iCAST and 5 VBX). A total of 143 stents (57% iCAST and 43% VBX) were successfully deployed with 100% initial patency. Follow-up patency was similar for both stent types (100% VBX vs 98.7% iCAST). VBX and iCAST had the same follow-up Type 1a endoleak occurrence (9%). Average aneurysm sac sizes for iCAST decreased more than VBX (9% iCAST and 4% VBX, P=0.21), however, the iCAST group had longer follow-up. Our experience demonstrates that the use of VBX stents for ChEVAR and FEVAR is a safe and effective alternative to iCAST stents with excellent mid-term patency without a negative impact on endoleak frequency.

Fetal sex prediction measuring yolk sac size and yolk sac-fetal pole distance in the first trimester via ultrasound screening.

The aim of the study was to determine the accuracy of fetal sex definition by measuring the yolk sac size and the yolk sac-fetal pole distance in the first trimester via ultrasound (US) screening. We enrolled 92 gestational women in this prospective study. In the first trimester of US examination, the gestational sac, the gestational sac-fetal pole distance, and the yolk sac size were measured. When the fetal pole was in the longitudinal position, the distance between the fetal pole and the yolk sac was measured in millimeters (mm). The crown-rump length (CRL) was measured in the same position. US examination at 22weeks was performed to determine whether the fetal gender was male or female. The genders of the fetuses were recorded. The sexes were also confirmed and recorded after birth. Fifty-five (59.8%) of the newborns were found to be male, while 37 (40.2%) of them were found to be female. We compared the yolk sac size and the yolk sac-fetal pole distance in both the female and male groups. We found that the genders showed a significant difference in terms of yolk sac-fetal pole distance, whereas the yolk sac size showed no significant difference between the genders. The optimal cutoff value of the yolk sac-fetal pole distance was 1.80mm, with 70% sensitivity and 67% specificity for female gender prediction. The distance also showed an independent association with gender prediction in the first trimester. Yolk sac-fetal pole distance may have the potential to predict gender in the first trimester of pregnancy.

Transcaval approach to treat a type II endoleak

An 87-year-old man had an elective endovascular aneurysm repair in 2015 (Endurant; Medtronic, Santa Rosa, Calif). A type II endoleak from the inferior mesenteric artery (IMA) was noticed in the first surveillance scan. All subsequent ultrasound scans showed the endoleak with a stable sac (A). He has severe obstructive pulmonary disease and ischemic heart disease (American Society of Anesthesiologists class 3) while leading an independent life. In 2019, although he was asymptomatic, sac size grew by 1 cm.

Long-term Impact of Sac Behavior at 12 Months After Elective Endovascular Aneurysm Repair on Survival, Endoleaks, and Reintervention

Failure of the sac to regress at 12 months after endovascular aneurysm repair (EVAR) was reported to be associated with higher long-term mortality independent of reinterventions or endoleaks in a large Vascular Quality Initiative database. We reviewed our single-center closely monitored cohort of patients after elective EVAR to see whether sac behavior at 12 months affects survival, reintervention, and endoleak-free survival. All patients undergoing EVAR (15 fenestrated EVARs) between 2001 and 2018 with an imaging study at 1 year postoperatively (±6 months) were included. Those with sac diameter decrease ≥5 mm (group I, n = 238) were compared with those who remained stable (group II, n = 151) or increased (group III, n = 14). Of 449 patients, 403 were included (26 died within 6 months, 20 did not have follow-up computed tomography). Group I patients were younger (70.5 ± 7.2 years vs 72.8 ± 9.0 years vs 79.4 ± 9.1 years; P < .01). Group III had less hyperlipidemia (85% vs 81% vs 57%; P = .021). Mean diameter was 5.8 ± 0.9 cm, 5.8 ± 1.0 cm, and 6.0 ± 1.4 cm (P = NS). Follow-up was 65.6 ± 39.5 months clinically, 53 ± 37.3 months for last imaging. Overall survival (5 years: 76% ± 3% vs 64% ± 4% vs 71% ± 12%; P = .116; Fig) was similar, but aneurysm-related mortality-free survival was significantly less in group III but similar in groups I and II (5 years: 100%, 99% ± 0.1%, 92% ± 8%; P = .002). One patient each from group II and group III had aneurysm-related mortality. Endoleak-free survival (5 years: 93% ± 2% vs 72% ± 4% vs 7% ± 7%; P < .001) and reintervention-free survival (94% ± 2% vs 76% ± 4% vs 16% ± 10%; P < .001) were significantly different between groups. During follow-up, 4.2% in group I had sac increase. In group II, 29.8% had sac size decrease, 58.3% remained stable, and 11.9% had sac size increase, half of which decreased again after reinterventions. Last mean sac diameters were 4.2 ± 1.3 cm vs 5.5 ± 1.3 cm vs 7.5 ± 2.5 cm; P < .001). In closely monitored patients, failure of sac diameter decrease at 12 months is not associated with survival but is associated with new endoleaks and reinterventions. Patients with stable sacs should probably be more closely monitored as the endoleak and reintervention rate is significantly higher than for those with sac size decrease.

