Adjunctive Techniques Research Articles

Early Thrombus Removal for Acute Lower Extremity Deep Vein Thrombosis: Update on Inclusion, Technical Aspects, and Postprocedural Management.

Acute lower extremity deep vein thrombosis (DVT) is a common disorder with significant associated morbidity, including pain and swelling, as well as the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE) and chronic debilitating post-thrombotic syndrome (PTS). Anticoagulation is standard of care for DVT treatment. It assists in reducing thrombus progression and the occurrence of PE, but incomplete DVT resolution increases the risk of recurrent VTE, valvular insufficiency, and PTS. Endovascular DVT interventions, such as catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy offer an alternative therapeutic strategy for DVT management. This paper will discuss technical factors and current issues when performing lower extremity DVT interventions including patient selection, anticoagulation, choice of device for endovascular thrombus removal, adjunctive techniques, and venous stent management.Level of Evidence: No level of evidence for: review articles, basic science, laboratory investigations, and experimental study articles.

INTRACRANIAL ARTERIAL LOOP WITH A COMPLEX PARTIALLY THROMBOSED LARGE ANEURYSM ON THE POSTERIOR CIRCULATION: WHAT TO DO NEXT?

Introduction Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. Material and Methods A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. Results Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. Conclusions This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes.

Efficacy and safety of the contralateral approach to vascular lesions in the vertebral artery: patient series.

Endovascular treatment is preferred over microsurgical clipping for intracranial aneurysms in the posterior circulation. However, access to lesions, particularly those in the regions of the vertebral artery (VA) and the posterior inferior cerebellar artery (PICA), is technically challenging in terms of the vessel diameter of the ipsilateral VA or the branching angle of the PICA. Nine cases of intracranial aneurysms in the region of the PICA, which were endovascularly treated with an approach beyond the vertebrobasilar junction (VBJ) from the contralateral VA in the last 4 years, are described herein. All procedures, namely stent deployment, the use of a balloon catheter, and coiling, were safely performed using the contralateral approach. Neither rebleeding nor ischemic complications occurred. All patients had favorable outcomes and no recurrence. All aneurysms were successfully treated using an adjunctive technique with an additional approach beyond the VBJ from the contralateral VA. The combination of both ipsilateral and contralateral approaches to VA-PICA or PICA lesions contributes to safe and effective endovascular treatment. https://thejns.org/doi/10.3171/CASE24420.

A neuromuscular clinician's guide to magnetic resonance neurography.

Magnetic resonance neurography (MRN) is increasingly used in clinical practice for the evaluation of patients with a wide spectrum of peripheral nerve disorders. This review article discusses the technical aspects of MRN highlighting the core sequences performed for clinical care. A robust, high-resolution, heavily T2-weighted fluid-sensitive sequence performed on a 3.0 Tesla magnet system remains the main workhorse MRN sequence. In specific clinical scenarios, adjunct techniques such as diffusion-weighted imaging can be added to a protocol for disease characterization. In addition, gadolinium-based contrast material can also be administered for the purposes of image optimization (suppress adjacent vascular signal) and disease characterization. Technical modifications to field of view and planes of imaging can be made based on the clinical question and discussion with the radiologist(s). On fluid-sensitive MRN sequences, a normal peripheral nerve exhibits iso- to minimally hyperintense signal relative to skeletal muscle with a predictable trajectory, preserved "fascicular" architecture, and tapered caliber from proximal to distal. Peripheral nerve abnormalities on MRN include alterations in signal, caliber, architecture, diffusion characteristics as well as enhancement and provide information regarding the underlying etiology. Although some MRN findings including nerve hyperintensity and long-segmental enlargement are nonspecific, there are certain diagnoses that can be made with high certainty based on imaging including benign peripheral nerve tumors, high-grade peripheral nerve injury, and intraneural ganglia. The purpose of this article is to familiarize a neuromuscular clinician with fundamentals of MRN acquisition and interpretation to facilitate communication with the neuromuscular radiologist and optimize patient care.

Assessment of microvascular occlusion in re-perfused myocardial infarction patients using cardiac magnetic resonance

