Background-Advances in imaging techniques have increased the recognition of aortic intramural hematomas (IMHs) and penetrating atherosclerotic ulcers (PAUs); however, distinction between IMH and PAU remains unclear. We intended to clarify differences between IMH coexisting with PAU and IMH not associated with PAU by comparisons of clinical features, imaging findings, and patient outcome to derive the optimal therapeutic approach. Methods and Results-We performed a retrospective analysis of 65 symptomatic patients with aortic IMH. There were 34 patients with IMH associated with PAU (group 1) and 31 patients with IMH unaccompanied by PAU (group 2). Involvement of the ascending aorta (type A) was more frequent in group 2 (8 of 31, 26%), whereas most of the patients in group 1 had exclusive involvement of the descending aorta (type B) (31of 34, 91%). Patients were subdivided into 2 categories, those with clinical progression and those with stable disease. Forty-eight percent of patients in group 1 and 8% in group 2 were in the progressive category (Pϭ0.002). Clinical and radiological findings were compared between those group 1 patients who had a progressive disease course (nϭ12) and those who were stable (nϭ13). Sustained or recurrent pain (PϽ0.0001), increasing pleural effusion (Pϭ0.0003), and both the maximum diameter (Pϭ0.004) and maximum depth (Pϭ0.003) of the PAU were reliable predictors of disease progression. Considered by many to be a variant of aortic dissection, the pathogenesis of IMH still remains unclear. Two different pathophysiological processes can lead to intramural hematoma formation. One is IMH without intimal disruption; in this entity, it is believed that spontaneous rupture of aortic vasa vasorum is responsible for hematoma formation within the aortic wall. 1 The other type of IMH is associated with an atherosclerotic ulcer that penetrates into the internal elastic lamina and allows hematoma formation within the media of the aortic wall. [2][3][4] Conclusions-This See p 284In previous reports, these 2 types of IMH are rarely distinguished in discussing prognoses and optimal treatment methods. 3,5,6 The concept of the Stanford classification scheme for aortic dissection has been applied to IMH because the prognostic impact of the location of IMH and its standard treatment have been considered similar to those for classic aortic dissection. 5 It is generally accepted that patients with type B (exclusive involvement of the descending aorta) IMH can be managed conservatively in the absence of disease progression, whereas early surgical interventions are recommended for type A (involvement of the ascending aorta) IMH. 5,6 On the other hand, Coady et al 7 recently reported that the prognoses of acutely symptomatic hospitalized patients with penetrating atherosclerotic ulcers (PAUs) was worse than those with classic aortic dissection due to a higher incidence of aortic rupture.We reviewed 65 symptomatic patients with aortic IMH. Thirty-four patients had a PAU that was considered to be the cause of I...

Poor efficacy is one of the issues for clinical islet transplantation. Recently, we demonstrated that pancreatic ductal preservation significantly improved the success rate of islet isolation; however, two transplants were necessary to achieve insulin independence. In this study, we introduced iodixanol-based purification, thymoglobulin induction, and double blockage of IL-1β and TNF-α as well as sirolimus-free immunosuppression to improve the efficacy of clinical islet transplantation. Nine clinical-grade human pancreata were procured. Pancreatic ductal preservation was performed using ET-Kyoto solution in all cases. When the isolated islets met the clinical criteria, they were transplanted. We utilized two methods of immunosuppression and antiinflammation. The first protocol prescribed daclizumab for induction, then sirolimus and tacrolimus to maintain immunosuppression. The second protocol used thymoglobulin for induction and tacrolimus and mycophenolate mofetil to maintain immunosuppression. Eternacept and anakinra were administered as anti-inflammatory drugs. The total amount of insulin required, HbA1c, and the SUITO index were determined to analyze and compare the results of transplantation. All isolated islet preparations (9/9) met the criteria for clinical transplantation, and they were transplanted into six type 1 diabetic patients. All patients achieved insulin independence with normal HbA1c levels; however, the first protocol required two islet infusions (N = 3) and the second protocol only required a single infusion (N = 3). The average SUITO index, at 1 month after a single-donor islet transplantation, was significantly higher in the second protocol (49.6 ± 8.3 vs. 19.3 ± 6.3, p < 0.05). Pancreatic ductal preservation, iodixanol-based purification combined with thymoglobulin induction, and blockage of IL-1β and TNF-α as well as sirolimus-free immunosuppression dramatically improved the efficacy of clinical islet transplantations. This protocol enabled us to perform successful single-donor islet transplantations. Further large-scale studies are necessary to confirm these results and clarify the mechanism of each component.

Lymphangiography might be useful for the treatment of refractory postoperative chylothorax and chylous ascites.

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