Laparoscopic Management of Cesarean Scar Ectopic Pregnancy after Failed Medical Management

Study Objective We describe a step-by-step approach of laparoscopic resection of cesarean scar ectopic pregnancy. Design A case report video. Setting Teaching hospital. Patients or Participants A 29-year-old gravida 4 para 1 woman who underwent a cesarean section two years back. She was diagnosed with cesarean scar ectopic pregnancy by transvaginal ultrasound scan with a 6-week live pregnancy. The patient received 2 doses of intramuscular injections of methotrexate. But on monitoring, the size of the ectopic sac remained the same with decline in the beta hCG. Suction evacuation was planned and post suction evacuation, patient started bleeding through os profusely for which uterine tamponade was done. After keeping patient in observation for 24 hours, the bleeding had not stopped. Thus, patient was considered for life saving laparoscopic excision of cesarean scar ectopic pregnancy. Interventions Laparoscopic management of cesarean scar ectopic pregnancy. Measurements and Main Results The diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The lower uterine segment was extremely thinned out. The uterovesical fold of peritoneum was dissected and bladder was pushed caudally. Adhesiolysis was done between the previous cesarean scar and the bladder. The ectopic gestational sac was identified, and incision was given at the most prominent site of the cesarean scar. The products of conception were evacuated in an EndoBag and extracted through the infra-umbilical port. The specimen was sent for histopathological examination. The margins of the previous scar were excised, and the uterine defect was repaired in two layers. Hemostasis was achieved. Intraoperative blood loss was minimal. Patient tolerated the procedure well and was discharged on POD3. Conclusion Laparoscopy is a safe and effective procedure of managing cesarean scar ectopic pregnancy after failed medical management. This gives an advantage of minimal blood loss, decrease post-operative pain and better cosmetic results.