Abstract Background and objective Primary percutaneous coronary intervention (PPCI) is the gold standard for myocardial reperfusion in ST-segment elevation myocardial infarction (STEMI). Numerous studies have shown that thrombus aspiration can prevent distal embolization, reducing the risk of microvascular obstruction (MVO). Cardiac magnetic resonance (CMR) is considered the gold standard for evaluation of MVO. The aim of this study is to evaluate the efficacy of thrombus aspiration as adjunctive technique to primary PCI, in reducing incidence and extent of MVO in STEMI patients evaluated by CMR. Methods Ninety-three patients with heavy thrombus burden were enrolled in this study, sixty-five met our inclusion criteria. Aspiration thrombectomy followed by PCI was done for thirty-one patients (aspiration group) and conventional PCI, without aspiration thrombectomy, was done for thirty-four patients (conventional group). Primary end points were occurrence and extent of microvascular obstruction (MVO) evaluated by cardiac magnetic resonance (CMR). Results The incidence of microvascular obstruction (MVO) was significantly higher in conventional group (18 patients, 52.9%) when compared with aspiration group (7 patients, 22.6%) (p-value = 0.012). Moreover, significant difference existed between studied groups as regard MVO extent. In aspiration group, MVO extended to > 4 segments in 3 patients (9.7%) while in conventional group, MVO extended to > 4 segments in 13 patients (38.2%) (p-value = 0.012). Conclusion Aspiration thrombectomy as adjunctive technique to PCI in STEMI population maintains the integrity of coronary microvasculature and reduces both incidence and extent of MVO.

Influence of the Inferior Turbinate on the Accuracy of Superior Maxillary Repositioning.

Notably, many studies have focused on the bony interference in the maxillary segment when performing maxillary superior repositioning; however, few reports have described the interference with the inferior nasal turbinate. Therefore, the authors aimed to retrospectively analyze the soft tissue or bone tissue volume of the inferior nasal turbinate and the accuracy of maxillary superior repositioning in Le Fort I osteotomy (LF1). The authors included 83 patients with facial deformities who underwent conventional LF1 (maxillary molar elevation between 4.0 and 6.0mm) with/without bilateral sagittal split ramus osteotomy. The ratio of the soft tissue of the inferior turbinate to that of the inferior nasal cavity was used to divide the participants into 2 subgroups (large and small ratio). Similarly, the bony tissue volume of the inferior turbinate was used to divide the participants into 2 subgroups (large and small bony tissues), and the planned or actual amount of superior repositioning was compared 3 dimensionally. In the soft tissue group, the subgroups showed no significant differences (P=0.934). However, the actual maxillary superior repositioning was significantly lower in the large bone group than in the planned maxillary elevation group (P<0.01). In cases where the maxillary molar needs to be elevated by >4mm and the bone tissue of the inferior nasal turbinate is well developed, an adjunctive technique such as horseshoe osteotomy or partial inferior turbinate resection should be considered in addition to LF1 to avoid interference between the inferior nasal turbinate and the maxillary bone fragments.

Utilizing surface-enhanced Raman spectroscopy for the adjunctive diagnosis of osteoporosis

Osteoporosis (OP) is a chronic disease characterized by diminished bone mass and structural deterioration, ultimately leading to compromised bone strength and an increased risk of fractures. Diagnosis primarily relies on medical imaging findings and clinical symptoms. This study aims to explore an adjunctive diagnostic technique for OP based on surface-enhanced Raman scattering (SERS). Serum SERS spectra from the normal, low bone density, and osteoporosis groups were analyzed to discern OP-related expression profiles. This study utilized partial least squares (PLS) and support vector machine (SVM) algorithms to establish an OP diagnostic model. The combination of Raman peak assignments and spectral difference analysis reflected biochemical changes associated with OP, including amino acids, carbohydrates, and collagen. Using the PLS-SVM approach, sensitivity, specificity, and accuracy for screening OP were determined to be 77.78%, 100%, and 88.24%, respectively. This study demonstrates the substantial potential of SERS as an adjunctive diagnostic technology for OP.

Adjunctive aspiration technique for the surgical management of deep orbital cavernous hemangioma.

To propose a needle aspiration technique for the surgical removal of orbital cavernous hemangioma. In this retrospective case series, we enrolled 13 patients with orbital cavernous hemangioma, who underwent excisional surgery assisted with needle aspiration technique from June 2013 to April 2022. Preoperative symptoms, clinical examination, and imaging features were recorded. Surgical outcomes, including the improvement of visual acuity, proptosis, and ocular motility, were assessed. Postoperative complications were also reported. There were 11 female and two male patients, with a mean age of 50.2 ± 8.0 years (range: 38-61 years). The most common symptom was proptosis (12 cases, 92%), followed by blurred vision (6 cases, 46%). The diameter of the lesions was between 1.8 and 3.2 cm on preoperative imaging. The surgical approaches included sub-brow orbitotomy in 11 patients and the inferior transconjunctival approach in two cases. All the tumors were removed successfully after needle aspiration of 1-3 cc of intralesional blood to reduce the tumor size. Preoperative proptosis, blurred vision, and diplopia improved after the surgery in all cases. There were no serious complications or recurrence of orbital hemangioma. The study presented an effective application of the needle aspiration technique in the surgical management of orbital cavernous hemangioma. Such an innovative method can bring significant benefits, especially for those with large cavernous hemangioma within the deep orbital region.

