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Targets to Prevent Prolonged Length of Stay After EVAR
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Abstracts 811
Table. Comparison of compression pressures at baseline and after usage Brand
Baseline Minimal Ankle Circ., mmHg
A B C D E F
18.9 21.3 22.3 24.5 24.9 25.4
6 6 6 6 6 6
0.3 0.3 0.3 0.2 0.3 0.4
Usage Minimal Ankle Circ., mmHg 18.3 22.0 25.0 25.1 25.3 26.4
6 6 6 6 6 6
0.3a 0.2 0.3c 0.3d 0.4 0.5
Baseline Average Ankle Circ., mmHg 23.2 23.9 23.3 25.7 27.7 26.9
6 6 6 6 6 6
0.3 0.3 0.3 0.2 0.3 0.4
Usage Average Ankle Circ., mmHg 22.6 24.7 26.2 26.3 28.0 27.7
6 6 6 6 6 6
0.2a 0.2b 0.3c 0.3 0.4 0.5
Baseline Maximal Ankle Circ., mmHg 26.7 26.0 24.4 26.8 30.3 27.8
6 6 6 6 6 6
0.4 0.3 0.3 0.20 0.4 0.6
Usage Maximal Ankle Circ., mmHg 26.1 26.9 27.6 27.5 30.5 28.9
6 6 6 6 6 6
0.2a 0.2b 0.3c 0.3 0.4 0.5
Comparison of baseline and following usage: aP < .03; bP < .04; cP <.001; dP < .001.
Durability of Compression Provided by Commercial Stockings After Usage Harry Ma, MD, PhD, John Blebea, MD, MBA, Rafael D. Malgor. University of Oklahoma, Tulsa, Okla Objectives: Compression stockings are commonly prescribed by physicians for lower extremity edema and venous insufficiency. They are usually recommended for replacement after 6 months. However, there are no data available to assess the relative durability of compression provided by various brands, particularly low-cost brands directly available on the Internet. We examined the durability of compression provided by stockings after 6 months of simulated use. Methods: A total of 72 class 2 (20-30 mm Hg) men’s medium-sized below-knee compression stockings from six different manufacturers (n ¼ 12 of each brand) with approximately the same quality and materials were chosen. Identifying brand names were removed, and they were divided into two groups, usage and baseline. To simulate 6 months of clinical wear, the usage group was subjected to 90 stretch cycles for a duration of 1 minute at 110% of maximal stocking circumference on a custom-designed device. This was followed by 90 wash and dry cycles at a commercial laundromat. The baseline group was neither stretched nor washed. All stockings were randomly and blindly tested by a technician in accordance with accepted industry standards using a calibrated constant rate of extension tensile instrument (Zwick Z010, Germany). Testing was done in duplicate, and pressures at the ankle and calf expressed as mean 6 standard error of the mean. Results: The compression pressures generated by all stockings were mostly within the stated range of 20 to 30 mm Hg before and after treatment. One brand had significantly lower pressures generated after usage, whereas two others exhibited higher pressures after stretching and washing (Table). The pressure gradient from the ankle to the calf increased by up to 7% in two brands after usage (P < .05). The stockings of another brand developed significantly increased stiffness (P < .001). Conclusions: Most stockings provided durability in ankle compression after 6 months of simulated usage, with the discount stockings providing similar results as the more expensive brands. Some brands, however, had lower pressures and others higher pressures with more stiffness after stretching and washing, suggesting significant variability between brands, which may affect clinical efficacy. Author Disclosures: H. Ma: None; J. Blebea: None; R. D. Malgor: None. Early Results of Using the Spiral Flow AV Graft: Is It a Breakthrough Solution to a Difficult Problem? Hosam F. El Sayed, MBBCh, PhD1, Mark Davies, MD2. 