Vessel Plus is an international, open access, peer-reviewed journal which was launched on 31 March 2017 by OAE Publishing Inc and has been accepted for indexed in Scopus in October 2021.
Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic se... more Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic severe aortic stenosis in intermediate and high-risk patients. However, as TAVI indications increase, concerns regarding adverse events and complications rise in the same proportion. Stroke is one of the most feared TAVI complications and a hard endpoint present in all TAVI studies. TAVI-related stroke incidence becomes even more relevant with TAVI indications spreading to younger, low/intermediate-risk patients. Several devices have been developed to prevent this catastrophic event, some of them being broadly used. Nevertheless, the evidence for routine use of cerebral embolic protection devices is still controversial.
The use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has garnered widespre... more The use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has garnered widespread attention in the medical community over the past ten years. A number of landmark trials have demonstrated the efficacy of PCSK9 inhibitors in lowering low-density lipoprotein (LDL) levels dramatically when added to background statin therapy. Importantly, their use has led to a significant reduction in adverse events in patients at risk and with established cardiovascular diseases. Published evidence is sparse in the heart failure (HF) population, especially in those with Stage D disease. While the use of PCSK9 inhibitors has not been reported in patients with durable mechanical circulatory support devices, limited data exist in heart transplant recipients. Management of dyslipidemia is critically important in post-heart transplant population as it contributes to the development of cardiac allograft vasculopathy (CAV). However, most 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) interfere with the metabolism of commonly used immunosuppressant agents, such as tacrolimus. Case studies in post-heart transplant patients demonstrated significant LDL reduction with PCSK9 inhibitor use, without significant drug-drug interactions or adverse events. Two trials are currently underway examining their efficacy in reducing CAV progression. This paper aims to review the available clinical evidence for PCSK9 inhibitor use in HF patients, with specific focus on the advanced heart failure group.
Aim: The effectual use of frozen elephant trunk (FET) has been for total aortic arch replacement ... more Aim: The effectual use of frozen elephant trunk (FET) has been for total aortic arch replacement (TAR) of acute aortic dissection because of positive aortic remodeling. However, the use of FET in the non-dissecting aortic arch aneurysm is still contr oversial. We aim to investigate the outcomes of TAR using the FET technique for distal aortic arch aneurysms. Methods: Between August 2014 and February 2020, 40 patients (35 males, mean age 77.0 years) underwent TAR by using the FET technique with the J Graft Open Stent Graft for distal aortic arch aneurysms including 8 patients with shaggy aorta. In 5 of 40 patients, coronary bypass grafting was concomitantly performed. We followed up for 29.0 months. Results: The mortality were 0%. Stroke occurred in three patients (7.5%) one of whom had shaggy aorta, paraparesis in one patient (2.5%) who recovered fully, and respiratory complication in two patients (5.0%). There was no recurrent nerve palsy. During the follow-up period, death had no relationship with aortic disease. Conclusion: We conclude the FET has the potential to improve TAR for distal aortic arch aneurysms.
Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during ... more Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during endovascular abdominal aortic aneurysm repair (EVAR). Methods: A retrospective observational study was conducted in patients managed with EVAR for the aorto-iliac aneurysmal disease. The IIA was sacrificed by extension of the stent-graft into the external iliac artery in the absence of the distal landing zone, while it was preserved if the landing zone was available. Results: From 2002 to 2018, 540 patients underwent EVAR for aorto-iliac aneurysmal disease in our center. Sixtyfive (12.04%, n = 65/540) had iliac aneurysm extension. Among these 65 cases, the IIA was not covered in 32 patients (IIA salvage/spared group), while they were covered in 33 patients (IIA sacrifice group). The IIA sacrifice group consisted of 25 unilateral and 8 bilateral coverages. There was 100% technical success and no 30-day mortality in both groups. The IIA sacrifice group had more postoperative complications in general when compared to the IIA salvage group, but they were not significant (P < 0.05). There were one patient with buttock claudication (P = 1.000) with bilateral IIA coverage, two cases of lower limb microembolization (P = 0.492) and one case of erectile dysfunction (P = 1.000) in IIA sacrifice group, while they were not seen in IIA salvage group. There was no ruptured iliac access, device-related malfunction, spinal cord ischemia or bowel ischemia in either group.
Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.
Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinica... more Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinical implications as TAVI expands to younger patients in whom lifetime treatment of aortic valve disease and coronary artery disease is of particular importance. Numerous studies have shown that lack of commissural alignment may adversely affect coronary reaccess and the feasibility of redo-TAVI in this patient population. To assess the risk of commissural misalignment more accurately, we have pioneered and validated the use of a preprocedural imaging protocol that determines valve orientation using multi-detector computed tomography-fluoroscopy co-registration. Furthermore, we have shown that a modified delivery system insertion technique during initial valve deployment results in improved commissural alignment and reduced coronary artery overlap following TAVI with a self-expanding device. However, numerous unanswered questions remain about the impact of commissural misalignment on balloonexpandable valve-in-valve TAVI, especially in patients with unfavorable aortic root anatomy. It is imperative that clinicians consider these anatomic, device-related, and procedure factors, among others, when evaluating patients for transcatheter therapies.
