Adjunctive Procedures Research Articles

Orthodontists’ perception and attitude toward accelerated orthodontic treatments in Australia

Abstract Introduction The purpose of this cross-sectional study was to survey the perception and attitude of Australian orthodontists toward accelerated orthodontic treatments. Methods An online questionnaire was distributed to 427 members of the Australian Society of Orthodontists. The questions related to: clinic demographics, familiarity with appliances/procedures to accelerate orthodontic treatment, the use of appliances/procedures to accelerate orthodontic treatment, and satisfaction with the outcomes when employing these appliances/procedures. Results The response rate was 42.38%. Of the respondents, 26.6% used customised fixed appliances which provided satisfactory outcomes. A small proportion of the respondents routinely used adjunctive procedures to accelerate treatment: 3.5% (n=6) corticotomies, 1.2% (n=2) piezocision, and 1.2% (n=2) intraoral vibrating devices. Conclusion Although a significant number of Australian orthodontists use customised fixed appliances to improve the efficiency of orthodontic treatment, the use of adjunctive procedures to accelerate tooth movement remains very low. Further research is needed to understand the possible limitations and restrictions surrounding this area of practice.

Enhancing subgingival margin restoration: a comprehensive review and meta-analysis of deep margin elevation's impact on microleakage.

Restorative dentistry faces complex challenges with deep proximal surface destruction, requiring novel approaches like DME (Deep Margin Elevation). In order to achieve the best results while treating severe tooth damage, this study examines the advantages, disadvantages, and possible collaborations of different treatments. This systematic review investigates the efficacy of DME as an adjunctive procedure in restorative dentistry, specifically focusing on its impact on microleakage. The study adheres to PRISMA guidelines and employs the PICOS framework for eligibility criteria. 394 potentially qualifying studies were discovered andthorough literature search was carried out via databases. After applying inclusion criteria, 7 studies were included in the analysis. Articles were selected based on criteria that included indirect restoration and performing DME and were compared with indirect restorations without DME. Composite resin was used for DME. Other materials for DME performing, including GI and composite flow, were systematically reviewed. Data analysis was done by biostat software (α = 0.05). The meta-analysis of selected studies reveals a statistically significant positive effect of DME on reduction of microleakage (p = 0.001). The results of this study underscore the potential of DME in addressing subgingival margin challenges and provide valuable insights for restorative dentistry practices.

The minimal important difference in orthodontic treatment duration: a survey across adult patients.

The minimal important difference (MID) is defined as the smallest difference that the patient perceives as important. Furthermore, the smallest worthwhile effect (SWE) is the important change measured with the benefit-harm trade-off method. The aim of this study was to evaluate the MID in orthodontic treatment duration to inform the decision regarding seeking procedures to accelerate orthodontic tooth movement and reduce treatment duration. We constructed a survey eliciting views of the MID from adult participants from four countries undergoing orthodontic treatment. Ten questions addressed reduction in the treatment duration for both durations 12 and 24 months, and four questions were related to the reduction in treatment duration that the patients would require to undergo surgical or non-surgical adjunctive procedures. We applied a univariable random effects logistic regression model to examine the association between the participants' characteristics and the MID. Then, we fitted a multivariable logistic random effects regression including significant predictors. Four hundred and fifty adults, with a median age of 21 (interquartile range: 19-24), undergoing orthodontic treatment participated in the survey. Of the respondents, 60% considered 15 days as a trivial reduction from 12 months duration of therapy and 70% considered15 daysa trivial reduction from 24 months. Of the respondents, 48% considered the period of 2 months a moderate reduction from 12 months, and 60% considered 2 months a moderate reduction from 24 months. From these results, we inferred that patients considered reductions of approximately 1 month as the MID in the treatment duration for both 12 and 24 months. However, SWE was considerably more than the MID for most of the participants to decide undergoing surgical adjunctive procedures to reduce the time of therapy. The participants required smaller SWE to undergo non-surgical procedurescompared to surgical procedures. The MID in the treatment duration is one month for both treatment durations 12 and 24 months. Patients require a greater SWE than the MID to undergo adjunctive procedures to shorten the duration, particularly for surgical procedures.