Most Cesarean Scar Pregnancies Can be Managed with a Single Dose of Methotrexate

Study Objective To investigate the effectiveness of single dose methotrexate (MTX) regimen in cases of cesarean scar pregnancy (CSP). Design A retrospective cohort study of all CSPs from a tertiary medical center between the years 2011-2019. Conservative management included treatment with systemic MTX with ultrasound (US) guided needle aspiration of the gestational sac in the presence of fetal heartbeat. We divided the cohort into two groups: women that were treated according to the conservative protocol, and women treated with additional curettage or hysteroscopy. Maternal and gestational characteristics were compared between the groups. Setting N/A Patients or Participants The final study cohort included 32 women diagnosed with CSP and treated according to the conservative protocol. Interventions N/A Measurements and Main Results 16(47.1%) women underwent additional US guided needle aspiration. Nineteen patients(59.4%) had a successful conservative treatment. Baseline maternal characteristics were similar in both groups. There was no difference between the two groups in the time from last cesarean delivery(25 month vs 32, respectively, p=0.31), gestational age(47 vs 49 days respectively, p=0.63), gestational sac size(23 vs. 21 mm, respectively, p=0.54), level of βHCG at presentation(17049 vs. 18612, respectively, p=0.77), or evidence of fetal heart beat(48% vs. 54%, respectively, p=0.71). The presence of gestational sac hematoma upon admission was identified as a negative predictive factor for successful conservative management(5.3% vs 38.5%,OR [95%CI] 11.2, (1.1-112.5),p=0.02). Conclusion Single dose MTX is an effective mode of treatment in cases of CSP. The presence of a gestational sac hematoma on US was identified as a negative predictor for successful conservative treatment of CSP. No other predictive factors were identified. To investigate the effectiveness of single dose methotrexate (MTX) regimen in cases of cesarean scar pregnancy (CSP). A retrospective cohort study of all CSPs from a tertiary medical center between the years 2011-2019. Conservative management included treatment with systemic MTX with ultrasound (US) guided needle aspiration of the gestational sac in the presence of fetal heartbeat. We divided the cohort into two groups: women that were treated according to the conservative protocol, and women treated with additional curettage or hysteroscopy. Maternal and gestational characteristics were compared between the groups. N/A The final study cohort included 32 women diagnosed with CSP and treated according to the conservative protocol. N/A 16(47.1%) women underwent additional US guided needle aspiration. Nineteen patients(59.4%) had a successful conservative treatment. Baseline maternal characteristics were similar in both groups. There was no difference between the two groups in the time from last cesarean delivery(25 month vs 32, respectively, p=0.31), gestational age(47 vs 49 days respectively, p=0.63), gestational sac size(23 vs. 21 mm, respectively, p=0.54), level of βHCG at presentation(17049 vs. 18612, respectively, p=0.77), or evidence of fetal heart beat(48% vs. 54%, respectively, p=0.71). The presence of gestational sac hematoma upon admission was identified as a negative predictive factor for successful conservative management(5.3% vs 38.5%,OR [95%CI] 11.2, (1.1-112.5),p=0.02). Single dose MTX is an effective mode of treatment in cases of CSP. The presence of a gestational sac hematoma on US was identified as a negative predictor for successful conservative treatment of CSP. No other predictive factors were identified.

Risk factors for poor hemostasis of prophylactic uterine artery embolization before curettage in cesarean scar pregnancy.

ObjectiveTo observe the hemostatic effect of prophylactic uterine artery embolization (UAE) in patients with cesarean scar pregnancy (CSP) and to examine the risk factors for poor hemostasis.MethodsClinical data of 841 patients with CSP who underwent prophylactic UAE and curettage were retrospectively analyzed to evaluate the hemorrhage volume during curettage. A hemorrhage volume ≥200 mL was termed as poor hemostasis. The risk factors of poor hemostasis were analyzed and complications within 60 days postoperation were recorded.ResultsAmong the 841 patients, 6.30% (53/841) had poor postoperative hemostasis. The independent risk factors of poor hemostasis were gestational sac size, parity, embolic agent diameter (>1000 μm), multivessel blood supply, and incomplete embolization. The main postoperative complications within 60 days after UAE were abdominal pain, low fever, nausea and vomiting, and buttock pain, with incidence rates of 71.22% (599/841), 47.44% (399/841), 39.12% (329/841), and 36.39% (306/841), respectively.ConclusionsProphylactic UAE before curettage in patients with CSP is safe and effective in reducing intraoperative hemorrhage. Gestational sac size, parity, embolic agent diameter, multivessel blood supply, and incomplete embolization of all arteries supplying blood to the uterus are risk factors of poor hemostasis.

Endograft platform does not influence aortic neck dilatation after infrarenal endovascular aneurysm repair with primary endostapling.