Aim: Chronic venous disease (CVD) is very common in nurses. Noticeably, operating room (OR) nurse... more Aim: Chronic venous disease (CVD) is very common in nurses. Noticeably, operating room (OR) nurses are predicted to have a major prevalence of varicose veins. We investigated whether the prevalence of CVD in OR nurses was more than non-OR nurses. Methods: Study populations were OR nurses and non-OR nurses at the Faculty of Medicine, Chiang Mai University. Information was compiled by questionnaire. Physical examination was operated by examiners for CVD based on clinical finding using Comprehensive Classification System for Chronic Venous Disorders classification. Results: 222 nurses were included. The prevalence of C0-C2 was notably different between the two groups (P < 0.001). The prevalence of C1 in OR nurses and non-OR nurses was 59.6% and 72.1% while the prevalence of C2 in OR nurses and non-OR nurses was 8.1% and 16.4%, respectively. Nevertheless, the quality of life was not remarkably different between the two groups. Conclusion: The results demonstrated that CVD in non-OR nurses appear to be higher than OR nurses.
Stroke is a leading cause of morbidity and mortality worldwide. There have been significant advan... more Stroke is a leading cause of morbidity and mortality worldwide. There have been significant advances in the hyperacute treatment of patients with ischemic stroke with the advent and application of reperfusion therapies, including intravenous thrombolysis and endovascular thrombectomy. Endovascular thrombectomy involves the removal of thrombus from an artery using a mechanical retriever or aspiration with angiographic visualization. This review aims to outline the current evidence to support the use of endovascular thrombectomy and highlight areas of ongoing research.
Aim: Sodium-glucose cotransporter-2 (SGLT2)-inhibitors improve survival in adults with reduced ej... more Aim: Sodium-glucose cotransporter-2 (SGLT2)-inhibitors improve survival in adults with reduced ejection fraction. Clinical outcomes in adults with heart failure (HF) with preserved ejection fraction (HFpEF) have not been systematically reviewed. Methods: We conducted a systematic rapid literature review and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: We identified post-hoc subgroup analyses of four randomized controlled clinical trials (RCTs) and unpublished results from 2 RCTs. In 2 RCTs vs. placebo, Canagliflozin reduced the risk of fatal or hospitalized HF in adults with HF and documented or assumed left ventricular ejection fraction (LVEF) ≥ 50% (hazard rate ratio, HR = 0.71, 95%CI: 0.52-0.97) but had no effect in a subpopulation with documented LVEF ≥ 50% (HR = 0.83, 95%CI: 0.55-1.25). Dapagliflozin or ertugliflozin did not improve all-cause or cardiovascular death or hospitalization for HF in adults with HF and LVEF > 45% in two pivotal RCTs vs. placebo. Empagliflozin did not improve exercise ability, patient-reported outcomes or congestion, diuretic use and all-cause healthcare resource utilization in unpublished RCT vs. placebo. Various definitions of HFpEF, post-hoc interaction analyses suggesting outcome improvement regardless of heart failure type, small number of events, and probable publication bias hampered the quality of evidence. Conclusion: Existing evidence is insufficient to support definitive clinical recommendations for use of SGLT2inhibitors in adults with HFpEF. Future research should employ consistent definitions of HFpEF and examine the effects from SGLT2-Inhibitors in patients with various HFpEF phenotypes and underlying causes.
Circumflex aorta is an unusual form of congenital arch malformation with a retroesophageal arch s... more Circumflex aorta is an unusual form of congenital arch malformation with a retroesophageal arch segment. Circumflex aorta crosses the midline behind the oesophagus and above the level of carina to become continuous with the proximal descending aorta on the opposite side to form a true vascular ring with the arterial ligament. The term is often used to refer to the more common variant of circumflex aorta with a retroesophageal right-sided aortic arch with a left-sided descending aorta and left-sided ligamentum. Its mirror-form with a retroesophageal left-sided aortic arch is much rarer. Although originally described without obstruction, it may occur in association with aortic arch hypoplasia, adding to its clinical burden. This article describes the morphology of circumflex aorta and its clinical presentation, and provides review of surgical management of circumflex aortic arch.
Thoracic aortic aneurysm represents a deadly condition, particularly when it evolves into rupture... more Thoracic aortic aneurysm represents a deadly condition, particularly when it evolves into rupture and dissection. Proper surgical timing is the key to positively influencing the survival of patients with this pathology. According to the most recent guidelines, ascending aorta size ≥ 55 mm and a rate of growth ≥ 0.5 cm per year are the most important factors for surgical indication. Nevertheless, a lot of evidence show that aortic ruptures and dissections might occur also in small size ascending aorta. In this review, we sought to analyze a new biological and morphological network behind the aortic diameter that need to be considered in order to identify the portion of patients with thoracic aortic aneurysm who are at increased risk of aortic complications, despite current aortic guidelines not advising surgical intervention in this group.
The development of the frozen elephant trunk (FET) technique for a simplified treatment of comple... more The development of the frozen elephant trunk (FET) technique for a simplified treatment of complex lesions of the thoracic aorta originated as an evolution of the classic elephant trunk technique, described for the first time by Borst et al. [1] in 1983. Novel technologies and standardization of the surgical approach produced a progressive improvement of early and late outcomes. Most of the time and for specific indications, FET procedure allows physicians to treat lesions involving extensive portions of the thoracic aorta in one single step. Spinal cord injury remains one of the main complications of this procedure, even though spinal protection strategies have led to better results. We hereby report our opinions and recommendations based on our experience started in 2007.
