Research Spotlight

Balceniuk, M. D., M. A. Hosn, R. S. Corn, T. DerDerian, B. R. Grimsley, P. Long, W. S. Moore, P. J. Rossi, H. J. Shakir, A. H. Siddiqui, D. P. Spadone, M. Waqas and M. C. Stoner (2019). “Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.” J Vasc Surg Nov 15. [Epub ahead of print].

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OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Assia Batzir, N., P. Kishor Bhagwat, A. Larson, Z. Coban Akdemir, M. Baglaj, L. Bofferding, K. B. Bosanko, S. Bouassida, B. Callewaert, A. Cannon, Y. Enchautegui Colon, A. D. Garnica, M. H. Harr, S. Heck, A. C. Hurst, S. N. Jhangiani, B. Isidor, R. O. Littlejohn, P. Liu, P. Magoulas, H. Mar Fan, R. Marom, S. McLean, M. M. Nezarati, K. M. Nugent, M. B. Petersen, M. Linda Rocha, E. Roeder, R. Smigiel, I. Tully, J. Weisfeld-Adams, K. O. Wells, J. E. Posey, J. R. Lupski, A. L. Beaudet and M. F. Wangler (2019). “Recurrent Arginine Substitutions in the ACTG2 Gene are the Primary Driver of Disease Burden and Severity in Visceral Myopathy.” Hum Mutat Nov 26. [Epub ahead of print].

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Visceral myopathy with abnormal intestinal and bladder peristalsis includes a clinical spectrum with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS), and Chronic Intestinal Pseudo-Obstruction (CIPO). The vast majority of cases are caused by dominant variants in ACTG2; however, the overall genetic architecture of visceral myopathy has not been well-characterized. We ascertained 53 families, with visceral myopathy based on megacystis, functional bladder/gastrointestinal obstruction or microcolon. A combination of targeted ACTG2 sequencing and exome sequencing was used. We report a molecular diagnostic rate of 64% (34/53), of which 97% (33/34) is attributed to ACTG2. Strikingly, missense mutations in five conserved arginine residues involving CpG dinucleotides, accounted for 49% (26/53) of disease in the cohort. As a group, the ACTG2- negative cases had a more favorable clinical outcome and more restricted disease. Within the ACTG2-positive group, poor outcomes (characterized by total parenteral nutrition dependence, death or transplantation) were invariably due to one of the arginine missense alleles. Analysis of specific residues suggests a severity spectrum of p.Arg178 > p.Arg257 > p.Arg40 along with other less frequently reported sites p.Arg63 and p.Arg211. These results provide genotype-phenotype correlation for ACTG2-related disease and demonstrate the importance of arginine missense changes in visceral myopathy.

Asrani, S. K., J. Trotter, J. Lake, A. Ahmed, A. Bonagura, A. Cameron, A. DiMartini, S. Gonzalez, G. Im, P. Martin, P. Mathurin, J. Mellinger, J. P. Rice, V. H. Shah, N. Terrault, A. Wall, S. Winder and G. Klintmalm (2019). “Meeting Report: The Dallas consensus conference on liver transplantation for alcohol related hepatitis.” Liver Transpl Nov 19. [Epub ahead of print].

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Liver transplantation (LT) for alcohol related hepatitis (AH) remains controversial. We convened a consensus conference to examine various aspects of LT for AH. The goal was not to unequivocally endorse LT for AH; instead it was to propose recommendations for programs that perform or plan to perform LT for AH. Criteria were established to determine candidacy for LT in the setting of AH and included the following: (1) AH patients presenting for the first time with decompensated liver disease that are non-responders to medical therapy without severe medical or psychiatric comorbidities (2) A fixed period of abstinence prior to transplantation is not required (3) Assessment with a multidisciplinary psychosocial team including a social worker and a addiction specialist/mental health professional with addiction and transplantation expertise. Supporting factors include lack of repeated unsuccessful attempts at addiction rehabilitation, lack of other substance use/dependency, acceptance of diagnosis/insight with commitment of patient/family to sobriety and formalized agreement to adhere to total alcohol abstinence and counseling. LT should be avoided in AH patients that are likely to spontaneously recover. Short- and long-term survival comparable to other indications for LT must be achieved. There should not be further disparity in LT either by indication, geography, or other sociodemographic factors. Treatment of alcohol use disorders should be incorporated into pre and post-LT care. The restrictive and focused evaluation process described in the initial LT experience for AH worldwide may not endure as this indication gains wider acceptance at more LT programs. Transparency in selection process is crucial with collection of objective data to assess outcomes and minimize center variation in listing. Oversight of program adherence is important to harmonize listing practices and outcomes.

Dutton, R. P., T. M. McLoughlin, Jr., F. V. Salinas and L. C. Torsher (2019). “Anesthesia Practice on the Rise.” Adv Anesth 37: xix-xxi.

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Welcome to Advances in Anesthesia! We are pleased to present you with 11 articles covering topics across the spectrum of perioperative care. These include traditional clinical science articles on management of hemodynamics during cesarean section, treatment of malignant hyperthermia, and perioperative blood conservation; cutting edge information on new regional anesthetic techniques, use of tranexamic acid, and an overview of implanted nerve stimulation technology. In addition, we have included articles that could be drawn directly from our current headlines: diversity in the anesthesia workforce, perioperative management of patients with substance abuse disorder, and a focused look at artificial intelligence and clinical informatics for anesthesiologists. One unusual article in this year’s volume is a Pro:Pro:Pro review of career options for anesthesiologists, team written by 2 academic anesthesiologists, a small-group practitioner, and a representative from the largest private practice in the United States. There is no “con” to this article because overall it’s a great time to be an anesthesiologist! Driven by our profession’s ability to care for any kind of patient, from neonate (or even in utero) to centenarian, and to facilitate any procedural aspect of modern medicine from electroconvulsive therapy to cardiac transplantation, anesthesiology is at a peak of influence never before achieved. Compensation is good; case numbers are growing, and residency positions are hotly sought after. Any kind of anesthesiology practice today has much to recommend it and represents a smart career choice for the talented medical student. Beyond the overall picture though, we solicited this article to share some hard-won information not commonly found in academic papers or conference presentations. The goal was to compare the benefits and challenges of different anesthesia practice models in a way that will help graduating residents and fellows pick the best spot to launch their own careers, thus helping to keep our profession on the rise. (Excerpt from text of this introduction to a special issue of Advances in Anesthesia, p. xix.)

Follow-up trends after emergency department discharge for acutely symptomatic hernias: A southwestern surgical congress multi-center trial.

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BACKGROUND: The objective of this multi-center study was to examine the follow-up trends after emergency department (ED) discharge in a large and socioeconomically diverse patient population. METHODS: We performed a 3-year retrospective analysis of adult patients with acutely symptomatic hernias who were discharged from the EDs of five geographically diverse hospitals. RESULTS: Of 674 patients, 288 (43%) were evaluated in the clinic after discharge from the ED and 253 (37%) underwent repair. Follow-up was highest among those with insurance. A total of 119 patients (18%) returned to the ED for hernia-related complaints, of which 25 (21%) underwent urgent intervention. CONCLUSION: The plan of care for patients with acutely symptomatic hernias discharged from the ED depends on outpatient follow-up, but more than 50% of patients are lost to follow-up, and nearly 1 in 5 return to the ED. The uninsured are at particularly high risk.