Outcomes of iliofemoral conduits during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveTo describe the technical pitfalls and outcomes of iliofemoral conduits during fenestrated-branched endovascular repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).MethodsWe retrospectively reviewed the clinical data of 466 consecutive patients enrolled in a previous prospective nonrandomized study to investigate FB-EVAR for CAAAs/TAAAs (2013-2021). Iliofemoral conduits were performed through open surgical technique (temporary or permanent) in patients with patent internal iliac arteries or endovascular technique among those with occluded internal iliac arteries. End points were assessed in patients who had any iliac conduit or no conduits, and in patients who had conduits performed prior or during the index FB-EVAR, including procedural metrics, technical success, and major adverse events (MAE).ResultsThere were 138 CAAAs, 141 extent IV, and 187 extent I-III TAAAs treated by FB-EVAR with an average of 3.89 ± 0.52 vessels incorporated per patient. Any iliac conduit was required in 35 patients (7.5%), including 24 patients (10.4%) treated between 2013 and 2017 and 11 (4.7%) who had procedures between 2018 and 2021 (P = .019). Nineteen patients had permanent conduits using iliofemoral bypass, 11 had temporary iliac conduits, and 5 had endoconduits. Iliofemoral conduits were necessary in 12% of patients with extent I to III TAAA, in 6% with extent IV TAAA, and in 3% with CAAA (P = .009). The use of iliofemoral conduit was more frequent among women (74% vs 27%; P < .001) and in patients with chronic obstructive pulmonary disease (49% vs 28%; P = .013), peripheral artery disease (31% vs 15%; P = .009), and American Society of Anesthesiologists classification of III or higher (74% vs 51%; P = .009). There were no inadvertent iliac artery disruptions in the entire study. The 30-day mortality and MAE were 1% and 19%, respectively, for all patients. An iliofemoral conduit using retroperitoneal exposure during the index FB-EVAR was associated with longer operative time (322 ± 97 minutes vs 323 ± 110 minutes vs 215 ± 90 minutes; P < .001), higher estimated blood loss (425 ± 620 mL vs 580 ± 1050 mL vs 250 ± 400 mL; P < .001), and rate of red blood transfusion (92% vs 78% vs 32%; P < .001) and lower technical success (83% vs 87% vs 98%; P < .001), but no difference in intraoperative access complications and MAEs, compared with iliofemoral conduits without retroperitoneal exposure during the index FB-EVAR and control patients who had FB-EVAR without iliofemoral conduits, respectively. There were no differences in mortality or in other specific MAE among the three groups.ConclusionsFB-EVAR with selective use of iliofemoral conduits was safe with low mortality and no occurrence of inadvertent iliac artery disruption or conversion. A staged approach is associated with shorter operating time, less blood loss, and lower transfusion requirements in the index procedure.     

Interpretation of liver stiffness measurement‐based approach for the monitoring of hepatitis B patients with antiviral therapy: A 2‐year prospective study

Liver biopsy is not routinely performed in treated chronic hepatitis B. Liver stiffness measurement has been validated for noninvasive liver fibrosis assessment in pretreatment chronic hepatitis B but has not been assessed for fibrosis monitoring during antiviral therapy. Liver stiffness was systemically monitored by Fibroscan^® every 6 months in a cohort of patients with hepatitis B receiving antiviral therapy and compared with liver biopsies at baseline and week 104. A total of 534 hepatitis B e antigen‐positive treatment‐naive patients receiving telbivudine‐based therapy with qualified liver stiffness measurement at baseline and week 104 were analyzed, 164 of which had adequate paired liver biopsies. Liver stiffness decreased rapidly (?2.2 kP a/24 weeks) in parallel with alanine aminotransferase (ALT ) from 8.6 (2.6‐49.5) kP a at baseline to 6.1 (2.2‐37.4) kP a at week 24. Interestingly, liver stiffness decreased slowly (?0.3 kP a/24 weeks) but continually from week 24 to week 104 (6.1 vs 5.3 kP a, P  <  .001) while ALT levels remained stable within the normal range. More importantly, liver stiffness declined significantly irrespective of baseline ALT levels and liver necroinflammation grades. From baseline to week 104, the proportion of patients with no or mild fibrosis (Ishak, 0‐2) increased from 74.4% (122/164) to 93.9% (154/164). Multivariate analysis revealed that percentage decline of 52‐week liver stiffness from baseline was independently associated with 104‐week liver fibrosis regression (odds ratio, 3.742; P  =  .016). Early decline of 52‐week liver stiffness from baseline may reflect the remission of both liver inflammation and fibrosis and was predictive of 104‐week fibrosis regression in treated patients with chronic hepatitis B.     

Acid-base and blood gas analysis

The concentration of hydrogen ions is one of the most tightly controlled systems in the body. Defence of normal body pH is thought to be from three basic mechanisms: respiratory control of carbon dioxide, renal excretion of acids, and plasma buffering systems. The traditional approach to acid-base control centres around the Henderson-Hasselbalch equation, in which pH can be defined as the ratio of bicarbonate to carbon dioxide. Alterations in pH result from changes in carbon dioxide (respiratory) or bicarbonate (metabolic). Most pH disturbances can be classified into one of four main types.

