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Samra HS, Severance SE, Gutwein AR, Gupta AK. Osteochondroma as an Unusual Cause of Popliteal Artery Pseudoaneurysm and Occlusion. Vasc Endovascular Surg 2023; 57:251-256. [PMID: 36223909 DOI: 10.1177/15385744221132909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Osteochondromas are the most common benign bony tumour, usually occurring in the 2nd/3rd decade of life and generally asymptomatic. However, there have been reports of bony tumours causing arterial vascular injuries via erosion into vessel walls. We present a case of a 16-year-old M with no significant past medical history who presented with acute-on-chronic Right Lower Extremity (RLE) pain and numbness who was found to have a popliteal artery pseudoaneurysm and occlusion. We will discuss our initial work up, management, outcomes and follow up and compared our results with an English language literature search for comparable cases.
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Affiliation(s)
- Humraaz S Samra
- Division of Vascular Surgery, 12250Indiana University School of Medicine Department of Surgery, Indianapolis, IN, USA
| | - Sarah E Severance
- Division of Vascular Surgery, 12250Indiana University School of Medicine Department of Surgery, Indianapolis, IN, USA
| | - Ashley R Gutwein
- Division of Vascular Surgery, 12250Indiana University School of Medicine Department of Surgery, Indianapolis, IN, USA
| | - Alok K Gupta
- Division of Vascular Surgery, 12250Indiana University School of Medicine Department of Surgery, Indianapolis, IN, USA
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Gutwein AR, Sawchuk AP. An Interesting Case of a Patient With Disabling Bilateral Lower Extremity Claudication and a Persistent Sciatic Artery. Vasc Endovascular Surg 2022; 56:808-811. [PMID: 35948009 DOI: 10.1177/15385744221120744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A persistent sciatic artery is a rare congenital anomaly. This case report highlights the treatment for a patient with a persistent sciatic artery no longer in continuity with the internal iliac artery and atherosclerotic peripheral vascular disease resulting in disabling bilateral lower extremity claudication. It highlights the types and anatomic locations of the sciatic artery and discusses an effective way to treat a patient with arterial insufficiency and this variant anatomy as well as other treatment options.
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Affiliation(s)
- Ashley R Gutwein
- Department of Surgery, Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alan P Sawchuk
- Department of Surgery, Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
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Motaganahalli RL, Kapoor R, Timsina LR, Gutwein AR, Ingram MD, Raman S, Roberts SD, Rahman O, Rollins D, Dalsing MC. Clinical and laboratory characteristics of patients with novel coronavirus disease-2019 infection and deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 9:605-614.e2. [PMID: 33190816 PMCID: PMC7581378 DOI: 10.1016/j.jvsv.2020.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Early reports suggest that patients with novel coronavirus disease-2019 (COVID-19) infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical and laboratory characteristics. METHODS We reviewed the demographics, clinical presentation, laboratory and radiologic evaluations, results of venous duplex imaging and mortality of COVID-19-positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiologic findings, and need for advanced respiratory therapies, patients were classified into mild, moderate, or severe categories of COVID-19 infection. A descriptive analysis was performed using univariate and bivariate Fisher's exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the adjusted odds ratio of experiencing DVT and a receiver operating curve analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan-Meier plots. RESULTS Our study included 71 unique COVID-19-positive patients (mean age, 61 years) categorized as having 3% mild, 14% moderate, and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% of examinations) at an average of 5.9 days after admission. Patients with DVT were predominantly male (67%; P = .032) with proximal venous involvement (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ± 7032 ng/mL (P = .0101), and alkaline phosphatase of 110 IU/L (P = .0095) than those without DVT. On multivariable analysis, elevated d-dimer (P = .038) and alkaline phosphatase (P = .021) were associated with risk for DVT, whereas age, sex, elevated C-reactive protein, and ferritin levels were not. A receiver operating curve analysis suggests an optimal d-dimer value of 2450 ng/mL cutoff with 70% sensitivity, 59.5% specificity, and 61% positive predictive value, and 68.8% negative predictive value. CONCLUSIONS This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers and alkaline phosphatase along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment.