1The Ohio State University, Columbus, Ohio; 2University of Texas, San Antonio, Tex Objectives: Arteriovenous (AV) access grafts are used in those patients where there are no available superficial veins for native AV fistula creation. Their usable life and patency rates are far from being ideal, requiring frequent interventions to maintain their use for dialysis. Their failure is usually related to neointimal hyperplasia leading to stenosis of the venous outflow near the venous anastomosis. Studies have shown that spiral laminar flow is the normal pattern of flow in most of the large-sized and mediumsized vessels in vivo as well as in many functioning native AV fistulas. The Spiral Flow graft has a design that creates a spiral laminar flow at the venous end that a hypothetically reduces intimal hyperplasia and graft failure. We here report the midterm results of the largest reported series of using the graft in AV access. Methods: After Investigational Review Board approval, a prospective study of using the Spiral Flow graft for AV access in our institution between January 2012 and December 2014 was performed. Enrolled patients had no suitable superficial veins for native AV fistula creation. Patient demographics and comorbidities were recorded. Kaplan-Meier curve analysis was used to calculate patency rates compared with historic controls of straight expanded
polytetrafluoroethylene (ePTFE) and heparin-bonded grafts in our institution. Complications were also recorded. Results: Forty-eight cases were included. The access site was the upper arm in 32, the forearm in 13, and the chest wall in 3. Mean age was 61 years, and mean follow-up was 14 months. At 12 months, the assisted primary and secondary patency rates were 70% and 82%, respectively, which was significantly better than historic controls using straight ePTFE and heparin-bonded grafts in our own institution. Complications included graft infection in 4, severe steal syndrome in 3, seroma in 4, and arm swelling in 3. There were only two early graft failures. Conclusions: Spiral Flow grafts are a valid successful option for AV access. One-year results are superior to using straight ePTFE and heparinbonded grafts. This may be explained on the basis of the hemodynamic environment created by the spiral laminar flow and may be a significant contribution to preventing neointimal hyperplasia and hence AV access graft failure. The Spiral Flow graft is a significant improvement in the field of vascular access surgery. Further work is required to study the hemodynamic mechanism of their action in an attempt to optimize the graft and anastomosis design to further improve the results in vascular access surgery. Author Disclosures: H. F. El Sayed: Other financial benefit, 2000, travel grant. M. Davies: None. Middle Aortic Syndrome Treated by Axillary Bifemoral Bypass George Hines, MD, Pamela Kim, MD. Winthrop University Hospital, Mineola, NY Objectives: Middle aortic syndrome usually presents in children and young adults as claudication, hypertension, or postprandial abdominal pain. Treatment usually involves direct open or endovascular repair or aortic bypass. We present a patient who presented with acute renal failure and paraplegia and was treated with axillary bifemoral bypass. Methods: A 61-year-old woman presented to an outlying hospital with shortness of breath and uncontrollable hypertension. While being treated, she developed hypotension, acute renal failure requiring dialysis, and paraplegia. Her history included hypertension, cholecystectomy, and appendectomy. Medications included amiodarone, Norvasc, hydralazine, labetalol, and nitroglycerin. On physical examination, she had normal upper extremity pulses but absent femoral pulses. A computed tomography angiogram demonstrated a long-segment (13 cm) narrowing, extending from the mid-descending aorta to just proximal to the celiac axis. Magnetic resonance imaging demonstrated central spinal cord signal abnormality from T11-12 to conus. Results: Because of her precarious cardiac situation, renal failure, and paraplegia, axillary bifemoral bypass was performed to avoid aortic clamping. She did well postoperatively, with immediate return of renal function. Her lower extremity weakness resolved, and she now walks without significant weakness. Conclusions: Our patient had an unusual presentation of middle aortic syndrome. Although the standard repair of this lesion is aortoaortic bypass, open patch angioplasty, or endovascular stent, we elected to perform an axillary bifemoral bypass to obviate the need for cross-clamping the aorta to prevent intraoperative ischemia to both the kidneys and the spinal cord. Author Disclosures: G. L. Hines: None; P. Kim: None. Targets to Prevent Prolonged Length of Stay After EVAR James H. Mehaffey, MD, Damien J. LaPar, MD, MSc, Margret C. Tracci, MD, JD, Kenneth J. Cherry, MD, John A. Kern, MD, Gilbert R. Upchurch Jr, MD. UVA, Charlottesville, Va Objectives: Endovascular abdominal aortic aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of