Aortic endografts used for endovascular aneurysm repair (EVAR) are based on varying skeletal platforms such as stainless steel or nitinol stents, using radial force applied to seal at the aneurysm neck, and varying proximal fixation methods, applying either suprarenal or infrarenal fixation. This study assesses whether varying skeleton/fixation platforms affect neck-related outcomes after primary endostapling with Heli-FX EndoAnchors at EVAR. Retrospective analysis of a prospective database of infrarenal EVAR undertaken at a single centre. Chimney-EVAR, secondary cases were excluded. Primary outcomes analysed included neck diameter evolution from pre-EVAR to latest imaging follow-up, including a comparison of stent platforms to see if there was any outcome difference between those using stainless steel or nitinol, as also freedom from type I endoleakage and migration. Secondary outcomes assessed included average number of EndoAnchors, and sac size patterns before and after EVAR. A total of 101 patients underwent endostapled infrarenal EVAR between September 2013 and March 2020. After exclusion of ineligible patients, 84 patients (76 male, 8 female, age 73.7 ± 7.8 years) were available for analysis. 57/27 endografts used suprarenal/infrarenal fixation, whilst 16/68 devices were based on stainless steel/nitinol platforms, respectively. Mean oversizing was higher for stainless steel/suprarenal fixation endografts (p = 0.02). A total of 582 EndoAnchors were deployed, averaging 7 ± 2 per patient. Median neck diameter was 25 mm (IQR 22-31) with 22 necks having non-parallel morphology (conical, tapered or bubble). Median follow-up period was 28.5 (IQR 12-43) months. Neck evolution studies suggested aortic neck dilatation of 5 ± 4 mm (p <0.001, paired T-test), independent of platforms employed (p = NS, ANOVA). There was no endograft migration; one immediate post-EVAR endoleak settled by eight weeks. There was a mean 5.7 ± 8.2 mm sac size reduction (p < 0.001, paired T-test). Aortic neck dilatation occurs after EVAR with primary endostapling, but the process may be independent of stainless steel/nitinol platforms, possibly due to the attenuating effect of EndoAnchors. Adjunct aneurysm neck fixation by primary endostapling prevents migration regardless of whether suprarenal/infrarenal fixation is the primary fixative method. Device platform choice therefore may be left to the operator discretion if primary endostapling is applied at EVAR. Freedom from complications such as migration and endoleakage in the intermediate term suggests a higher level of 'tolerance' to aortic neck dilatation with primary endostapling. We would therefore suggest routine usage of EndoAnchors at EVAR when not otherwise contraindicated.

Risk Factors for Early and Late Type Ib Endoleak Following Endovascular Abdominal Aortic Aneurysm Repair

A type Ib endoleak (T1bEL) is a postoperative complication that usually requires additional interventions following endovascular aortic aneurysm repair. Previous studies have focused on iliac artery tortuosity or common iliac artery (CIA) diameter. However, we investigated the various risk factors for early and late T1bELs more comprehensively. This retrospective case-control study of a prospectively maintained database compared anatomical, demographic and technical factors between patients with early or late T1bELs and a control group. Early T1bEL was defined as a T1bEL occurring within 6months of endovascular aneurysm repair (EVAR), while late T1bEL was defined as a T1bEL, initially identified more than 6months after EVAR. Anatomical values including neck diameter, length, and angle; maximum sac diameter and length; CIA length, diameter, and tortuosity; and distal sealing length were measured and included in the analysis. We performed uni- and multivariable analyses using logistic regression and Cox proportional hazard models. This study included 635 iliac limbs of 383 patients. Overall, T1bELs occurred in 22 iliac limbs during the follow-up period (22/635, 3.5%). Among them, the early and late T1bEL groups each included 11 limbs. The median follow-up duration of the 383 patients was 23 (8-58) months, and in the early T1bEL and early control groups, the durations were 15 (9-35) and 29 (15-60) months, respectively (P=0.01). The median overall follow-up durations in the late T1bEL and late control groups were 87 (76-102) and 62 (48-80) months, respectively (P=0.01). The median follow-up duration until the occurrence of late T1bEL was 44 (32-82) months, which was shorter than that of the late control group (P=0.03). No significant differences in sex, age, or brand of stent-graft were observed between the T1bEL and control groups. In the multivariable analysis, patients in the early T1bEL group had significantly more tortuous and short CIAs, and short distal sealing lengths (P=0.02, P=0.04, P=0.03, respectively), and the late T1bEL group had significantly larger maximum aortic aneurysm sac diameters, short CIAs and short distal sealing lengths (P<0.001, P=0.02, P=0.002, respectively). The suspected mechanisms of the T1bELs were CIA dilatation with or without sac expansion and aggravation of sac angulation. Except for one patient with aortic dissection, T1bELs were treated with iliac limb extensions. The various mechanisms of T1bELs differed depending on the time of onset from the procedure. An extensive sealing length may be protective against T1bEL, especially when the size of the aortic aneurysm sac is large or when the CIA has risky features, including large diameter or short length. Careful preoperative consideration of aortic aneurysm size and CIA length and tortuosity is essential, and patients with risky features should undergo strict postoperative surveillance.

Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry

Aneurysm sac remodeling is a complex multifactorial process with unknown factors influencing sac regression after endovascular aortic aneurysm repair (EVAR). We sought to identify factors associated with this process by analyzing data obtained from patients treated with the GORE EXCLUDER endovascular aneurysm repair (EVAR) endoprosthesis from December 2010 to October 2016 enrolled in the Global Registry for Endovascular Aortic Treatment (GREAT). All patients enrolled in GREAT with three years CT angiography (CTA) follow-up in each of the three successive years after EVAR were included. The percentage of sac size reduction toward device diameter was calculated and used as a surrogate for sac regression with the formula used being: sac size reduction = ((AAA baseline diameter - AAA diameter at follow-up)/(AAA baseline diameter - device diameter))∗100. The cohort was divided into two groups in accordance with the percentage of aneurysm sac reduction at three years; one with the top quartile of patients and the other with the lowest three quartiles. Demographic and procedural variables were analyzed using univariate and regression modeling to determine factors predictive of sac regression. There were 3265 subjects enrolled with follow-up as of May 2018 of which 526 (16.2%) had three years of CTA surveillance. Overall aneurysm sac size decreased from a mean of 58.0mm (Std Dev: 10.4, range: 34.2, 100.0) to a mean of 49.3mm (Std Dev: 14.1, range: 0, 140) for a percentage reduction toward device diameter of a mean 28.2% (Std Dev: 39.0, range: -103.7, 183.9). On multivariate logistic regression model; two factors proved to be statistically significant contributors to a larger percentage reduction in aneurysm sac: a conical neck (odds ratio [OR]=1.64, P-value=0.023) and a larger proximal device diameter (OR=1.09, P-value=0.023). On the other hand, two factors were negative predictors of sac shrinkage, namely: old age (OR=0.96, P-value=0.002) and larger baseline aneurysm sac diameter (OR=0.98, P-value=0.028). Aneurysms with conical necks and larger proximal device neck diameters have an increased percentage change in sac size over time after EVAR. Older age and larger initial diameters of aneurysms were negatively associated with percentage change in sac size as well as sac regression. Further study is needed to determine the clinical utility of these observations and applicability across multiple endoprosthesis platforms.

Effect of Stent Graft Active Fixation and Oversizing on Aortic Neck Degeneration After Endovascular Aneurysm Exclusion for Infrarenal Aortic Aneurysm

Aortic neck degeneration after endovascular aneurysm repair (EVAR) has been implicated in the long-term development of endoleak and the subsequent reintervention. Optimal endograft sizing is a vital aspect to successful repair. This study looked at percentage of graft oversizing as well as type of fixation on aortic neck degeneration. We retrospectively evaluated all EVARs completed at Loyola University from 2006 to 2015 after Institutional Review Board approval. Exclusion criteria were patients without follow-up scans within a year. We collected demographics, comorbidities, graft type, size, aortic neck diameter, and maximum sac size diameters from the preoperative and follow-up scans. We reviewed and collected data of 432 patients but analyzed 154. We measured the largest aortic diameter on axial images 1 cm above and 1 cm below the renal arteries. Change in suprarenal and infrarenal aortic measurements were evaluated by calculating the millimeter difference from each scan compared with the preoperative scan. Linear mixed effects models were used to estimate patients’ mean differences over time. We compared three groups of neck fixation grafts. Those with active suprarenal fixation had a significant change in suprarenal aortic diameter at 4-year follow-up (1.86 mm; confidence interval [CI], 0.65-3.06) compared to those with active infrarenal (0.22 mm; CI, −0.67 to 1.11) or passive suprarenal fixation (1.52 mm; CI, −0.11 to 3.15; Fig 1). Those with active suprarenal fixation were the only ones to have significant increase in suprarenal aortic diameter (P = .0026). Degree of oversizing was also divided into three groups. Oversizing by <10% had less impact on the suprarenal aorta than >15% oversizing at 4 years (0.41 mm [CI, −0.31 to 1.14] vs 3.26 mm [CI, 1.63-4.88]; P < .001; Fig 2). Oversizing had a more pronounced effect on the infrarenal aorta: 4.43 mm [CI, 2.79-6.08], 5.57 mm [CI, −0.25 to 11.38], and 6.48 mm [CI, 2.99-9.97] for <10%, 10% to 15%, and >15% oversizing at 4 years, respectively. Stent grafts with active fixation below the renal arteries as well as oversizing by <10% seem to have the least effect on aortic neck degeneration over time. These factors should be considered in performing EVARs as aortic neck degeneration could lead to endoleaks. Further research defining the optimal stent graft type and oversizing is warranted.Fig 2Suprarenal aortic diameter change over time for each stent graft type. CI, Confidence interval.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Thyroid disrupting effects of perfluoroundecanoic acid and perfluorotridecanoic acid in zebrafish (Danio rerio) and rat pituitary (GH3) cell line