Carotid artery diseases can result in many extracranial manifestations. Tinnitus is a recognised ... more Carotid artery diseases can result in many extracranial manifestations. Tinnitus is a recognised symptom and has long been correlated with significant internal carotid artery stenosis. It has been largely classified into pulsatile and non-pulsatile types with variable management approaches and prognoses. Surgical and endovascular approaches to treat carotid artery stenosis have not only aimed to reduce stroke rates but also to manage such symptoms. The clinical and cognitive evidence of such practices are broad and managed in a combined spectrum with otolaryngologists. This literature review aims to focus on current evidence and practice with vascular surgeons on the importance of dealing with tinnitus in managing carotid artery stenosis.
Granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited anti-neutrophil cyto... more Granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited anti-neutrophil cytoplasm antibody (ANCA) associated vasculitis are the main ANCA-associated vasculitidies (AAV). Multiple induction therapies for AAV exist and have proven successful in achieving disease remission. Azathioprine and methotrexate have been used to maintain remission of AAV, however, relapse rates and adverse effects with these medications remain high. Rituximab (RTX), a B cell depleting monoclonal antibody, was shown to be safe and effective in maintaining disease remission in AAV in early retrospective reviews. In 2014, the first randomized control trial to compare RTX and azathioprine in maintenance therapy of newly diagnosed AAV (MAINRITSAN trial), revealed that patients who received RTX after cyclophosphamide induction had higher rates of sustained remission, fewer adverse effects and, better overall survival rates as compared to azathioprine. MAINRITSAN 2 revealed that patients receiving tailored regimens of maintenance RTX received fewer infusions but did not have higher rates of relapse than patients who received fixed dose therapy. The RITAZAREM trial conveyed that patients who experienced AAV relapse after induction therapy that received induction and maintenance RTX were significantly less likely to develop a relapse at 24 months vs. patients who received maintenance therapy with azathioprine. Overall, these studies suggest that maintenance therapy with RTX represents an exceptional treatment option in patients with AAV in terms of safety and efficacy, resulting in lower relapse rates and less drug toxicity than conventional treatments. As a result, patients have fewer exposures to cytotoxic medications and thus, improved outcomes.
Aim: To investigate whether patients with symptomatic heart failure and exercise-induced dynamic ... more Aim: To investigate whether patients with symptomatic heart failure and exercise-induced dynamic severe mitral regurgitation (MR) benefit from percutaneous mitral valve repair (PMVR). Methods: We included patients who underwent PMVR with the MitraClip system in an all-comers observational study. Handgrip echocardiography was performed in patients with a discrepancy between symptoms and echocardiographic findings at rest, giving rise to the suspicion of an exercise-induced increase in MR severity. The primary endpoint of the study was a composite of all-cause mortality or admission for heart failure at 1-year follow-up. The secondary endpoint was the reduction in NYHA functional class. Results: Two hundred twenty-one patients who underwent MitraClip implantation were included. Ninety-three patients with moderate to severe MR at rest received handgrip echocardiography prior to PMVR. The remaining 128 patients presented with severe MR at rest, making exercise echocardiography unnecessary. Handgrip exercise led to an increase in MR severity in 81% of patients with moderate MR at rest, irrespective of the subtype of MR. Following PMVR, patients with dynamic severe MR experienced comparable clinical improvement as patients with severe MR already at rest: During 1-year follow-up, 37 patients died, and 71 patients were re-admitted to the hospital because of heart failure. In this regard, 13 patients (30%) with dynamic severe MR experienced the combined endpoint, while 72 patients (43%) with severe MR at rest did as well (P = 0.121). Moreover, the majority of patients with dynamic severe MR similar to patients with severe MR at rest experienced clinical improvement from NYHA class III/IV to I/II (59% vs . 56%; P = 0.566). Conclusion: The data presented provide evidence of a clinical benefit from PMVR using MitraClip in patients with moderate MR at rest who display exercise-induced increases in MR severity during handgrip exercise.
their contribution to pathogenesis in malaria, African sleeping sickness, Chagas disease, and lei... more their contribution to pathogenesis in malaria, African sleeping sickness, Chagas disease, and leishmaniasis and toxoplasmosis with an emphasis on their actions on the innate and adaptive immune mechanisms of resistance.
Utilization of contrast media to visualize vasculature structures in the setting of cardiovascula... more Utilization of contrast media to visualize vasculature structures in the setting of cardiovascular disorders (CVD) can lead to acute kidney injury, referred to as contrast-induced nephropathy (CIN). CIN can potentiate mortality and hospitalization in aged individuals, patients with CVD, nephropathy, enhancing kidney damage, and cardiac events. Preventing CIN by identifying risk factors is important. The underlying mechanisms of CIN pathology are unclear, but the key factors include direct cytotoxicity, oxidative stress, vascular and endothelial dysfunction and inflammatory processes. Reactive Oxygen Species and inflammatory mediators have been proposed as key factors influencing the development of CIN and CVD, and the elucidation of the interplay between the mechanisms evoked by them may provide a better understanding of the signaling processes happening in these conditions, thereby potentially enabling early identification, prevention and characterization of novel drug targets.