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Affiliation(s)
- Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.
| | - Rajat Kapoor
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Lava R Timsina
- Department of Surgery, Center for Outcomes Research in Surgery, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael D Ingram
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Subha Raman
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Scott D Roberts
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Omar Rahman
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - David Rollins
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
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Leckie K, Green L, Wang KS, Gutwein AR, Motaganahalli RL, Fajardo A, Murphy MP, Maijub JG. SS20. Medium-term Effect of Intramuscular Injection of Autologous Bone Marrow Cells in Patients With Critical Limb Ischemia: Two-Year Follow-up of the MOBILE Trial. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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5
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Wang SK, Green LA, Gutwein AR, Drucker NA, Murphy MP. Metformin Does Not Reduce Inflammation in AAA and At-Risk Patients. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2018.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Wang SK, Gutwein AR, Gupta AK, Lemmon GW, Sawchuk AP, Motaganahalli RL, Murphy MP, Fajardo A. Institutional experience with the Zenith Fenestrated aortic stent graft. J Vasc Surg 2018; 68:331-336. [DOI: 10.1016/j.jvs.2017.11.063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Wang SK, Murphy MP, Gutwein AR, Drucker NA, Dalsing MC, Motaganahalli RL, Lemmon GW, Akingba AG. Perioperative Outcomes are Adversely Affected by Poor Pretransfer Adherence to Acute Limb Ischemia Practice Guidelines. Ann Vasc Surg 2018; 50:46-51. [DOI: 10.1016/j.avsg.2017.11.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
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Wang SK, Green LA, Gutwein AR, Kenyon B, Motaganahalli RL, Fajardo A, Gupta AK, Murphy MP. Metformin does not reduce inflammation in diabetics with abdominal aortic aneurysm or at high risk of abdominal aortic aneurysm formation. Vascular 2018; 26:608-614. [PMID: 29871586 DOI: 10.1177/1708538118777657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The protective effect of diabetes mellitus on abdominal aortic aneurysm formation and growth has been repeatedly observed in population studies but continues to be poorly understood. However, recent investigations have suggested that metformin, a staple antihyperglycemic medication, may be independently protective against abdominal aortic aneurysm formation and growth. Therefore, we describe the effect of metformin in abdominal aortic aneurysm and at-risk patients on markers of inflammation, the driver of early abdominal aortic aneurysm formation and growth. METHODS Peripheral blood was collected from patients previously diagnosed with abdominal aortic aneurysm or presenting for their U.S. Preventive Task Force-recommended abdominal aortic aneurysm screening. Plasma and circulating peripheral blood mononuclear cells were isolated using Ficoll density centrifugation. Circulating plasma inflammatory and regulatory cytokines were assessed with enzyme-linked immunosorbent assays. CD4+ cell phenotyping was performed using flow cytometric analysis and expressed as a proportion of total CD4+ cells. To determine the circulating antibody to self-antigen response, a modified enzyme-linked immunosorbent assay was performed against antibodies to collagen type V and elastin fragments. RESULTS Peripheral blood was isolated from 266 patients without diabetes mellitus ( n=182), with diabetes mellitus not treated with metformin ( n=34), and with diabetes mellitus actively taking metformin ( n=50) from 2015 to 2017. We found no differences in the expression of Tr1, Th17, and Treg CD4+ fractions within diabetics ± metformin. When comparing inflammatory cytokines, we detected no differences in IL-1β, IL-6, IL-17, IL-23, IFN-γ, and TNF-α. Conversely, no differences were observed pertaining to the expression to regulatory cytokines IL-4, IL-10, IL-13, TSG-6, or TGF-β. Lastly, no differences in expression of collagen type V and elastin fragment antigen and/or antibodies were detected with metformin use in diabetics. CONCLUSION Metformin in diabetics at-risk for abdominal aortic aneurysm or diagnosed with abdominal aortic aneurysm does not seem to alter the peripheral inflammatory environment.