Effectiveness and safety of irreversible electroporation when used for the ablation of stage 3 pancreatic adenocarcinoma: A registry study (DIRECT).

e16301 Background: Outcomes for patients with Stage 3 pancreatic ductal adenocarcinoma (PDAC) remain poor with a mean overall survival (OS) of 11 months. Irreversible electroporation (IRE) is a method of local tumor ablation that causes cell death by disrupting homeostasis in the cell membrane. Previous research suggests IRE can be useful in the multi-disciplinary treatment of Stage 3 PDAC. The present study was designed to assess the effectiveness and safety of IRE for Stage 3 PDAC in a real-world setting after induction chemotherapy. Methods: Patients with Stage 3 PDAC treated with IRE were prospectively enrolled in a multicenter registry study. Enrollment required 3 months of active multi-agent chemotherapy, with no progression before IRE treatment. Endpoints were 30- and 90-day mortality from enrollment and the new onset of an adverse event (AE). Results: 87 patients were enrolled in the registry between May 2019 and May 2023. Mean age was 64.0 ± 8.4 years, 57.5% were female and mean tumor diameter was 2.2 ± 0.7 cm. Mean time from diagnosis to IRE treatment was 8.9 ± 4.9 months. All subjects underwent induction chemotherapy with the most common being FOLFIRINOX alone, gemcitabine with albumin-bound paclitaxel, or a combination of both in 47 (54.0%) patients. Thirty-seven (42.5%) patients had prior radiation therapy. All procedures were performed using an open approach with 50 (57.5%) for in-situ tumor ablation and 37 (42.5%) with the intent of margin accentuation in combination with resection. Major adjunctive procedures were performed for 70 (80.5%) patients. Common adjunctive surgeries were cholecystectomy (33.3%), Whipple procedure (28.7%) and either distal or subtotal pancreatectomy (11.4%). Mean IRE delivery time was 55.7 ± 54.5 minutes with an average of 3.1 probes (range 2 to 6) used per procedure. There was a mean of 1031.1 ± 882.1 pulses delivered per procedure. The 30- and 90-day mortality was 3/87 (3.4%) and 4/82 (4.9%) respectively. There were 21 (24.1%) patients who developed AEs related to IRE treatment during the 90-day post-procedure period (9 patients had AEs that were definitely related to IRE, 5 probably and 7 possibly). Of these related events, only three were Grade 4 or higher (arterial hemorrhage, cardiac arrest, and septic shock). Overall, gastrointestinal related AEs were the most common representing 16 of the 28 (57.1%) of all AEs associated with the IRE procedure. One patient died within 30 days of the procedure due to an intraperitoneal arterial hemorrhage that was deemed to be definitely related to the IRE treatment. Conclusions: The use of IRE for curative intent tumor ablation alone or in combination with resection following induction chemotherapy in patients with locally advanced Stage 3 PDAC has acceptable safety and is associated with acceptable morbidity and mortality rates in appropriately selected patients. Clinical trial information: NCT03899649 .

Simplified Fabrication of a Lingual Splint for Management of Mandibular Fractures.

Lingual splints have been used to treat mandibular fractures, particularly in cases of complicated mandibular fractures, and serve as a noninvasive adjunctive procedure for reduction and fixation. Furthermore, when used in conjunction with open reduction and internal fixation, the lingual splint provides feasible external fixation against displacing forces exerted by the robust musculature of the mandible. However, the conventional method for lingual splint fabrication is performed preoperatively, and the procedure is time-consuming. This technical note describes a simplified and efficient technique for the intraoperative manufacture of a lingual splint for mandibular fractures using a thermoplastic material, polycaprolactone. Our results demonstrated satisfactory fixation outcomes, reduced lingual splint fabrication time, and superior cost-effectiveness, offering an alternative option for adjunctive external fixation of mandibular fractures.

Enhancing Inverted Internal Limiting Membrane Flap Stability in Macular Hole Retinal Detachment by the "Viscoelastic Agent Pool" Technique.

To evaluate the surgical, anatomical, and functional results of "viscoelastic agent pool" technique-assisted stability of inverted internal limiting membrane flap in macular hole retinal detachment. The innovative surgical technique was performed on 10 patients with macular hole retinal detachment. The primary outcomes included best-corrected visual acuity after surgery, rate of closure of macular hole, retinal reattachment, and occurrence of complications. The mean age of the individuals was 67.70 ± 8.75 (range, 55-84) years; mean axial length, 29.34 ± 1.53 (range, 27.10-30.93) mm; mean corrected MH diameter, 685.30± 345.65 (range, 172-1,325) µ m; and average follow-up period, 6.01 ± 1.71 (range, 3.10-8.4) months. In 6 eyes (60%), the postoperative best-corrected visual acuity showed improvement. All patients had macular hole closure, and the retinal reattachment rate was 100%. No postoperative complications were noted. The "viscoelastic agent pool" technique, an innovative surgical approach designed to enhance the stability of the internal limiting membrane flap, serves as an effective adjunctive procedure for the inverted internal limiting membrane flap technique. It presents a viable option for patients with macular hole retinal detachment.