Sucrose nonfermenting 1-related kinase (SNRK) is a serine/threonine kinase and a member of the ad... more Sucrose nonfermenting 1-related kinase (SNRK) is a serine/threonine kinase and a member of the adenosine monophosphate (AMP)-activated protein kinase (AMPK) family that is involved in the metabolic regulatory mechanisms in various cell types. SNRK is an important mediator in maintaining cellular metabolic homeostasis. In this review, we discuss the role of SNRK in metabolic tissues where it is expressed, including heart and adipose tissue. We discuss its role in regulating inflammation in these tissues and the pathways associated with regulating inflammation. We also discuss SNRK's role in vascular development and the processes associated with it. Finally, we review SNRK's potential as a target in various metabolic dysfunction-associated diseases such as cardiovascular diseases, diabetes, obesity, and cancer. This comprehensive review on SNRK suggests that it has therapeutic value in the suppression of inflammation in cardiac and adipose tissue.
Aim: To evaluate the prognostic value of high-sensitivity cardiac troponin (hscTnT) levels in uns... more Aim: To evaluate the prognostic value of high-sensitivity cardiac troponin (hscTnT) levels in unselected emergency medical admissions. Methods: We report on all hscTnT tests in emergency medical admissions, performed over an eight year period from 2011-2018. The prognostic significance of hscTnT was related to 30-day in-hospital mortality with multivariable logistic regression, adjusted for Acute Illness Severity Score, Comorbidity Score, Sepsis, and Deprivation Status. Results: There were 52,214 admissions from 28,982 patients during the study period. HscTnT level was a univariate-odds ratios (OR) 1.67 [95% confidence intervals (CI): 1.60-1.73] and an independent risk predictor in the multivariable logistic regression model-OR = 1.23 (95%CI: 1.16-1.29). 30-day in-hospital mortality increased as a linear function of hscTnT; not performed = 3.6%, ≥ 25 ng/L = 5.3%, > 100 ng/L = 7.4%, > 1000 ng/L = 8.8%. Increasing Comorbidity Score exacerbated risk; 30-day in-hospital mortality at a Score of 6, 10 and 16 points for those with no hscTnT performed or hscTnT < 25 ng/L were 1.8%, 6.5% and 31.3% respectively; for hscTnT ≥ 25 ng/L these increased to 2.2%, 8.8% and 41.3%. Conclusion: HscTnT is prognostic in acutely ill medical patients; incorporation into hospital mortality predictive algorithms appears warranted.
Takayasu arteritis (TA) is a chronic vasculitis involving large vessels of unknown aetiology, a d... more Takayasu arteritis (TA) is a chronic vasculitis involving large vessels of unknown aetiology, a disease that is more common among the Asian population and predominant in young women. Cardiac manifestations include hypertension and involvement of the cardiac valves, myocardium and coronary arteries. Surgery on these patients is always a challenge given the tissue quality and the disease activity. They are prone to long-term complications such as restenosis and graft occlusion, hence requiring lifelong surveillance. The prevalence of coronary artery disease (CAD) in TA ranges from 9 to 11%. Coronary artery bypass grafting is preferred to percutaneous coronary intervention, as the latter has a high rate of restenosis and major adverse cardiovascular events. As left subclavian artery is commonly involved, saphenous vein graft is advised as a conduit rather than internal mammary artery. Other surgical procedures described for CAD are surgical angioplasty of the left main coronary artery and transaortic coronary ostial endarterectomy. Aortic regurgitation in TA has an incidence of approximately 20%. These patients tend to have prosthetic valve detachment, paravalvular leak or pseudoaneurysm at the anastomotic site. Further repair of these valves have a high rate of failure. Considering these facts, it is advisable to do an aortic root replacement for TA patients than to consider an aortic valve replacement or David's procedure.
Platelet-derived growth factor (PDGF) receptors are expressed throughout the body, including the ... more Platelet-derived growth factor (PDGF) receptors are expressed throughout the body, including the central nervous system (CNS). Although the physiological role of PDGF receptors in the developed CNS is not fully characterized, PDGF signaling appears to provide neuroprotective effects against several neuronal insults. One of the bestcharacterized neuroprotective effects of PDGF type-b receptors is against human immunodeficiency virus (HIV) protein-induced neurotoxicity, with potential physiological relevance to HAD. PDGFb receptors are also neuroprotective against glutamate excitotoxicity, which is associated with both stroke and neurodegenerative diseases, including Alzheimer's disease. The neuroprotective effects of PDGFb receptors occur both via direct activation by ligand (PDGF-BB), as well as by PDGFb receptors activated downstream of G protein-coupled receptor signaling. In addition to the involvement of PDGF signaling in various pathologies and potential therapies, there is also an emerging body of evidence that PDGF may serve as a biomarker for neurological or psychiatric diseases.
Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic se... more Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic severe aortic stenosis in intermediate and high-risk patients. However, as TAVI indications increase, concerns regarding adverse events and complications rise in the same proportion. Stroke is one of the most feared TAVI complications and a hard endpoint present in all TAVI studies. TAVI-related stroke incidence becomes even more relevant with TAVI indications spreading to younger, low/intermediate-risk patients. Several devices have been developed to prevent this catastrophic event, some of them being broadly used. Nevertheless, the evidence for routine use of cerebral embolic protection devices is still controversial.