812 Abstracts
stay (LOS) varies greatly even within institutions. In the present study, the morbidity and mortality, as well as financial effect of increased LOS, were reviewed to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. Methods: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, longterm outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS #2 days and >2 days. Results: Complete 30-day variable and cost data were available for 162 patients with an average follow-up of 12 months. The LOS for 66 patients (41%) was >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P ¼ .007), American Society of Anesthesiologists score (P ¼ .0001), thromboembolectomy (P ¼ .006), and postoperative cardiac (P ¼ .0001) and renal (P ¼ .0001) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P ¼ .0001), increased iodinated contrast (P ¼ .027), placement in an intensive care unit (P ¼ .0001), return to the operating room (P ¼ .001), and the use of vasoactive medications (P ¼ .0001). Hospital charges (P ¼ .002) and costs (P ¼ .003) were both significantly higher in patients with prolonged LOS; however, there was no difference in physician charges (P ¼ .124). Increased LOS after EVAR was associated with an increase in 1-month (P ¼ .015), 6-month (P ¼ .020), and 12-month mortality (P ¼ .006). Conclusions: This study highlights several modifiable risk factors leading to increased LOS after EVAR. Further, increased LOS was associated with increased charges, costs, as well as morbidity and mortality after EVAR. This study highlights specific areas of focus for improving quality in vascular surgery.
JOURNAL OF VASCULAR SURGERY September 2015
protein (YAP) is a mechanosignaling protein that controls growth and proliferation, depending on cell shape. Previous experiments have shown that the level of ERK5 and YAP decrease significantly in human umbilical vein endothelial cells on exposure to steady laminar flow (CLF). The aim of this study was to elucidate the mechanism for degradation of ERK5 and YAP under CLF. Methods: Bovine aortic endothelial cells (BAECs) seeded on fibronectin-coated glass slides were grown to confluence in culture medium containing 10% fetal bovine serum, then serum starved for 16 hours. Cells were then exposed to CLF using a parallel plate flow chamber system for 4 hours at 37 C in the presence or absence of 7.5 mM MG132, a ubiquitin proteasome system inhibitor. BAECs kept under static conditions served as the control. Cell lysates were immunoblotted with anti-ERK5, anti-YAP, and anti-ubiquitin antibodies. Fold-change compared with static control at 0 hour was calculated and compared by t-test. A P value of <.05 was considered statistically significant. Results: Exposure of BAECs to CLF for 4 hours significantly decreased the levels of ERK5 (64.6% 6 20.0%; P < .02) and YAP (66.6% 6 23.8%; P < .05) compared with static control (Fig, A). The addition of MG132 increased total ubiquitinated products in the cell but failed to significantly inhibit the decrease in the level of ERK5 and YAP caused by exposure to CLF (60.0% 6 23.5% and 59.0% 6 28.9%; respectively; Fig, B and C). Conclusions: Steady laminar flow decreases the levels of ERK5 and YAP in BAECs despite the presence of ubiquitin proteasome system inhibitors, suggesting the possibility of an alternative proteasomal-independent mechanism that results in degradation of YAP and ERK5 under CLF. Further studies are being done to elucidate this novel mechanism of degradation and to understand its possible role in the pathogenesis of atherosclerosis.