Fenestrated Endovascular Repair Using Short Tipped Distal Components with No Cross Concept to Prevent Crushing of Target Vessel Bridging Stents

To compare and evaluate early and midterm outcomes of a "no cross" novel approach with short tip vs. standard tip introducer systems for all distal components to prevent target vessel bridging stent kink or collapse during fenestrated endovascular aortic repair (FEVAR). A retrospective analysis was conducted on all patients who underwent FEVAR at a tertiary referral centre between October 2016 and July 2022. The inclusion criterion was the use of renal artery fenestrations. Patients who had chronic dissections were included. Endpoints were analysed in two groups comprising the "no cross" group and the standard group, with all cases being consecutive in their respective groups. Cone beam computed tomography was used intra-operatively in all cases, and post-operative compute tomography angiograms and re-interventions were reviewed. Primary endpoints included technical success, intra-operative adjunctive procedures, adverse events related to the fenestration, and re-interventions, while secondary endpoints were secondary interventions and overall mortality. A total of 70 patients (35 in each group) were enrolled in the study, with 64 (91%) having juxta-renal aneurysms. There were no differences in demographics, cardiovascular risk factors, or aneurysm characteristics between the two groups. The "no cross" group demonstrated a significantly higher technical success rate (100% in all cases) compared with the standard group (29 cases, 83%; p = .010). Additionally, there were statistically significantly fewer intra-operative adjunctive procedures required in the "no cross" group (1.5% of fenestrations) compared with the standard group (8.2% of fenestrations) (p = .013). Overall median follow up was 32 months (interquartile range 22, 62 months). Implementation of a novel "no cross" concept during FEVAR, utilising a short dilator introducer tip on the distal bifurcated component and iliac extensions, significantly reduces intra-operative fenestration related adverse events and enhances technical success. Further studies with larger patient populations and longer follow up are needed to confirm these findings.

Initial Experience of the Covered Endovascular Reconstruction of Iliac Bifurcation Technique.

The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique. This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate. Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB. The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability. The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.

Bypass Patency and Amputation-Free Survival after Popliteal Aneurysm Exclusion Significantly Depends on Patient Age and Medical Complications: A Detailed Dual-Center Analysis of 395 Consecutive Elective and Emergency Procedures.

Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo-popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3-78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo-popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient's overall condition should be considered.

Comparison of St. Thomas II Cardioplegia and Modified Del Nido Cardioplegia in Dogs Undergoing Mitral Valve Surgery.

Myocardial protection has become an essential adjunctive procedure in veterinary cardiac surgery. Del Nido cardioplegia is a good alternative to the traditional St. Thomas II (ST) cardioplegia in open heart surgery in humans. This study aims to compare intra- and postoperative results between ST cardioplegia and modified del Nido (mDN) cardioplegia in mitral valve surgery in dogs with myxomatous mitral valve disease (MMVD). This retrospective study was conducted using clinical records of 16 MMVD dogs that underwent either ST or mDN cardioplegia. We measured cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, total operation time, the number of cardioplegia doses, total amount of cardioplegia, required defibrillations, in-hospital mortality and pre- and one-month postoperative echocardiographic variables. CPB (159.4 ± 16.1 vs. 210.1 ± 34.0 min), ACC (101.4 ± 7.0 vs. 136.0 ± 24.8 min) and total operation time (262.3 ± 13.1 vs. 327.0 ± 45.4 min) were significantly shorter in the mDN group (p < 0.05). The number of cardioplegia doses (3.25 ± 0.4 vs. 6.25 ± 1.2) and total amount of cardioplegia (161.3 ± 51.5 vs. 405.0 ± 185.9 mL) in the mDN group were also significantly smaller than the ST group (p < 0.05). No difference was observed in the requirement of defibrillation, in-hospital mortality and pre- and postoperative echocardiographic variables. The utilization of mDN cardioplegia was associated with shorter operative time in mitral valve surgery in dogs.

Update on corneal crosslinking for keratoconus and corneal ectasia.