The use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has garnered widespre... more The use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has garnered widespread attention in the medical community over the past ten years. A number of landmark trials have demonstrated the efficacy of PCSK9 inhibitors in lowering low-density lipoprotein (LDL) levels dramatically when added to background statin therapy. Importantly, their use has led to a significant reduction in adverse events in patients at risk and with established cardiovascular diseases. Published evidence is sparse in the heart failure (HF) population, especially in those with Stage D disease. While the use of PCSK9 inhibitors has not been reported in patients with durable mechanical circulatory support devices, limited data exist in heart transplant recipients. Management of dyslipidemia is critically important in post-heart transplant population as it contributes to the development of cardiac allograft vasculopathy (CAV). However, most 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) interfere with the metabolism of commonly used immunosuppressant agents, such as tacrolimus. Case studies in post-heart transplant patients demonstrated significant LDL reduction with PCSK9 inhibitor use, without significant drug-drug interactions or adverse events. Two trials are currently underway examining their efficacy in reducing CAV progression. This paper aims to review the available clinical evidence for PCSK9 inhibitor use in HF patients, with specific focus on the advanced heart failure group.
Aim: The effectual use of frozen elephant trunk (FET) has been for total aortic arch replacement ... more Aim: The effectual use of frozen elephant trunk (FET) has been for total aortic arch replacement (TAR) of acute aortic dissection because of positive aortic remodeling. However, the use of FET in the non-dissecting aortic arch aneurysm is still contr oversial. We aim to investigate the outcomes of TAR using the FET technique for distal aortic arch aneurysms. Methods: Between August 2014 and February 2020, 40 patients (35 males, mean age 77.0 years) underwent TAR by using the FET technique with the J Graft Open Stent Graft for distal aortic arch aneurysms including 8 patients with shaggy aorta. In 5 of 40 patients, coronary bypass grafting was concomitantly performed. We followed up for 29.0 months. Results: The mortality were 0%. Stroke occurred in three patients (7.5%) one of whom had shaggy aorta, paraparesis in one patient (2.5%) who recovered fully, and respiratory complication in two patients (5.0%). There was no recurrent nerve palsy. During the follow-up period, death had no relationship with aortic disease. Conclusion: We conclude the FET has the potential to improve TAR for distal aortic arch aneurysms.
Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during ... more Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during endovascular abdominal aortic aneurysm repair (EVAR). Methods: A retrospective observational study was conducted in patients managed with EVAR for the aorto-iliac aneurysmal disease. The IIA was sacrificed by extension of the stent-graft into the external iliac artery in the absence of the distal landing zone, while it was preserved if the landing zone was available. Results: From 2002 to 2018, 540 patients underwent EVAR for aorto-iliac aneurysmal disease in our center. Sixtyfive (12.04%, n = 65/540) had iliac aneurysm extension. Among these 65 cases, the IIA was not covered in 32 patients (IIA salvage/spared group), while they were covered in 33 patients (IIA sacrifice group). The IIA sacrifice group consisted of 25 unilateral and 8 bilateral coverages. There was 100% technical success and no 30-day mortality in both groups. The IIA sacrifice group had more postoperative complications in general when compared to the IIA salvage group, but they were not significant (P < 0.05). There were one patient with buttock claudication (P = 1.000) with bilateral IIA coverage, two cases of lower limb microembolization (P = 0.492) and one case of erectile dysfunction (P = 1.000) in IIA sacrifice group, while they were not seen in IIA salvage group. There was no ruptured iliac access, device-related malfunction, spinal cord ischemia or bowel ischemia in either group.
Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.
Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinica... more Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinical implications as TAVI expands to younger patients in whom lifetime treatment of aortic valve disease and coronary artery disease is of particular importance. Numerous studies have shown that lack of commissural alignment may adversely affect coronary reaccess and the feasibility of redo-TAVI in this patient population. To assess the risk of commissural misalignment more accurately, we have pioneered and validated the use of a preprocedural imaging protocol that determines valve orientation using multi-detector computed tomography-fluoroscopy co-registration. Furthermore, we have shown that a modified delivery system insertion technique during initial valve deployment results in improved commissural alignment and reduced coronary artery overlap following TAVI with a self-expanding device. However, numerous unanswered questions remain about the impact of commissural misalignment on balloonexpandable valve-in-valve TAVI, especially in patients with unfavorable aortic root anatomy. It is imperative that clinicians consider these anatomic, device-related, and procedure factors, among others, when evaluating patients for transcatheter therapies.
Aim: Chronic venous disease (CVD) is very common in nurses. Noticeably, operating room (OR) nurse... more Aim: Chronic venous disease (CVD) is very common in nurses. Noticeably, operating room (OR) nurses are predicted to have a major prevalence of varicose veins. We investigated whether the prevalence of CVD in OR nurses was more than non-OR nurses. Methods: Study populations were OR nurses and non-OR nurses at the Faculty of Medicine, Chiang Mai University. Information was compiled by questionnaire. Physical examination was operated by examiners for CVD based on clinical finding using Comprehensive Classification System for Chronic Venous Disorders classification. Results: 222 nurses were included. The prevalence of C0-C2 was notably different between the two groups (P < 0.001). The prevalence of C1 in OR nurses and non-OR nurses was 59.6% and 72.1% while the prevalence of C2 in OR nurses and non-OR nurses was 8.1% and 16.4%, respectively. Nevertheless, the quality of life was not remarkably different between the two groups. Conclusion: The results demonstrated that CVD in non-OR nurses appear to be higher than OR nurses.