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Affiliation(s)
- S Keisin Wang
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Linden A Green
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Ashley R Gutwein
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Bianca Kenyon
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Raghu L Motaganahalli
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Andres Fajardo
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Alok K Gupta
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Michael P Murphy
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, USA
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Wang SK, Lemmon GW, Drucker NA, Motaganahalli RL, Dalsing MC, Gutwein AR, Gray BW, Murphy MP. Results of nonoperative management of acute limb ischemia in infants. J Vasc Surg 2018; 67:1480-1483. [DOI: 10.1016/j.jvs.2017.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
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10
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Wang SK, Green LA, Gutwein AR, Drucker NA, Motaganahalli RL, Gupta AK, Fajardo A, Murphy MP. Description of human AAA by cytokine and immune cell aberrations compared to risk-factor matched controls. Surgery 2018; 164:354-358. [PMID: 29716755 DOI: 10.1016/j.surg.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/01/2018] [Accepted: 03/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The pathogenesis driving the formation of abdominal aortic aneurysms continues to be poorly understood. Therefore, we systemically define the cytokine and circulating immune cell environment observed in human abdominal aortic aneurysm compared with risk-factor matched controls. METHODS From 2015 to 2017, a total of 274 patients donated blood to the Indiana University Center for Aortic Disease. Absolute concentrations of circulating cytokines were determined, using enzyme-linked immunosorbent assays while the expression of circulating immune cell phenotypes were assayed via flow cytometric analysis. RESULTS Human abdominal aortic aneurysm is characterized by a significant depletion of the antigen-specific, CD4+ Tr1 regulatory lymphocyte that corresponds to an upregulation of the antigen-specific, inflammatory Th17 cell. We found no differences in the incidence of Treg, B10, and myeloid-derived suppressor regulatory cells. Similarly, no disparities were noted in the following inflammatory cytokines: IL-1β, C-reactive protein, tumor necrosis factor α, interferon γ, and IL-23. However, significant upregulation of the inflammatory cytokines osteopontin, IL-6, and IL-17 were noted. Additionally, no changes were observed in the regulatory cytokines IL-2, IL-4, IL-13, TNF-stimulated gene 6 protein, and prostaglandin E2, but we did observe a significant decrease in the essential regulatory cytokine IL-10. CONCLUSION In this investigation, we systematically characterize the abdominal aortic aneurysm-immune environment and present preliminary evidence that faulty immune regulation may also contribute to aneurysm formation and growth.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alok K Gupta
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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11
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Wang SK, Gutwein AR, Motaganahalli RL, Fajardo A, Dalsing MC, Lemmon GW, Akingba AG, Murphy MP. Acute Limb Ischemia at a Tertiary Referral Center: Analysis of Compliance with Practice Guidelines. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2018.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Wang SK, Green LA, Gutwein AR, Drucker NA, Babbey CM, Gupta AK, Fajardo A, Motaganahalli RL, Wilson MG, Murphy MP. Ethnic minorities with critical limb ischemia derive equal amputation risk reduction from autologous cell therapy compared with whites. J Vasc Surg 2018; 68:560-566. [PMID: 29503004 DOI: 10.1016/j.jvs.2017.11.