To review corneal crosslinking for keratoconus and corneal ectasia, and recent developments in the field. This study will review the mechanism of crosslinking, clinical approaches, current results, and potential future innovations. Corneal crosslinking for keratoconus was first approved by U.S. FDA in 2016. Recent studies have confirmed the general long-term efficacy of the procedure in decreasing progression of keratoconus and corneal ectasia. New types of crosslinking protocols, such as transepithelial treatments, are under investigation. In addition, adjunctive procedures have been developed to improve corneal contour and visual function in these patients. Crosslinking has been found to be well tolerated and effective with the goal of decreasing progression of ectatic corneal diseases, keratoconus and corneal ectasia after refractive surgery. Studies have shown its long-term efficacy. New techniques of crosslinking and adjunctive procedures may further improve treatments and results.

Post-dissection Thoraco-abdominal Aortic Aneurysm Managed by Fenestrated or Branched Endovascular Aortic Repair

Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients. Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis. Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p= .006) compared with B-EVAR. Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR.

Evaluation of Anterior Tibial Translation Under Physiological Axial Load After ACL Reconstruction With Lateral Extra-articular Tenodesis.

Postoperative laxity correlates with negative clinical outcomes after anterior cruciate ligament reconstruction (ACLR). The influence of lateral extra-articular tenodesis (LET) on anteroposterior translation is unclear. This study aimed to evaluate the reduction in radiographic static anterior tibial translation (SATT) and dynamic anterior tibial translation (DATT) after LET as an adjunctive procedure to ACLR. It was hypothesized that adding a LET procedure would have no effect on postoperative SATT and DATT. Cohort study; Level of evidence, 3. Patients who underwent primary ACLR with hamstring tendon autografts between 2020 and 2022 were reviewed, and those who underwent ACLR and LET as an anterolateral associate procedure were paired 1 to 1 with those who underwent isolated ACLR (control) based on age, sex, preoperative SATT, and posterior tibial slope (PTS). The indications for LET were age <18 years and anterolateral rotary instability (grade ≥2 pivot shift). A previously validated technique was used to measure SATT, DATT, and PTS on lateral weightbearing and lateral stress knee radiographs. Preoperative and 9-month postoperative radiographs were compared between the 2 groups. A total of 72 patients were included in the analysis (n = 36 patients in each group). The inter- and intraobserver reliability of the SATT, DATT, and PTS measurements was excellent (intraclass correlation coefficients, 0.88-0.99). The mean pre- and postoperative SATT in the ACLR+LET group was 2.44 ± 2.90 mm and 2.44 ± 2.38 mm, respectively, compared with 2.60 ± 2.99 mm and 2.12 ± 2.74 mm, respectively, in the control group. The mean pre- and postoperative reduction in side-to-side DATT in the ACLR+LET group was 5.44 ± 4.65 mm and 1.13 ± 2.95 mm, respectively, compared with 5.03 ± 3.66 mm and 2 ± 3.12 mm, respectively, in the control group. There was no pre- to postoperative difference in SATT (P = .51). However, the side-to-side DATT was reduced by 3.66 ± 3.37 mm postoperatively (P < .001), without significant differences between groups (P = .24). Including a LET procedure for patients undergoing ACLR did not reduce SATT; that is, it did not decrease the amount of tibial translation due to physiological axial load.

Autologous Fat Grafting Air-valve Loading Technique.

Autologous fat transfer is fast becoming a common adjunct procedure in plastic surgical operations, especially in breast reconstruction. Postharvest fat processing can be performed actively or passively with various techniques. All techniques require the final step of loading the harvested fat into a syringe for injection. We describe here an innovative and elegant technique for safer and more efficient loading of the plunger back into the barrel of a fat-filled syringe before injection. This technique improves ease of loading, reduces loss of harvested fat, and eliminates the risk of bodily fluid splash.

Staged implantation of active transcutaneous bone conduction hearing devices (BCHD) after explantation of older generation bone anchored hearing aids (BAHAs): Surgical outcomes and approach to management