Stroke is a leading cause of morbidity and mortality worldwide. There have been significant advan... more Stroke is a leading cause of morbidity and mortality worldwide. There have been significant advances in the hyperacute treatment of patients with ischemic stroke with the advent and application of reperfusion therapies, including intravenous thrombolysis and endovascular thrombectomy. Endovascular thrombectomy involves the removal of thrombus from an artery using a mechanical retriever or aspiration with angiographic visualization. This review aims to outline the current evidence to support the use of endovascular thrombectomy and highlight areas of ongoing research.
Aim: Sodium-glucose cotransporter-2 (SGLT2)-inhibitors improve survival in adults with reduced ej... more Aim: Sodium-glucose cotransporter-2 (SGLT2)-inhibitors improve survival in adults with reduced ejection fraction. Clinical outcomes in adults with heart failure (HF) with preserved ejection fraction (HFpEF) have not been systematically reviewed. Methods: We conducted a systematic rapid literature review and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: We identified post-hoc subgroup analyses of four randomized controlled clinical trials (RCTs) and unpublished results from 2 RCTs. In 2 RCTs vs. placebo, Canagliflozin reduced the risk of fatal or hospitalized HF in adults with HF and documented or assumed left ventricular ejection fraction (LVEF) ≥ 50% (hazard rate ratio, HR = 0.71, 95%CI: 0.52-0.97) but had no effect in a subpopulation with documented LVEF ≥ 50% (HR = 0.83, 95%CI: 0.55-1.25). Dapagliflozin or ertugliflozin did not improve all-cause or cardiovascular death or hospitalization for HF in adults with HF and LVEF > 45% in two pivotal RCTs vs. placebo. Empagliflozin did not improve exercise ability, patient-reported outcomes or congestion, diuretic use and all-cause healthcare resource utilization in unpublished RCT vs. placebo. Various definitions of HFpEF, post-hoc interaction analyses suggesting outcome improvement regardless of heart failure type, small number of events, and probable publication bias hampered the quality of evidence. Conclusion: Existing evidence is insufficient to support definitive clinical recommendations for use of SGLT2inhibitors in adults with HFpEF. Future research should employ consistent definitions of HFpEF and examine the effects from SGLT2-Inhibitors in patients with various HFpEF phenotypes and underlying causes.
Circumflex aorta is an unusual form of congenital arch malformation with a retroesophageal arch s... more Circumflex aorta is an unusual form of congenital arch malformation with a retroesophageal arch segment. Circumflex aorta crosses the midline behind the oesophagus and above the level of carina to become continuous with the proximal descending aorta on the opposite side to form a true vascular ring with the arterial ligament. The term is often used to refer to the more common variant of circumflex aorta with a retroesophageal right-sided aortic arch with a left-sided descending aorta and left-sided ligamentum. Its mirror-form with a retroesophageal left-sided aortic arch is much rarer. Although originally described without obstruction, it may occur in association with aortic arch hypoplasia, adding to its clinical burden. This article describes the morphology of circumflex aorta and its clinical presentation, and provides review of surgical management of circumflex aortic arch.
Thoracic aortic aneurysm represents a deadly condition, particularly when it evolves into rupture... more Thoracic aortic aneurysm represents a deadly condition, particularly when it evolves into rupture and dissection. Proper surgical timing is the key to positively influencing the survival of patients with this pathology. According to the most recent guidelines, ascending aorta size ≥ 55 mm and a rate of growth ≥ 0.5 cm per year are the most important factors for surgical indication. Nevertheless, a lot of evidence show that aortic ruptures and dissections might occur also in small size ascending aorta. In this review, we sought to analyze a new biological and morphological network behind the aortic diameter that need to be considered in order to identify the portion of patients with thoracic aortic aneurysm who are at increased risk of aortic complications, despite current aortic guidelines not advising surgical intervention in this group.
The development of the frozen elephant trunk (FET) technique for a simplified treatment of comple... more The development of the frozen elephant trunk (FET) technique for a simplified treatment of complex lesions of the thoracic aorta originated as an evolution of the classic elephant trunk technique, described for the first time by Borst et al. [1] in 1983. Novel technologies and standardization of the surgical approach produced a progressive improvement of early and late outcomes. Most of the time and for specific indications, FET procedure allows physicians to treat lesions involving extensive portions of the thoracic aorta in one single step. Spinal cord injury remains one of the main complications of this procedure, even though spinal protection strategies have led to better results. We hereby report our opinions and recommendations based on our experience started in 2007.
Carotid artery diseases can result in many extracranial manifestations. Tinnitus is a recognised ... more Carotid artery diseases can result in many extracranial manifestations. Tinnitus is a recognised symptom and has long been correlated with significant internal carotid artery stenosis. It has been largely classified into pulsatile and non-pulsatile types with variable management approaches and prognoses. Surgical and endovascular approaches to treat carotid artery stenosis have not only aimed to reduce stroke rates but also to manage such symptoms. The clinical and cognitive evidence of such practices are broad and managed in a combined spectrum with otolaryngologists. This literature review aims to focus on current evidence and practice with vascular surgeons on the importance of dealing with tinnitus in managing carotid artery stenosis.
Granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited anti-neutrophil cyto... more Granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited anti-neutrophil cytoplasm antibody (ANCA) associated vasculitis are the main ANCA-associated vasculitidies (AAV). Multiple induction therapies for AAV exist and have proven successful in achieving disease remission. Azathioprine and methotrexate have been used to maintain remission of AAV, however, relapse rates and adverse effects with these medications remain high. Rituximab (RTX), a B cell depleting monoclonal antibody, was shown to be safe and effective in maintaining disease remission in AAV in early retrospective reviews. In 2014, the first randomized control trial to compare RTX and azathioprine in maintenance therapy of newly diagnosed AAV (MAINRITSAN trial), revealed that patients who received RTX after cyclophosphamide induction had higher rates of sustained remission, fewer adverse effects and, better overall survival rates as compared to azathioprine. MAINRITSAN 2 revealed that patients receiving tailored regimens of maintenance RTX received fewer infusions but did not have higher rates of relapse than patients who received fixed dose therapy. The RITAZAREM trial conveyed that patients who experienced AAV relapse after induction therapy that received induction and maintenance RTX were significantly less likely to develop a relapse at 24 months vs. patients who received maintenance therapy with azathioprine. Overall, these studies suggest that maintenance therapy with RTX represents an exceptional treatment option in patients with AAV in terms of safety and efficacy, resulting in lower relapse rates and less drug toxicity than conventional treatments. As a result, patients have fewer exposures to cytotoxic medications and thus, improved outcomes.
Aim: To investigate whether patients with symptomatic heart failure and exercise-induced dynamic ... more Aim: To investigate whether patients with symptomatic heart failure and exercise-induced dynamic severe mitral regurgitation (MR) benefit from percutaneous mitral valve repair (PMVR). Methods: We included patients who underwent PMVR with the MitraClip system in an all-comers observational study. Handgrip echocardiography was performed in patients with a discrepancy between symptoms and echocardiographic findings at rest, giving rise to the suspicion of an exercise-induced increase in MR severity. The primary endpoint of the study was a composite of all-cause mortality or admission for heart failure at 1-year follow-up. The secondary endpoint was the reduction in NYHA functional class. Results: Two hundred twenty-one patients who underwent MitraClip implantation were included. Ninety-three patients with moderate to severe MR at rest received handgrip echocardiography prior to PMVR. The remaining 128 patients presented with severe MR at rest, making exercise echocardiography unnecessary. Handgrip exercise led to an increase in MR severity in 81% of patients with moderate MR at rest, irrespective of the subtype of MR. Following PMVR, patients with dynamic severe MR experienced comparable clinical improvement as patients with severe MR already at rest: During 1-year follow-up, 37 patients died, and 71 patients were re-admitted to the hospital because of heart failure. In this regard, 13 patients (30%) with dynamic severe MR experienced the combined endpoint, while 72 patients (43%) with severe MR at rest did as well (P = 0.121). Moreover, the majority of patients with dynamic severe MR similar to patients with severe MR at rest experienced clinical improvement from NYHA class III/IV to I/II (59% vs . 56%; P = 0.566). Conclusion: The data presented provide evidence of a clinical benefit from PMVR using MitraClip in patients with moderate MR at rest who display exercise-induced increases in MR severity during handgrip exercise.
their contribution to pathogenesis in malaria, African sleeping sickness, Chagas disease, and lei... more their contribution to pathogenesis in malaria, African sleeping sickness, Chagas disease, and leishmaniasis and toxoplasmosis with an emphasis on their actions on the innate and adaptive immune mechanisms of resistance.
Utilization of contrast media to visualize vasculature structures in the setting of cardiovascula... more Utilization of contrast media to visualize vasculature structures in the setting of cardiovascular disorders (CVD) can lead to acute kidney injury, referred to as contrast-induced nephropathy (CIN). CIN can potentiate mortality and hospitalization in aged individuals, patients with CVD, nephropathy, enhancing kidney damage, and cardiac events. Preventing CIN by identifying risk factors is important. The underlying mechanisms of CIN pathology are unclear, but the key factors include direct cytotoxicity, oxidative stress, vascular and endothelial dysfunction and inflammatory processes. Reactive Oxygen Species and inflammatory mediators have been proposed as key factors influencing the development of CIN and CVD, and the elucidation of the interplay between the mechanisms evoked by them may provide a better understanding of the signaling processes happening in these conditions, thereby potentially enabling early identification, prevention and characterization of novel drug targets.
Sucrose nonfermenting 1-related kinase (SNRK) is a serine/threonine kinase and a member of the ad... more Sucrose nonfermenting 1-related kinase (SNRK) is a serine/threonine kinase and a member of the adenosine monophosphate (AMP)-activated protein kinase (AMPK) family that is involved in the metabolic regulatory mechanisms in various cell types. SNRK is an important mediator in maintaining cellular metabolic homeostasis. In this review, we discuss the role of SNRK in metabolic tissues where it is expressed, including heart and adipose tissue. We discuss its role in regulating inflammation in these tissues and the pathways associated with regulating inflammation. We also discuss SNRK's role in vascular development and the processes associated with it. Finally, we review SNRK's potential as a target in various metabolic dysfunction-associated diseases such as cardiovascular diseases, diabetes, obesity, and cancer. This comprehensive review on SNRK suggests that it has therapeutic value in the suppression of inflammation in cardiac and adipose tissue.