• 1Respiratory acidosis, where the primary change is an increase in carbon dioxide with attempted compensatory increase in bicarbonate (e.g. ventilatory failure).
• 2Respiratory alkalosis, where the primary change is a fall in carbon dioxide followed by attempted compensatory fall in bicarbonate (e.g. hyperventilation).
• 3Metabolic acidosis, where there is a fall in bicarbonate with attempted compensatory fall in carbon dioxide (e.g. aspirin overdose).
• 4Metabolic alkalosis, where the primary change is raised bicarbonate with attempted compensatory increase in carbon dioxide (e.g. gastric acid losses).

The Stewart hypothesis is an alternative approach to acid-base analysis. It challenges the concept that changes in bicarbonate concentration can alter pH. This theory, based on mathematical solution, is that only three things, alone or in combination, can determine the hydrogen ion concentration: strong ion difference (net charge balance of dissociated ions in plasma); partial pressure of carbon dioxide; and the sum of acids present.     

A panel of four cytokines predicts the prognosis of patients with malignant gliomas

A comprehensive evaluation of cytokine levels in patients with gliomas could provide important information for the progression and host responses of gliomas. We studied a panel of 120 cytokines and growth factors and investigated their prognostic values for glioma. A protein antibody array was first performed to study the prognostic significance of 120 cytokines in the plasma samples of 45 glioblastoma patients prior to craniotomy or biopsy procedure. An independent set of plasma samples from 260 patients with astrocytomas (80 grade II, 80 grade III, 100 grade IV) with complete clinicopathologic data and follow-ups were used for validation. Ten cytokines were identified by significance analysis of microarray, in which four were associated with poor prognosis (IL-15, MCP-1, GDNF, IL-1R4/ST2), and six were associated with good prognosis (IGFBP-6, MIP-1δ, ICAM-3, IL-7, MIP-3β, and sgp130) of the glioblastoma patients. Moreover, a 4-cytokine panel composed of IL-7, IL1R4/ST2, sgp130 and MCP-1 showed significant correlation with overall survival of the glioblastoma patients (HR 2.068; 95 % CI 1.357–3.153; p = 0.001). In the validation set, the cytokine panel was significantly correlated with overall survival in the 260 glioma patients (HR 3.480, 95 % CI 1.890–6.422) in multivariate Cox regression analysis. It also showed strong correlation with survival in patients with malignant gliomas (grade III: HR 2.790, 95 % CI 1.597–3.984, p = 0.002; grade IV: HR 1.753; 95 % CI 1.502–2.255, p < 0.001). This panel of four cytokines: IL-7, IL1R4/ST2, sgp130, and MCP-1 can serve as a prognostic marker for patients with malignant gliomas.     

Efficacy and safety of pemetrexed/cisplatin versus gemcitabine/cisplatin as first-line treatment in Chinese patients with advanced nonsquamous non-small cell lung cancer

Objectives

Retrospective subgroup analysis in JMDB study indicates that the between-arm differences in overall survival (OS) in the East Asian subgroup were consistent with those observed in the entire JMDB study population. This bridging study (JMIL) further evaluated the efficacy and safety of first-line pemetrexed/cisplatin (PC) versus gemcitabine/cisplatin (GC) in Chinese patients with nonsquamous non-small cell lung cancer (NSCLC). The primary endpoint of this local registration trial was designed to compare OS in the combined dataset, consisting of Chinese patients in JMIL and 1252 nonsquamous patients in JMDB.

Materials and methods

Chinese patients with stage IIIB/IV nonsquamous NSCLC were randomly assigned (1:1) to 6 cycles maximum (21 days/cycle) of pemetrexed 500 mg/m² + cisplatin 75 mg/m² (day 1), or gemcitabine 1250 mg/m² (days 1 and 8) + cisplatin 75 mg/m² (day 1).

Results

In JMIL, 256 Chinese patients were randomized (PC, n = 126; GC, n = 130). Patient baseline characteristics were balanced between treatment arms. In the combined dataset, PC was superior to GC in prolonging OS, with adjusted hazard ratio (HR) of 0.87 (95% CI: 0.77–0.98, p = 0.023) and median OS of 11.76 versus 10.94 months. In the JMIL-only population, no significant OS difference observed between treatment arms (adjusted HR = 1.03 [95% CI: 0.77–1.39, p = 0.822]; unadjusted HR = 0.996 [95% CI: 0.74–1.33, p = 0.980]), nor for other secondary efficacy endpoints. Significantly fewer patients in the PC arm experienced drug-related grade 3/4 toxicities, 54 (43.2%) versus 71 (55.9%) for GC (p = 0.045), with significantly lower rates of leukocytopenia, thrombocytopenia, and fatigue.

Conclusion

This study showed that in the combined population, OS of PC was superior to GC, while in the Chinese-only population, no significant difference was observed; a better safety and risk/benefit profile was found in the PC arm. A PC regimen should be considered as a standard of care in Chinese nonsquamous NSCLC patients in a first-line setting.