Author Disclosures: J. H. Mehaffey: None; D. J. LaPar: None; M. C. Tracci: None; K. J. Cherry: None; J. A. Kern: None; G. R. Upchurch: None. A Novel Endovascular Approach for the Treatment of Innominate Artery Pathology Pablo de los Santos, Saadat Shariff, MD, Karan Garg, MD, Evan C. Lipsitz, MD. Albert Einstein College of Medicine, Bronx, NY Objectives: Innominate artery injuries are traditionally treated with open surgical repair, often with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of three cases of successful management of innominate artery injuries using a modified Cook (Bloomington, Ind) Zenith ESLE stent graft. Methods: Two patients presented with pseudoaneurysms after attempted central venous catheterization, and one patient developed a tracheoinnominate fistula. Innominate artery diameters ranged from 13 mm to 16 mm, with a length of w4 cm in all patients. Access was obtained in a retrograde fashion via the right common carotid artery in two patients and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in two patients and a bovine arch in two patients. The ESLE limbs are of uniform diameter with three Z stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Grafts with diameters of 14 mm to 18 mm were used. Results: All three cases resulted in technical success, with complete exclusion of the injury. There were no new neurologic deficits, and all patients recovered uneventfully. Conclusions: This approach represents an off-label solution for a problem that frequently presents as an emergency. In two patients, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf graft. It addresses the need for a nontapered graft of short length and moderate vessel diameter. Although not the gold standard, it allows for minimally invasive treatment of anatomically complex pathology. Author Disclosures: P. de los Santos: None; S. Shariff: None; K. Garg: None; E. C. Lipsitz: None. Steady Laminar Flow Degrades ERK5 and YAP via a Ubiquitin Proteasome System (UPS)-Independent Pathway Jiro Kurita, MD, PhD, Gautham Chitragari, MBBS, Bauer E. Sumpio, MD, PhD. Yale University School of Medicine, New Haven, Conn
Fig. Effects of addition of MG132 on ubiquitinated products (A) and degradation of ERK5 (B) and YAP (C) in BAECs exposed to CLF.
Objectives: Extracellular signal-regulated kinase 5 (ERK5) is an intracellular protein that maintains endothelial cell integrity. Yes associated
Author Disclosures: J. Kurita: None; G. Chitragari: None; B. E. Sumpio: None.
Abstracts 811
Table. Comparison of compression pressures at baseline and after usage Brand
Baseline Minimal Ankle Circ., mmHg
A B C D E F
18.9 21.3 22.3 24.5 24.9 25.4
6 6 6 6 6 6
0.3 0.3 0.3 0.2 0.3 0.4
Usage Minimal Ankle Circ., mmHg 18.3 22.0 25.0 25.1 25.3 26.4
6 6 6 6 6 6
0.3a 0.2 0.3c 0.3d 0.4 0.5
Baseline Average Ankle Circ., mmHg 23.2 23.9 23.3 25.7 27.7 26.9
6 6 6 6 6 6
0.3 0.3 0.3 0.2 0.3 0.4
Usage Average Ankle Circ., mmHg 22.6 24.7 26.2 26.3 28.0 27.7
6 6 6 6 6 6
0.2a 0.2b 0.3c 0.3 0.4 0.5
Baseline Maximal Ankle Circ., mmHg 26.7 26.0 24.4 26.8 30.3 27.8
6 6 6 6 6 6
0.4 0.3 0.3 0.20 0.4 0.6
Usage Maximal Ankle Circ., mmHg 26.1 26.9 27.6 27.5 30.5 28.9
6 6 6 6 6 6
0.2a 0.2b 0.3c 0.3 0.4 0.5
Comparison of baseline and following usage: aP < .03; bP < .04; cP <.001; dP < .001.