Aim: To evaluate the prognostic value of high-sensitivity cardiac troponin (hscTnT) levels in uns... more Aim: To evaluate the prognostic value of high-sensitivity cardiac troponin (hscTnT) levels in unselected emergency medical admissions. Methods: We report on all hscTnT tests in emergency medical admissions, performed over an eight year period from 2011-2018. The prognostic significance of hscTnT was related to 30-day in-hospital mortality with multivariable logistic regression, adjusted for Acute Illness Severity Score, Comorbidity Score, Sepsis, and Deprivation Status. Results: There were 52,214 admissions from 28,982 patients during the study period. HscTnT level was a univariate-odds ratios (OR) 1.67 [95% confidence intervals (CI): 1.60-1.73] and an independent risk predictor in the multivariable logistic regression model-OR = 1.23 (95%CI: 1.16-1.29). 30-day in-hospital mortality increased as a linear function of hscTnT; not performed = 3.6%, ≥ 25 ng/L = 5.3%, > 100 ng/L = 7.4%, > 1000 ng/L = 8.8%. Increasing Comorbidity Score exacerbated risk; 30-day in-hospital mortality at a Score of 6, 10 and 16 points for those with no hscTnT performed or hscTnT < 25 ng/L were 1.8%, 6.5% and 31.3% respectively; for hscTnT ≥ 25 ng/L these increased to 2.2%, 8.8% and 41.3%. Conclusion: HscTnT is prognostic in acutely ill medical patients; incorporation into hospital mortality predictive algorithms appears warranted.
Takayasu arteritis (TA) is a chronic vasculitis involving large vessels of unknown aetiology, a d... more Takayasu arteritis (TA) is a chronic vasculitis involving large vessels of unknown aetiology, a disease that is more common among the Asian population and predominant in young women. Cardiac manifestations include hypertension and involvement of the cardiac valves, myocardium and coronary arteries. Surgery on these patients is always a challenge given the tissue quality and the disease activity. They are prone to long-term complications such as restenosis and graft occlusion, hence requiring lifelong surveillance. The prevalence of coronary artery disease (CAD) in TA ranges from 9 to 11%. Coronary artery bypass grafting is preferred to percutaneous coronary intervention, as the latter has a high rate of restenosis and major adverse cardiovascular events. As left subclavian artery is commonly involved, saphenous vein graft is advised as a conduit rather than internal mammary artery. Other surgical procedures described for CAD are surgical angioplasty of the left main coronary artery and transaortic coronary ostial endarterectomy. Aortic regurgitation in TA has an incidence of approximately 20%. These patients tend to have prosthetic valve detachment, paravalvular leak or pseudoaneurysm at the anastomotic site. Further repair of these valves have a high rate of failure. Considering these facts, it is advisable to do an aortic root replacement for TA patients than to consider an aortic valve replacement or David's procedure.
Platelet-derived growth factor (PDGF) receptors are expressed throughout the body, including the ... more Platelet-derived growth factor (PDGF) receptors are expressed throughout the body, including the central nervous system (CNS). Although the physiological role of PDGF receptors in the developed CNS is not fully characterized, PDGF signaling appears to provide neuroprotective effects against several neuronal insults. One of the bestcharacterized neuroprotective effects of PDGF type-b receptors is against human immunodeficiency virus (HIV) protein-induced neurotoxicity, with potential physiological relevance to HAD. PDGFb receptors are also neuroprotective against glutamate excitotoxicity, which is associated with both stroke and neurodegenerative diseases, including Alzheimer's disease. The neuroprotective effects of PDGFb receptors occur both via direct activation by ligand (PDGF-BB), as well as by PDGFb receptors activated downstream of G protein-coupled receptor signaling. In addition to the involvement of PDGF signaling in various pathologies and potential therapies, there is also an emerging body of evidence that PDGF may serve as a biomarker for neurological or psychiatric diseases.
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Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.
the hospital because of heart failure. In this regard, 13 patients (30%) with dynamic severe MR experienced the
combined endpoint, while 72 patients (43%) with severe MR at rest did as well (P = 0.121). Moreover, the majority
of patients with dynamic severe MR similar to patients with severe MR at rest experienced clinical improvement
from NYHA class III/IV to I/II (59% vs . 56%; P = 0.566).
Conclusion: The data presented provide evidence of a clinical benefit from PMVR using MitraClip in patients with
moderate MR at rest who display exercise-induced increases in MR severity during handgrip exercise.
Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.
the hospital because of heart failure. In this regard, 13 patients (30%) with dynamic severe MR experienced the
combined endpoint, while 72 patients (43%) with severe MR at rest did as well (P = 0.121). Moreover, the majority
of patients with dynamic severe MR similar to patients with severe MR at rest experienced clinical improvement
from NYHA class III/IV to I/II (59% vs . 56%; P = 0.566).
Conclusion: The data presented provide evidence of a clinical benefit from PMVR using MitraClip in patients with
moderate MR at rest who display exercise-induced increases in MR severity during handgrip exercise.