Lung Cancer Subtyping: A Short Review.

As of 2022, lung cancer is the most commonly diagnosed cancer worldwide, with the highest mortality rate. There are three main histological types of lung cancer, and it is more important than ever to accurately identify the subtypes since the development of personalized, type-specific targeted therapies that have improved mortality rates. Traditionally, the gold standard for the confirmation of histological subtyping is tissue biopsy and histopathology. This, however, comes with its own challenges, which call for newer sampling techniques and adjunctive tools to assist in and improve upon the existing diagnostic workflow. This review aims to list and describe studies from the last decade (n = 47) that investigate three such potential omics techniques-namely (1) transcriptomics, (2) proteomics, and (3) metabolomics, as well as immunohistochemistry, a tool that has already been adopted as a diagnostic adjunct. The novelty of this review compared to similar comprehensive studies lies with its detailed description of each adjunctive technique exclusively in the context of lung cancer subtyping. Similarities between studies evaluating individual techniques and markers are drawn, and any discrepancies are addressed. The findings of this study indicate that there is promising evidence that supports the successful use of omics methods as adjuncts to the subtyping of lung cancer, thereby directing clinician practice in an economical and less invasive manner.

Radiologic evaluation of the kidney transplant donor and recipient.

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections

ObjectiveEndovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. MethodsWe reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). ResultsAmong 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. ConclusionsTES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.

Utility of Image Morphometry in the Atypical Urothelial Cells and High-Grade Urothelial Carcinoma Categories of the Paris System for Reporting Urinary Cytology.

Urinary cytology (UrCy) is highly sensitive to diagnosing high-grade urothelial carcinoma (HGUC) but cannot predict muscularis propria invasion. Further, the atypical urothelial cell category (AUC) may have variable outcomes. Image morphometry (IM) may be a valuable adjunct technique in this setting. Hence, we evaluated IM in the AUC and HGUC categories to improve the diagnostic performance. The following six nuclear parameters were evaluated by IM on 3150 cells: nucleo-cytoplasmic (N:C) ratio, nuclear area, diameter, perimeter, standard deviation of the nuclear area (SDNA; pleomorphism) and integrated density (ID; nuclear chromasia), using the ImageJ software, in three cohorts based on the histopathology outcome: 20 cases of AUC - benign non-neoplastic outcome (AUC-B); 22 cases of HGUC Muscle invasive (HGUC-MI) and 21 cases of HGUC non-muscle invasive (HGUC-MF). A retrospective analysis of urine cytology. The patient's ages ranged from 36 to 85 years, with a mean age of 60.6. The male-to-female ratio was 5.4:1. A total of 20 cases of AUC-B and 43 cases of HGUC were selected for IM analysis. HGUC cases had higher nuclear parameters than AUC-B, and HGUC-MI had higher SDNA, ID, diameter, and area than HGUC-MF. SDNA and ID predict muscularis propria invasion in HGUC. Image morphometry successfully differentiates HGUC cases from benign non-neoplastic ones and might help to identify muscularis propria invasion in HGUC using a combination of nuclear parameters.

Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes

PurposeMeniscal wrapping is a fully arthroscopic technique that involves enhanced meniscal repair with a tissue-engineered collagen matrix wrapping. This study aims to investigate the feasibility of using the meniscal wrapping technique for the treatment of chronic or complex meniscal tears. The primary objective is to assess its failure rate. The secondary objectives are to analyse complication rate, functional outcomes and overall patient satisfaction.MethodsThis retrospective case series study included patients who sustained chronic and complex tears undergoing meniscal wrapping with autologous liquid bone marrow injection. Failure rate was considered if the patient underwent partial or complete meniscectomy or knee replacement during the follow-up, while other unexpected knee reoperations were considered as complications. Clinical outcomes were evaluated through the IKDC score, Tegner Activity Score and Short Assessment of Patient Satisfaction.ResultsTwenty-one patients were included (15 non-acute bucket-handle tears, three non-acute horizontal tears and three non-acute complex injuries). The failure rate was 9.5% at 33 months. The rate of other unplanned reoperations was 14.3%, but none of these complications were apparently directly related to the wrapping technique. The average postoperative IKDC was 73.3/100. No statistically significant difference was encountered between preinjury and postoperative Tegner Activity Score. The mean overall patient satisfaction was 88.3/100.ConclusionsMeniscal wrapping can be safely used as an adjunctive technique to meniscal repair in such difficult-to-treat cases to preserve the meniscus. The technique achieves a low failure rate and promising results of knee function, and patient satisfaction.

Microelectrode Recording During Deep Brain Stimulation Does Not Consistently Represent Lead Trajectory.