Durability of Compression Provided by Commercial Stockings After Usage Harry Ma, MD, PhD, John Blebea, MD, MBA, Rafael D. Malgor. University of Oklahoma, Tulsa, Okla Objectives: Compression stockings are commonly prescribed by physicians for lower extremity edema and venous insufficiency. They are usually recommended for replacement after 6 months. However, there are no data available to assess the relative durability of compression provided by various brands, particularly low-cost brands directly available on the Internet. We examined the durability of compression provided by stockings after 6 months of simulated use. Methods: A total of 72 class 2 (20-30 mm Hg) men’s medium-sized below-knee compression stockings from six different manufacturers (n ¼ 12 of each brand) with approximately the same quality and materials were chosen. Identifying brand names were removed, and they were divided into two groups, usage and baseline. To simulate 6 months of clinical wear, the usage group was subjected to 90 stretch cycles for a duration of 1 minute at 110% of maximal stocking circumference on a custom-designed device. This was followed by 90 wash and dry cycles at a commercial laundromat. The baseline group was neither stretched nor washed. All stockings were randomly and blindly tested by a technician in accordance with accepted industry standards using a calibrated constant rate of extension tensile instrument (Zwick Z010, Germany). Testing was done in duplicate, and pressures at the ankle and calf expressed as mean 6 standard error of the mean. Results: The compression pressures generated by all stockings were mostly within the stated range of 20 to 30 mm Hg before and after treatment. One brand had significantly lower pressures generated after usage, whereas two others exhibited higher pressures after stretching and washing (Table). The pressure gradient from the ankle to the calf increased by up to 7% in two brands after usage (P < .05). The stockings of another brand developed significantly increased stiffness (P < .001). Conclusions: Most stockings provided durability in ankle compression after 6 months of simulated usage, with the discount stockings providing similar results as the more expensive brands. Some brands, however, had lower pressures and others higher pressures with more stiffness after stretching and washing, suggesting significant variability between brands, which may affect clinical efficacy. Author Disclosures: H. Ma: None; J. Blebea: None; R. D. Malgor: None. Early Results of Using the Spiral Flow AV Graft: Is It a Breakthrough Solution to a Difficult Problem? Hosam F. El Sayed, MBBCh, PhD1, Mark Davies, MD2. 1The Ohio State University, Columbus, Ohio; 2University of Texas, San Antonio, Tex Objectives: Arteriovenous (AV) access grafts are used in those patients where there are no available superficial veins for native AV fistula creation. Their usable life and patency rates are far from being ideal, requiring frequent interventions to maintain their use for dialysis. Their failure is usually related to neointimal hyperplasia leading to stenosis of the venous outflow near the venous anastomosis. Studies have shown that spiral laminar flow is the normal pattern of flow in most of the large-sized and mediumsized vessels in vivo as well as in many functioning native AV fistulas. The Spiral Flow graft has a design that creates a spiral laminar flow at the venous end that a hypothetically reduces intimal hyperplasia and graft failure. We here report the midterm results of the largest reported series of using the graft in AV access. Methods: After Investigational Review Board approval, a prospective study of using the Spiral Flow graft for AV access in our institution between January 2012 and December 2014 was performed. Enrolled patients had no suitable superficial veins for native AV fistula creation. Patient demographics and comorbidities were recorded. Kaplan-Meier curve analysis was used to calculate patency rates compared with historic controls of straight expanded