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Ethnic minorities (nonwhites) with critical limb ischemia (CLI) have historically performed worse compared with whites with regard to major amputation risk reduction and amputation-free survival (AFS) after peripheral vascular intervention. This post hoc analysis was completed to determine whether this precedent also extended to treatment of CLI without a suitable revascularization option with intramuscular injections of concentrated bone marrow aspirate (cBMA). METHODS The treatment arm of the randomized, double-blind, multicenter MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial was stratified by ethnicity and evaluated for demographics, comorbidities, and outcomes. The primary and therapeutic end point was 1-year AFS and major amputation, respectively. Noninferiority analysis was performed with the margin set at historically reported hazard ratios. RESULTS Thirty-seven minority (African American, Hispanic, other) CLI patients (9 placebo, 28 cBMA) with no suitable revascularization option were randomized to cBMA or placebo at a 3:1 ratio during the MOBILE trial. At 1-year follow-up for the treatment group, overall AFS was 80%. Of the 28 minority patients randomized to cBMA intervention, an 89% AFS rate was observed compared with 77% in whites. Specifically, 22 of 24 (92%) African Americans survived amputation free at 1-year follow-up. Noninferiority testing confirmed no difference between whites and the ethnic minority treated with cBMA with respect to major amputation reduction; however, noninferiority could not be confirmed with regard to AFS. No significant differences favoring whites treated with cBMA were noted in the secondary end points of vascular quality of life, limb pain, ankle-brachial index, toe-brachial index, transcutaneous oximetry, and 6-minute walk testing. CONCLUSIONS This post hoc analysis of the MOBILE trial demonstrates noninferiority of cBMA intervention in minorities with no-option CLI for the therapeutic end point of major amputation prevention. cBMA represents a novel treatment paradigm and should be explored for minorities with poor revascularization options who face impending amputation secondary to progressive CLI.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Clifford M Babbey
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Wang SK, Gutwein AR, Drucker NA, Murphy MP, Fajardo A, Dalsing MC, Motaganahalli RL, Lemmon GW. Cryopreserved Homografts in Infected Infrainguinal Fields Are Associated with Frequent Reinterventions and Poor Amputation-Free Survival. Ann Vasc Surg 2018; 49:24-29. [PMID: 29421428 DOI: 10.1016/j.avsg.2017.10.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Single-length saphenous vein continues to be the conduit of choice in infected-field critical limb ischemia. However, half of these individuals have inadequate vein secondary to previous use or chronic venous disease. We reviewed our outcomes of infected-field infrainguinal bypasses performed with cryopreserved homografts (CHs), a widely accepted alternative to autogenous vein in this setting. METHODS This is a retrospective, institutional descriptive analysis of infected-field infrainguinal revascularizations between 2012 and 2015. RESULTS Twenty-four operations were performed in the same number of patients for limb ischemia with signs of active infection. The mean age of the cohort examined was 62.5 ± 14.4 (standard deviation) years. Mean Society of Vascular Surgery risk score was 3.9 with a baseline Rutherford's chronic ischemia score of 4.3 at presentation. Emergent procedures constituted 29% of cases, and the remainder cases were urgent procedures. The CH bypass captured was a reoperative procedure in all but one of the patients. Culture positivity was present in 75% of cases with Staphylococcus aureus (29%), the most commonly isolated organism. Thirty-day mortality and major adverse cardiovascular events were both 4%. Amputation-free survival (AFS) was 75% at 30 days. Similarly, 30-day reintervention was 38% with debridement (43%) and bleeding (29%), the most common indications. Average duration of follow-up was 27.9 ± 20.4 months (range: 0.5-60.4). Mean length of stay was 14.8 days. Reinfection requiring an additional procedure or antibiotic regimen separate from the index antibiotic course was 13%. Primary patency and AFS at 1 year was 50% and 58%, respectively. Primary patency and AFS at 2 years was 38% and 52%, respectively. Limb salvage at 1 and 2 years was 70% and 65%, respectively. Fifteen patients (63%) required reintervention during the follow-up period with 40% of those subjects undergoing multiple procedures. CONCLUSIONS CHs remain a marginal salvage conduit in the setting of infection and no autogenous choices. Therefore, clinicians should individualize usage of this high-cost product in highly selected patients only.