Due to global restriction on perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA), the use of long-chain perfluoroalkyl substances (PFASs, C > 8) and their environmental occurrences have increased. PFOS and PFOA have been known for thyroid disruption, however, knowledge is still limited on thyroid disrupting effects of long-chain PFASs (C > 10). In this study, two long-chain perfluorinated carboxylic acids (PFCAs), i.e., perfluoroundecanoic acid (PFUnDA) and perfluorotridecanoic acid (PFTrDA), were chosen and investigated for thyroid disrupting effects, using zebrafish embryo/larvae and rat pituitary cell line (GH3). For comparison, PFOA was also added as a test chemical and also investigated for its thyroid disruption potential. Following a 5 d exposure to PFTrDA, zebrafish larvae showed upregulation of the genes responsible for thyroid hormone synthesis (tshβ, nkx2.1, nis, tpo, mct8) and (de)activation (dio1, dio2). In contrast, both PFUnDA and PFOA induced no regulatory changes except for upregulation of a thyroid metabolism related gene (ugt1ab). Morphological changes such as decreased eyeball size, increased yolk sac size, or deflated swim bladder, occurred following exposure to PFUnDA, PFTrDA, and PFOA. In GH3 cells, exposure to PFUnDA and PFTrDA upregulated Tshβ gene, suggesting that these PFCAs increase thyroid hormone synthesis through stimulation by Tsh. In summary, both long-chain PFCAs could cause transcriptional changes of thyroid regulating genes that may lead to increased malformation of the zebrafish larvae, but the pathway of thyroid disruption appears to be different by the chain length. Confirmation and validation in adult fish following long term exposure are warranted.

Heart malformation is an early response to valproic acid in developing zebrafish.

Valproic acid (VPA) is a branched short-chain fatty acid primarily used in epilepsy, but is also used in bipolar disorder, migraine, and psychotic disorders. Despite its wide range of use, it is a teratogen resulting in various congenital abnormalities. Although a large number of scientific studies evidenced the teratogenic effects, there are limited data on embryonic exposure to VPA at specific or different stages of early embryogenesis. Based on this, the present study was planned to investigate the embryonic exposure to VPA at specific and different hours post fertilization (hpf) in zebrafish embryonic model. In first set of experiments, embryos from spawning groups of adult zebrafish were exposed to different molar concentrations of VPA at 2.5 hpf, and in the second set of experiments, embryos were exposed to VPA 100μM at 24 hpf, 36 hpf, 48 hpf, 72 hpf, and 96 hpf. The parameters examined were hatching rate, mortality, morphology, body length, pericardial sac size, heartrate, anatomical changes in heart, skeletal and notochord till 120 hpf. It was observed that the embryos exposed to VPA at 2.5 hpf suffered from cardiac abnormalities including heart malformation, bradycardia, circulatory failure, and pericardial sac enlargement which was more apparent in embryos exposed to 100μM VPA. In the second set of experiments, embryos exposed to VPA 100μM at 24 hpf and 36 hpf suffered from heart malformations, but there was no incidence of cardiac malformation in embryos exposed to VPA at 48 hpf, 72 hpf, and 96hpf. From the results, it was evident that exposure to VPA at early developmental stage of embryogenesis produced congenital cardiac abnormalities. Since VPA is a selective HDAC inhibitor, histone acetylation with aberrant gene expression during cardiogenesis might be the underlying cause of cardiac malformation.