polytetrafluoroethylene (ePTFE) and heparin-bonded grafts in our institution. Complications were also recorded. Results: Forty-eight cases were included. The access site was the upper arm in 32, the forearm in 13, and the chest wall in 3. Mean age was 61 years, and mean follow-up was 14 months. At 12 months, the assisted primary and secondary patency rates were 70% and 82%, respectively, which was significantly better than historic controls using straight ePTFE and heparin-bonded grafts in our own institution. Complications included graft infection in 4, severe steal syndrome in 3, seroma in 4, and arm swelling in 3. There were only two early graft failures. Conclusions: Spiral Flow grafts are a valid successful option for AV access. One-year results are superior to using straight ePTFE and heparinbonded grafts. This may be explained on the basis of the hemodynamic environment created by the spiral laminar flow and may be a significant contribution to preventing neointimal hyperplasia and hence AV access graft failure. The Spiral Flow graft is a significant improvement in the field of vascular access surgery. Further work is required to study the hemodynamic mechanism of their action in an attempt to optimize the graft and anastomosis design to further improve the results in vascular access surgery. Author Disclosures: H. F. El Sayed: Other financial benefit, 2000, travel grant. M. Davies: None. Middle Aortic Syndrome Treated by Axillary Bifemoral Bypass George Hines, MD, Pamela Kim, MD. Winthrop University Hospital, Mineola, NY Objectives: Middle aortic syndrome usually presents in children and young adults as claudication, hypertension, or postprandial abdominal pain. Treatment usually involves direct open or endovascular repair or aortic bypass. We present a patient who presented with acute renal failure and paraplegia and was treated with axillary bifemoral bypass. Methods: A 61-year-old woman presented to an outlying hospital with shortness of breath and uncontrollable hypertension. While being treated, she developed hypotension, acute renal failure requiring dialysis, and paraplegia. Her history included hypertension, cholecystectomy, and appendectomy. Medications included amiodarone, Norvasc, hydralazine, labetalol, and nitroglycerin. On physical examination, she had normal upper extremity pulses but absent femoral pulses. A computed tomography angiogram demonstrated a long-segment (13 cm) narrowing, extending from the mid-descending aorta to just proximal to the celiac axis. Magnetic resonance imaging demonstrated central spinal cord signal abnormality from T11-12 to conus. Results: Because of her precarious cardiac situation, renal failure, and paraplegia, axillary bifemoral bypass was performed to avoid aortic clamping. She did well postoperatively, with immediate return of renal function. Her lower extremity weakness resolved, and she now walks without significant weakness. Conclusions: Our patient had an unusual presentation of middle aortic syndrome. Although the standard repair of this lesion is aortoaortic bypass, open patch angioplasty, or endovascular stent, we elected to perform an axillary bifemoral bypass to obviate the need for cross-clamping the aorta to prevent intraoperative ischemia to both the kidneys and the spinal cord. Author Disclosures: G. L. Hines: None; P. Kim: None. Targets to Prevent Prolonged Length of Stay After EVAR James H. Mehaffey, MD, Damien J. LaPar, MD, MSc, Margret C. Tracci, MD, JD, Kenneth J. Cherry, MD, John A. Kern, MD, Gilbert R. Upchurch Jr, MD. UVA, Charlottesville, Va Objectives: Endovascular abdominal aortic aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of
812 Abstracts
stay (LOS) varies greatly even within institutions. In the present study, the morbidity and mortality, as well as financial effect of increased LOS, were reviewed to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. Methods: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, longterm outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS #2 days and >2 days. Results: Complete 30-day variable and cost data were available for 162 patients with an average follow-up of 12 months. The LOS for 66 patients (41%) was >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P ¼ .007), American Society of Anesthesiologists score (P ¼ .0001), thromboembolectomy (P ¼ .006), and postoperative cardiac (P ¼ .0001) and renal (P ¼ .0001) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P ¼ .0001), increased iodinated contrast (P ¼ .027), placement in an intensive care unit (P ¼ .0001), return to the operating room (P ¼ .001), and the use of vasoactive medications (P ¼ .0001). Hospital charges (P ¼ .002) and costs (P ¼ .003) were both significantly higher in patients with prolonged LOS; however, there was no difference in physician charges (P ¼ .124). Increased LOS after EVAR was associated with an increase in 1-month (P ¼ .015), 6-month (P ¼ .020), and 12-month mortality (P ¼ .006). Conclusions: This study highlights several modifiable risk factors leading to increased LOS after EVAR. Further, increased LOS was associated with increased charges, costs, as well as morbidity and mortality after EVAR. This study highlights specific areas of focus for improving quality in vascular surgery.