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Affiliation(s)
- S Keisin Wang
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - Ashley R Gutwein
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Natalie A Drucker
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andres Fajardo
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael C Dalsing
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Gary W Lemmon
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
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Wang SK, Green LA, Gutwein AR, Gupta AK, Babbey CM, Motaganahalli RL, Fajardo A, Murphy MP. Osteopontin may be a driver of abdominal aortic aneurysm formation. J Vasc Surg 2018; 68:22S-29S. [PMID: 29402664 DOI: 10.1016/j.jvs.2017.10.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Previous in vitro and animal studies have suggested that osteopontin (OPN), an inflammatory extracellular matrix protein, is involved in the formation and growth of abdominal aortic aneurysms (AAAs). However, the mechanism by which this occurs continues to be nebulous. The relationship between OPN and inflammation-suppressing lymphocytes present in the human AAA condition was investigated and presented herein. METHODS Serum OPN concentrations were measured in healthy, risk factor-matched non-AAA and AAA patients by enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry was used to determine the source of OPN secretion using aortic tissue collected from multiorgan donors and AAA patients undergoing open surgical repair. Vascular smooth muscle cells (VSMCs) were exposed to various inflammatory mediators, and OPN expression was evaluated by quantitative reverse transcriptase-polymerase chain reaction and ELISA. The inflammatory nature of OPN and the aortic wall was determined using a TR1 suppressor cell induction assay as a surrogate and characterized by ELISA and fluorescence-activated cell sorting. RESULTS OPN was found to be elevated in both the plasma and aortic homogenate of AAA patients compared with controls. On immunohistochemistry, OPN localized to the tunica media of the diseased aorta but was minimally expressed in healthy aorta. In vitro, cigarette smoke extract was the most potent stimulator of OPN secretion by VSMCs and increased both messenger RNA and supernatant concentrations. OPN demonstrated an ability to inhibit the induction of interleukin 10-secreting TR1 lymphocytes, a depleted population in the AAA patient, from naive precursors. Last, neutralizing receptor targets of OPN in the setting of AAA homogenate coincubation abrogated the inhibition of TR1 induction. CONCLUSIONS OPN, secreted by the VSMCs of the tunica media, is elevated in the circulating plasma and aortic wall of patients with AAA. It can inhibit the induction of the TR1 suppressor cell, leading to an overall proinflammatory state contributing to progressive aortic wall breakdown and dilation.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Alok K Gupta
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Clifford M Babbey
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard Roudebush VA Medical Center, Indianapolis, Ind.
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15
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Wang SK, Gutwein AR, Casciani T, Murphy MP, Lemmon GW. Staged endovascular repair of an abdominal aortic aneurysm adjacent to a chronic high-flow iliocaval traumatic arteriovenous fistula. J Vasc Surg Cases Innov Tech 2018; 3:247-250. [PMID: 29349437 PMCID: PMC5765185 DOI: 10.1016/j.jvscit.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/07/2017] [Indexed: 11/24/2022]
Abstract
Large-vessel chronic traumatic arteriovenous fistulas are a rare complication after trauma. Delayed presentation can consist of one or more features of high-output cardiac failure, pulsatile abdominal mass, bruit, limb ischemia, and venous congestion. We describe a patient with a complex iliocaval fistula secondary to a remote gunshot wound associated with a large 8.5-cm aortic aneurysm. Informed consent of the patient was obtained for publication of the case.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Tom Casciani
- Division of Interventional Radiology, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gary W Lemmon
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