PurposeTo evaluate outcomes following explantation of percutaneous or transcutaneous bone conduction implants (pBCIs or tBCIs) and subsequent implantation of transcutaneous active bone conduction hearing devices (BCHDs); to provide guidance regarding staging of surgery and adjunctive procedures. Materials and methodsRetrospective chart review of eight adult subjects (ten ears) with pBCIs or tBCIs who underwent explantation of their device and subsequent implantation with a BCHD [MED-EL BONEBRIDGE™ (n = 7, 70 %) or Cochlear™ Osia® (n = 3, 30 %)]. ResultsReasons for pBCI or tBCI explantation were pain (60 %, 6/10), infection (60 %, 6/10), skin overgrowth (50 %, 5/10), and inability to obtain new processors (20 %, 2/10). Median time between pBCI or tBCI removal and BCHD staged implant was 4.7 (IQR 2.2–8.1) months. Two subjects developed complications following BCHD implantation. One had a persistent wound overlying the osseointegrated screw after removal of the pBCI abutment, requiring removal and temporalis rotational flap. Staged Osia® implantation was performed, but ultimately wound dehiscence developed over the device. The second subject experienced an infection after BONEBRIDGE™ implantation (32 days after pBCI explant), necessitating washout and treatment with intravenous antibiotics. There was subsequent device failure. ConclusionThe transition from a pBCI or tBCI to a novel transcutaneous device is nuanced. Staged pBCI or tBCI explantation and novel BCHD implantation with sufficient time for wound healing is vital. Adjunctive procedures to augment soft tissue in cases of prior attenuation may be required to avoid complications with larger internal devices.

Differences in In-Hospital and Follow-Up Outcomes Between Non-A Non-B Aortic Dissection and Type B Aortic Dissection Treated by Endovascular Based Treatment.

Non-A non-B aortic dissection (AD) is a rare and life-threatening medical emergency, and it has been controversial whether it should be managed as type B aortic dissection (TBAD). The study aims to compare in-hospital and follow-up outcomes between patients with non-A non-B AD and those with TBAD treated by endovascular based treatment (EBT). From January 2017 to December 2021, 96 consecutive patients with non-A non-B AD met the inclusion criteria and underwent EBT. Patients with TBAD were matched to patients with non-A non-B AD at a 1:1 ratio using propensity score matching analysis to correct for baseline confounding factors. The primary endpoint was all-cause mortality. Aortic-related events were defined as dissection-related death, aortic rupture, retrograde type A aortic dissection, reintervention, and type Ia endoleak. Patients with non-A non-B AD required more TEVAR-related adjunctive procedures compared to TBAD patients during EBT and they required a longer ICU length of stay (36.0 vs 24.0 hours, P < .05) as well as a longer hospitalization (8.0 vs 7.0 days, P < .05) after EBT. There was no statistical difference in overall survival after EBT for patients with TBAD and non-A non-B AD. However, compared to patients with TBAD, non-A non-B AD patients had a higher rate of reintervention and experienced more aortic-related late events during follow-up. Patients with non-A non-B acute AD who are treated with EBT do not have higher in-hospital or follow-up mortality rates compared to patients with type B AD. However, there is an increased risk of reintervention and aortic-related late events after the intervention during follow-up.

Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic.

We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

Survival outcomes of postchemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: A retrospective cohort study from a single tertiary center in South India.

Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). We retrospectively studied 73 patients who had pcRPLND at a single tertiary-care center (2003-2022). Surgical and clinicopathological features and oncological outcomes are presented. The mean age was 28.27 years (15-48). Three-fourths had Stage III disease at diagnosis. International Germ Cell Cancer Collaborative Group risk stratification was 54.54% and 21.21% in intermediate risk, and poor risk, respectively. Sixty-two patients had Standard, 7 had Salvage and 4 underwent Desperation pcRPLND. Eleven patients (15.06%) required adjunctive procedures. Thirteen patients (17.8%) had ≥ class 3 Clavien-Dindo complications and postoperative mortality occurred in 5 (6.8%) patients. The histopathologies (HPE) of the pcRPLNDs were necrosis, teratoma, and viable tumor in 39.7%, 45.2%, and 15.1%, respectively. Seven patients underwent metastasectomy. An 85% size reduction in the size of RPLN predicted necrosis. There was 71.4% concordance between pcRPLND and metastasectomy HPEs. The median follow-up was 26.72 months (inter-quartile range - 13.25-47.84). The 2-year recurrence-free survival (RFS) rate was 93% (95% confidence interval [CI]-83%-97%) and the overall survival (OS) rate was 90% (95% CI-80%-95%). This is the largest series of pcRPLND for NSGCT in India to our knowledge. Although most of the cohort belonged to stage III, an RFS and OS rate of >90% at 2 years was achieved. We believe that successful management of postchemotherapy residual masses in NSGCT is contingent on the availability of multidisciplinary expertise and is therefore best done at tertiary-care referral centers.

Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm.

Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.

Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections.

The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.