Background-Experimentally, isoflurane, a commonly used volatile anesthetic agent, mimics the cardioprotective effects of ischemic preconditioning via a mechanism that could involve the activation of protein kinase C. The present study was designed to assess the clinical relevance of this observation in patients undergoing elective CABG. Methods and Results-Twenty patients were included in the study. In 10 of them, preconditioning was elicited after the onset of cardiopulmonary bypass via a 5-minute exposure to isoflurane (2.5 minimum alveolar concentration), followed by a 10-minute washout before aortic cross-clamping and cardioplegic arrest. Ten case-matched control patients underwent an equivalent period (15 minutes) of prearrest isoflurane-free bypass. Outcome measurements included troponin I and creatine kinase-MB isoenzyme (until the third postoperative day) levels and the activity of ecto-5Ј-nucleotidase, which contributes to adenosine production and is considered to be a reporter of protein kinase C activation, as assessed in right atrial biopsy samples taken before bypass and at the end of the preconditioning protocol (or after 15 minutes of bypass in control patients Key Words: ischemia Ⅲ bypass Ⅲ anesthesia I schemic preconditioning is recognized as one of the most effective means of reducing cellular necrosis. As such, its implementation during cardiac surgery might be clinically relevant, particularly in high-risk patients in whom any additional myocardial ischemic injury induced with cardiopulmonary bypass and superimposed cardioplegic arrest can adversely affect postoperative outcome. Because in this setting it is particularly desirable to avoid an ischemic-type preconditioning stimulus, 1-3 extensive research is targeted toward identifying the pharmacological mediators of the preconditioning phenomenon in an attempt to exploit them therapeutically.There is compelling evidence that the preconditioning signal activates various membrane receptors, which triggers a signaling pathway leading to the activation of several kinases, 4 in particular, protein kinase C (PKC), 5 and the subsequent opening of ATP-dependent potassium channels, possibly at the mitochondrial level. 6,7 How opening of these channels elicits cardioprotection is not yet established but might involve the limitation of calcium influx, better control of cellular volume, or both. This scheme provides a framework for rationalizing interventions targeted at mimicking preconditioning and, in this perspective, makes logical the use, among other drugs, of potassium channel openers.Within this class of drugs, only nicorandil is currently available for human use. However, aside from the fact that nicorandil cannot be administered intravenously, this compound has marked nitrovasodilatory properties, which can be Circulation is available at http://www.circulationaha.org II-340by guest on May 10, 2018http://circ.ahajournals.org/ Downloaded from of concern. Alternatively, isoflurane is a volatile anesthetic agent that has been reported in animal mo...

Mycotic aneurysms are exceptional complications after intravesical instillations of bacillus Calmette-Guérin (BCG) for bladder carcinoma. We report a patient who underwent an emergency operation for a ruptured carotid aneurysm 16 months after BCG therapy. Postoperative investigations discovered multiple other synchronous aneurysms. Culture of an abscess surrounding the right carotid artery identified Mycobacterium bovis var BCG. The patient improved clinically with antituberculous agents prescribed for 9 months but died from recurrence of bladder carcinoma 16 months later. A mycotic origin should be evoked when an aneurysm is discovered after BCG therapy. Microbiologic investigation of the artery wall is diagnostic.

WHAT THIS PAPER ADDSThis observational prospective multicentre series reports the longest term results of the third generation Anaconda device in infrarenal aortic aneurysms with good data consistency. The endograft provided high technical success. During this five year assessment, secondary interventions were performed in 35 of 176 patients (19.9%) and a significant aneurysm diameter decrease of À13.5% was observed, yet the limb occlusion rate remained high (15 limbs [4.3%] in 14 patients [7.9%]) and was significantly higher when additional leg extensions were implanted. Moreover, distal arterial embolisation occurred in some cases. Finally, implantation outside instructions for use should be avoided as it led to significantly higher rates of migration, surgical conversion, and aneurysm sac expansion.Objective: A significant decrease in aneurysm related survival is observed at long term follow up after infrarenal endovascular aneurysm repair (EVAR) compared with open repair. Therefore, longer term results with new generation endografts are essential. The aim of this post-approval French multicentre prospective observational study (EPI-ANA-01) was to evaluate the technical success and five year mortality and secondary intervention rates of the third generation Anaconda TM endograft. Methods: From June 2012 to October 2013, 176 consecutive unruptured infrarenal abdominal aortic aneurysms were included (160 male patients, mean age 75.3 AE 8.4 years). Survival, freedom from type Ia endoleak, limb events, and re-interventions were estimated using the KaplaneMeier method. Anatomical and clinical characteristics were compared according to the occurrence of migration, conversion, adverse limb events, endoleak, and sac enlargement. Results: The primary technical and clinical success rates were 98.3% and 94.9%, respectively. A hostile neck was identified in 33.9% of patients and 10.7% were treated outside instructions for use (IFU). An early post-operative ( 30 days) mortality rate of 1.7% was observed. At one and five years, respectively, the overall survival rate was 94.9% and 65.9% (aneurysm related in four patients [2.3%]) and the clinical success rate was 90.9% and 70.6%. Secondary interventions were performed in 35 of 176 patients (19.9%). The overall limb occlusion rate was 7.9% and the aneurysm sac diameter decreased significantly (pre-operative diameter 53.9 AE 8.6 mm vs. 42.3 AE 14.7 mm at five years; p < .001). Patients treated outside the instructions for use (IFU) had significantly higher rates of migration, surgical conversion, and aneurysm sac expansion (p ¼ .03). Conclusion:The Anaconda endograft provides high technical success and satisfactory five year aneurysm exclusion and clinical success rates. However, implantation outside the IFU should be avoided, as it leads to significantly worse outcomes, and caution over the risk of limb occlusion and distal embolisation should be observed.