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Wang SK, Green LA, Gutwein AR, Drucker NA, Motaganahalli RL, Fajardo A, Babbey CM, Murphy MP. Rationale and Design of the ARREST Trial Investigating Mesenchymal Stem Cells in the Treatment of Small Abdominal Aortic Aneurysm. Ann Vasc Surg 2017; 47:230-237. [PMID: 28916304 DOI: 10.1016/j.avsg.2017.08.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/21/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are a major source of morbidity and mortality despite continuing advances in surgical technique and care. Although the inciting factors for AAA development continue to be elusive, accumulating evidence suggests a significant periaortic inflammatory response leading to degradation and dilation of the aortic wall. Previous human trials have demonstrated safety and efficacy of mesenchymal stem cells (MSCs) in the treatment of inflammation-related pathologies such as rheumatoid arthritis, graft versus host disease, and transplant rejection. Therefore, herein, we describe the Aortic Aneurysm Repression with Mesenchymal Stem Cells (ARREST) trial, a phase I investigation into the safety of MSC infusion for patients with small AAA and the cells' effects on modulation of AAA-related inflammation. METHODS ARREST is a phase I, single-center, double-blind, randomized controlled trial (RCT) investigating infusion both dilute and concentrated MSCs compared to placebo in 36 small AAA (35-45 mm) patients. Subjects will be followed by study personnel for 12 months to ascertain incidence of adverse events, immune cell phenotype expression, peripheral cytokine profile, and periaortic inflammation. Maximum transverse aortic diameter will be assessed regularly for 5 years by a combination of computed tomography and duplex sonography. RESULTS Four patients have thus far been enrolled, randomized, and treated per protocol. We anticipate the conclusion of the treatment phase within the next 24 months with ongoing long-term follow-up. CONCLUSIONS ARREST will be pivotal in assessing the safety of MSC infusion and provide preliminary data on the ability of MSCs to favorably modulate the pathogenic AAA host immune response. The data gleaned from this phase I trial will provide the groundwork for a larger, phase III RCT which may provide the first pharmaceutical intervention for AAA.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Clifford M Babbey
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN.
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Wehrkamp CJ, Gutwein AR, Natarajan SK, Phillippi MA, Mott JL. XIAP antagonist embelin inhibited proliferation of cholangiocarcinoma cells. PLoS One 2014; 9:e90238. [PMID: 24603802 PMCID: PMC3946004 DOI: 10.1371/journal.pone.0090238] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 01/26/2014] [Indexed: 01/07/2023] Open
Abstract
Cholangiocarcinoma cells are dependent on antiapoptotic signaling for survival and resistance to death stimuli. Recent mechanistic studies have revealed that increased cellular expression of the E3 ubiquitin-protein ligase X-linked inhibitor of apoptosis (XIAP) impairs TRAIL- and chemotherapy-induced cytotoxicity, promoting survival of cholangiocarcinoma cells. This study was undertaken to determine if pharmacologic antagonism of XIAP protein was sufficient to sensitize cholangiocarcinoma cells to cell death. We employed malignant cholangiocarcinoma cell lines and used embelin to antagonize XIAP protein. Embelin treatment resulted in decreased XIAP protein levels by 8 hours of treatment with maximal effect at 16 hours in KMCH and Mz-ChA-1 cells. Assessment of nuclear morphology demonstrated a concentration-dependent increase in nuclear staining. Interestingly, embelin induced nuclear morphology changes as a single agent, independent of the addition of TNF-related apoptosis inducing ligand (TRAIL). However, caspase activity assays revealed that increasing embelin concentrations resulted in slight inhibition of caspase activity, not activation. In addition, the use of a pan-caspase inhibitor did not prevent nuclear morphology changes. Finally, embelin treatment of cholangiocarcinoma cells did not induce DNA fragmentation or PARP cleavage. Apoptosis does not appear to contribute to the effects of embelin on cholangiocarcinoma cells. Instead, embelin caused inhibition of cell proliferation and cell cycle analysis indicated that embelin increased the number of cells in S and G2/M phase. Our results demonstrate that embelin decreased proliferation in cholangiocarcinoma cell lines. Embelin treatment resulted in decreased XIAP protein expression, but did not induce or enhance apoptosis. Thus, in cholangiocarcinoma cells the mechanism of action of embelin may not be dependent on apoptosis.
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Affiliation(s)
- Cody J. Wehrkamp
- Department of Biochemistry and Molecular Biology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Ashley R. Gutwein
- Department of Biochemistry and Molecular Biology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sathish Kumar Natarajan
- Department of Biochemistry and Molecular Biology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Mary Anne Phillippi
- Department of Biochemistry and Molecular Biology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Justin L. Mott
- Department of Biochemistry and Molecular Biology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
- * E-mail:
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