Hatching and survival of the salmon 'gill maggot' Salmincola californiensis (Copepoda: Lernaeopodidae) reveals thermal dependence and undocumented naupliar stage.

Salmincola californiensis is a Lernaeopodid copepod parasitizing Pacific salmon and trout of the genus Oncorhynchus. Salmincola californiensis is of increasing concern in both native and introduced ranges because of its potential fish health impacts and high infection prevalence and intensity in some systems. Discrepancies in the documented life history phenology of S. californiensis with the sister species Salmincola edwardsii, as well as our laboratory observations, led us to question the existing literature. We documented a naupliar stage, thought lost for S. californiensis. In addition, we found a high degree of thermal sensitivity in egg development, with eggs developing faster under warmer conditions. Survival of copepodids was also highly dependent on temperature, with warmer conditions reducing lifespan. The longest lived copepodid survived 18 days at 4°C in stark contrast to the generally accepted <48 h survival for that life stage. We also note a consistent relationship between egg sac size and the number of eggs contained. However, egg sac sizes were highly variable. Our findings demonstrate that revisiting old assumptions for S. californiensis and related taxa will be a necessary step to improving our knowledge of the parasite life history and development that will be critical to disease management.

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks

To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12months. Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68min (mean 51.36min). Mean fluoroscopy time was 16.7min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Surgical treatment patterns and clinical outcomes of patients treated for expanding aneurysm sacs with type II endoleaks after endovascular aneurysm repair

ObjectivePersistent type II endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) with sac growth have been associated with adverse events, including rupture. Whereas intervention in the presence of aneurysm growth has become an accepted treatment paradigm for T2ELs, the efficacy and clinical success of such interventions remain unclear. Therefore, we examined the treatment patterns and clinical outcomes of patients undergoing T2EL interventions after EVAR. MethodsWe performed a retrospective review of all patients treated for expanding aneurysm sacs with T2ELs after EVAR at an academic medical center between 2006 and 2017. The primary outcomes assessed were need for repeated intervention; intervention types; and achievement of clinical success, defined as stable aneurysm sac size on computed tomography angiography after treatment. ResultsFifty-six patients underwent 119 interventions, of which 107 (90%) were technically successful. The median time from EVAR to index T2EL procedure was 37 months (interquartile range, 17-56 months), and the median follow-up time from first T2EL procedure was 27 months (interquartile range, 10-51 months). The most common index procedure was transarterial lumbar embolization (64%), followed by transarterial inferior mesenteric artery (20%), transcaval (14%), and translumbar embolization (1.8%). Thirty-three (59%) patients required further procedures for persistent aneurysm sac expansion. For subsequent T2EL interventions, the most common endovascular procedure was transarterial lumbar embolization (21%), followed by transcaval (21%), translumbar (11%), and transarterial inferior mesenteric artery embolization (8.6%). Twelve patients (21%) were found to have loss of proximal or distal seal on subsequent imaging and required graft extensions to stabilize aneurysm sac size. Ten patients (18%) ultimately underwent graft explantation or sacotomy with oversewing of the endoleak source. Freedom from any endoleak-related reintervention was 57% at 1 year and 36% at 3 years. Freedom from open treatment was 93% at 1 year and 82% at 3 years. Of the 44 patients with ≥6-month follow-up, 39 (89%) achieved clinical success. However, only 11 patients (25%) achieved clinical success without any further reintervention, and 29 patients (66%) achieved clinical success without open treatment. ConclusionsDespite high technical success, endoleak recurrence after T2EL treatment is common, and multiple interventions are often needed to stabilize aneurysm sac size in patients diagnosed with T2EL-associated sac growth. Notably, one in five patients treated for T2ELs was discovered, on further evaluation, to have proximal or distal seal zone loss that necessitated repair to achieve sac stability. Thus, thorough assessment of all endoleak types should be performed in patients with T2ELs associated with sac growth before T2EL treatment to ensure appropriate care and to minimize ineffective interventions.