JOURNAL OF VASCULAR SURGERY September 2015
protein (YAP) is a mechanosignaling protein that controls growth and proliferation, depending on cell shape. Previous experiments have shown that the level of ERK5 and YAP decrease significantly in human umbilical vein endothelial cells on exposure to steady laminar flow (CLF). The aim of this study was to elucidate the mechanism for degradation of ERK5 and YAP under CLF. Methods: Bovine aortic endothelial cells (BAECs) seeded on fibronectin-coated glass slides were grown to confluence in culture medium containing 10% fetal bovine serum, then serum starved for 16 hours. Cells were then exposed to CLF using a parallel plate flow chamber system for 4 hours at 37 C in the presence or absence of 7.5 mM MG132, a ubiquitin proteasome system inhibitor. BAECs kept under static conditions served as the control. Cell lysates were immunoblotted with anti-ERK5, anti-YAP, and anti-ubiquitin antibodies. Fold-change compared with static control at 0 hour was calculated and compared by t-test. A P value of <.05 was considered statistically significant. Results: Exposure of BAECs to CLF for 4 hours significantly decreased the levels of ERK5 (64.6% 6 20.0%; P < .02) and YAP (66.6% 6 23.8%; P < .05) compared with static control (Fig, A). The addition of MG132 increased total ubiquitinated products in the cell but failed to significantly inhibit the decrease in the level of ERK5 and YAP caused by exposure to CLF (60.0% 6 23.5% and 59.0% 6 28.9%; respectively; Fig, B and C). Conclusions: Steady laminar flow decreases the levels of ERK5 and YAP in BAECs despite the presence of ubiquitin proteasome system inhibitors, suggesting the possibility of an alternative proteasomal-independent mechanism that results in degradation of YAP and ERK5 under CLF. Further studies are being done to elucidate this novel mechanism of degradation and to understand its possible role in the pathogenesis of atherosclerosis.
Author Disclosures: J. H. Mehaffey: None; D. J. LaPar: None; M. C. Tracci: None; K. J. Cherry: None; J. A. Kern: None; G. R. Upchurch: None. A Novel Endovascular Approach for the Treatment of Innominate Artery Pathology Pablo de los Santos, Saadat Shariff, MD, Karan Garg, MD, Evan C. Lipsitz, MD. Albert Einstein College of Medicine, Bronx, NY Objectives: Innominate artery injuries are traditionally treated with open surgical repair, often with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of three cases of successful management of innominate artery injuries using a modified Cook (Bloomington, Ind) Zenith ESLE stent graft. Methods: Two patients presented with pseudoaneurysms after attempted central venous catheterization, and one patient developed a tracheoinnominate fistula. Innominate artery diameters ranged from 13 mm to 16 mm, with a length of w4 cm in all patients. Access was obtained in a retrograde fashion via the right common carotid artery in two patients and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in two patients and a bovine arch in two patients. The ESLE limbs are of uniform diameter with three Z stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Grafts with diameters of 14 mm to 18 mm were used. Results: All three cases resulted in technical success, with complete exclusion of the injury. There were no new neurologic deficits, and all patients recovered uneventfully. Conclusions: This approach represents an off-label solution for a problem that frequently presents as an emergency. In two patients, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf graft. It addresses the need for a nontapered graft of short length and moderate vessel diameter. Although not the gold standard, it allows for minimally invasive treatment of anatomically complex pathology. Author Disclosures: P. de los Santos: None; S. Shariff: None; K. Garg: None; E. C. Lipsitz: None. Steady Laminar Flow Degrades ERK5 and YAP via a Ubiquitin Proteasome System (UPS)-Independent Pathway Jiro Kurita, MD, PhD, Gautham Chitragari, MBBS, Bauer E. Sumpio, MD, PhD. Yale University School of Medicine, New Haven, Conn
Fig. Effects of addition of MG132 on ubiquitinated products (A) and degradation of ERK5 (B) and YAP (C) in BAECs exposed to CLF.
Objectives: Extracellular signal-regulated kinase 5 (ERK5) is an intracellular protein that maintains endothelial cell integrity. Yes associated
Author Disclosures: J. Kurita: None; G. Chitragari: None; B. E. Sumpio: None.