Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits

OBJECTIVES

The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access.

METHODS

A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention.

RESULTS

Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease.

CONCLUSIONS

Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.

Application of the VORTEC Technique in Creating a Proximal Inflow Conduit in the Circumferentially-Calcified or "Lead-Pipe" Aorta

A heavily calcified or "lead-pipe" aorta can present many challenges to any surgeon. There is higher risk of vessel wall rupture or disruption, distal embolization, and prolonged ischemia time of visceral organs due to longer clamp times. Hybrid revascularization techniques, which were originally described in visceral revascularization during complex aortic procedures, can be potentially utilized for lower extremity bypasses. These techniques, such as "VORTEC," are well-studied and have been shown to have similar patency rates as traditional bypass grafts with the added benefit of decreased ischemia time and lower levels of acute kidney injury and visceral organ ischemia. This allows VORTEC and other similar hybrid techniques to be utilized as options when traditional vessel control cannot be safely achieved during distal revascularization procedures, as we describe in our patient.

Accessory renal arteries involved in atherosclerotic occlusive disease at the aortic bifurcation

Accessory renal arteries (ARAs) are embryonic remnants found in more than one-third of patients and occurring bilaterally in 10% of the population. Very few reports have documented such vessels arising near or at the level of the aortic bifurcation. Furthermore, the presence of ARAs has yet to be described in the context of atherosclerotic disease. Here, we present a unique case of large bilateral ARAs originating above the aortic bifurcation concurrent with symptomatic aortoiliac atherosclerotic disease. We highlight the embryologic and clinical significance of these vessels as well as discuss their potential role in accelerating atherosclerotic disease processes.

Pseudoaneurysm of Patent Ductus Arteriosus Following Previous PDA Closure: Case Report and Literature Review

BACKGROUND

Pseudoaneurysm developing after repair of a patent ductus arteriosus (PDA) is uncommon, with only a handful of cases reported in the literature. While older literature cites infection, recent series suggest that formation of pseudoaneurysm off of a ligated PDA attributed to breakdown in the suture line. Thoracic endovascular aortic repair (TEVAR) for this rare pathology has been demonstrated in selected case reports.

METHODS/RESULTS

A 61-year-old woman presented with enlarging left chest mass and shortness of breath. The patient reported a history of a PDA with 2 attempts at closure. At age 6, she had undergone an attempt at endovascular closure of the PDA; this subsequently resulted in right lower extremity limb ischemia with resultant below-knee amputation. At age 12, she underwent open thoracotomy with ligation of the PDA; at this procedure, she had injury to her recurrent laryngeal nerve, resulting in permanent hoarseness of voice. A computed tomography angiogram of the chest was obtained, which demonstrated a saccular 4.5 × 3.8 cm pseudoaneurysm in the region of the PDA with calcific wall changes. Recommendation was made to proceed with operative repair and she agreed. A TEVAR was performed using a commercially available stent graft. During the procedure, intravascular ultrasound was performed; however, the connection between the PDA pseudoaneurysm and the aorta was not visualized. She had an uncomplicated operative and postoperative course. Follow-up imaging showed complete thrombosis of the pseudoaneurysm.

CONCLUSIONS

Pseudoaneurysm from previous PDA repair is a rare pathology. We present a unique case in which the patient had undergone attempts at both endovascular and open surgical repair. Open repair for PDA is still advocated; however, TEVAR appears to be a safe treatment in adults with this pathology following failed open closure.

Abstract 4557: Expression of p16 in colon cancer and cyclin D1 in gastric cancer predicts response to CDK4/6 inhibition in vitro

Background: Cyclin-dependent kinases (CDKs) play a significant role in regulating cell cycle progression through association with cyclins. CDK4 and CDK6 interact with cyclin D1 to mediate hyperphosphorylation of retinoblastoma (Rb) during early G1 phase. Palbociclib is a highly selective inhibitor of CDK4 and CDK6 which functions by blocking pRb phosphorylation resulting in G1 arrest in sensitive cell lines. We evaluated the effect of palbociclib in gastric and colon cancer cell lines to explore potential biomarkers of response and to guide patient selection in colon and gastric cancer.

Methods: Panels of 17 gastric and 27 colon cancer cell lines were exposed in vitro to palbociclib over various concentrations to generate dose response curves. Analysis of variance (ANOVA) was used to identify differentially expressed genes between sensitive and resistant cell lines. Genes identified by ANOVA and effects of palbociclib on pRB were analyzed via western blot.

Results: Palbociclib was found to have potent anti-proliferative activity in the low nanomolar range (< 150 nM) for 14 of the 44 gastric and colon cancer cell lines tested. In gastric cancer, cyclin D1-amplified cells cells expressed greater sensitivity to the compound when compared to cyclin D1-negative cells. HER2 amplified cell lines were also statistically more sensitive than HER2 negative cells. Combination studies with palbociclib and trastuzumab demonstrated significant synergy in HER2 amplified gastric cancer models. Furthermore, cyclin E emerged as a biomarker for resistance to the compound in gastric cancers. Contrary to observations made in other cancers, expression levels of p16 (CDK4 inhibitor) and p21 (CDK2 inhibitor) in colon cancer indicated that p16 loss and p21 gain predict for resistance rather than sensitivity to CDK4 and CDK6 inhibition.

Conclusions: Palbociclib demonstrates anti-proliferative activity in several gastric and colon cancer cell lines. Molecular markers found to predict for sensitivity to this agent enhance patient selection for future clinical studies of palbociclib.

Citation Format: Zev A. Wainberg, Ann Yufa, Adrian Anghel, Amy M. Rogers, Tin Manivong, Shahriar Adhami, Habib Hamidi, Dylan Conklin, Richard S. Finn, Dennis J. Slamon. Expression of p16 in colon cancer and cyclin D1 in gastric cancer predicts response to CDK4/6 inhibition in vitro. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4557. doi:10.1158/1538-7445.AM2014-4557

Attentional resource allocation during a cued saccade task

Attentional selection of sensory information and motor output is critical for successful interaction with one's surroundings. However, organization of attentional processes involved in selection of salient visual information, decision making, and movement planning has not yet been fully elucidated. We hypothesized that attentional processes involved in these tasks can function independently and draw from separate resources. If true, challenging the capacity limit of one attentional process would not affect performance of others. Healthy participants performed a cued saccade task in which target cues were embedded in a central stream of letters in a Rapid Serial Visual Presentation (RSVP). Participants performed saccades as quickly and as accurately as possible to a peripheral target location based on cue presentation within the central letter stream. To challenge visual attention, we parametrically varied the duration at which each letter of the RSVP was presented (50-200ms). In a separate experiment we challenged motor attention by increasing the number of possible saccade trajectories (1-6 peripheral targets). As expected, increasing attentional load in one domain of the task negatively affected performance in that domain, while performance in other domains was unaffected. We interpret our results as support for the independent allocation of attentional resources, at least in the early stages of processing, required across components of a cued saccade task. Deciphering the contributions of attention during visuomotor tasks is a critical step to understanding how humans process information necessary to successfully interact with the environment.