Long-term outcomes in deep brain stimulation (DBS) depend on accuracy of lead placement. Microelectrode recording (MER) is a long-used adjunct to leverage neurophysiological information to confirm satisfactory trajectory of implanted electrodes. The goal of this study was to evaluate the consistency in which electrodes are placed in sampled microelectrode trajectories. This is a retrospective study using intraoperative computed tomography to measure final electrode deviation from MER probe placement during the DBS insertion targeting subthalamic nucleus. Fifteen patients had 29 DBS leads placed using MER assistance. Radial distance between the probe and the lead were measured for each patient using intraoperative imaging. In addition, the preoperative target to final lead error was measured in 14 patients undergoing subthalamic nucleus implants without the use of MER and compared with the 15 patients in which MER was used as an adjunct. There was no significant difference in the mean radial target error (1.2 vs 1.0 mm, P = .156) when comparing the leads placed with or without MER assistance, respectively. The mean difference in final position of microelectrode compared with DBS lead was 0.9 ± 0.1 (range 0.4-2.0 mm). Of all MER-assisted electrodes placed, 44.8% (13) of electrode final positions radially deviated 1.0 mm or more from the MER probe. Electrode placement may deviate significantly from MER trajectories. Given the concern that physiological data may not be representative of the final electrode trajectory, surgeons should consider using intraoperative imaging or other adjunctive techniques during DBS to confirm accuracy and satisfactory trajectory of DBS leads.

A 1.9 mm Trilogy lithotripter in mini percutaneous nephrolithotomy Description of technique and case outcomes.

We aimed to evaluate the novel use of a 1.9 mm Trilogy lithotripter probe with varying locations and composition of renal stones. We prospectively enrolled patients to undergo mini percutaneous nephrolithotomy (mPCNL) procedures using the 1.9 mm (instead of the standard 1.5 mm) Trilogy probe from August 2021 to April 2022. Several adjunctive irrigation measures compensated for reduced flow with the larger probe. The primary outcome was treatment efficiency. Patient demographics, preoperative demographics, and comorbidities, as well as real-time surgical data were extracted. Statistical analysis was performed using Kruskal-Wallis tests to compare stone type and location. A total of 110 patients were included in this study. The median total treatment time was 6.8 minutes, median lithotripsy time was 3.3 minutes, median stone treatment efficiency was 0.34 mm/min, and treatment efficacy was 50.4 (lithotripter time/treatment time). Overall median lithotripter efficiency was 104.6 mm3/min. Treatment efficiency was similar among stone composition (p=0.245) and location (p=0.263). Lithotripter 3D and 1D efficiency was also similar among stone composition (p=0.637 and p=0.766, respectively). Lithotripter 1D efficiency was nearly twice as fast in the lower pole compared to other stone locations (p=0.010). The overall broken probe rate for this procedure was 12%, mostly at the beginning, suggesting a learning curve. Five patients had minor complications, including one patient who required admission to the hospital for postoperative pain management. The 1.9 mm Trilogy lithotripter can be effective in mPCNL procedures with the use of easily implementable adjunctive irrigation techniques, decreasing the gap between lithotripsy time and total treatment time.

Dielectrophoresis as an Adjunctive Technique for Fibroblast Cell Migration to Enhance Wound Closure

This study reports on DEP-based simulation and experimental validation of polystyrene (PS) beads and fibroblast cells for primary skin cell migration for enhancing wound closure. MyDEP software was used to calculate the numerical simulation of the Clausius-Mossotti factor (CMF). In order to examine particle trajectories based on input frequencies, the finite element technique (FEM) is used. The trajectories of PS beads and fibroblast cells were experimentally assessed to verify the impact of frequency applied on the polarisation of PS beads and fibroblast cells. The outcome illustrated the potential of employing FDEP to move particles and cells to regions of high and low electric field. Fibroblast cells exhibit negative dielectrophoresis (NDEP) at a broad range of frequencies. Thus, FDEP can be utilised for frequency optimisation to enhance wound closure.

Feasibility and accuracy of intraosseous endoscopy for inspection of thoracolumbar and lumbar pedicle drill tracts in a canine large-breed cadaveric model.

To evaluate the feasibility of endoscopic inspection of thoracolumbar and lumbar pedicle tracts in a canine large-breed model and its accuracy for the detection of breached versus nonbreached tracts. 2 greyhound cadavers. CT scans of 2 greyhound cadavers from the sixth thoracic vertebra to the sacrum were obtained. Fifty-six pedicles were randomized to have drill tracts with different modified Zdichavsky grades (nonbreached, partial/full medial breach, or partial/full lateral breach) using 3-D-printed guides. Endoscopy was performed on a single occasion from October 9 to 10, 2023, using a 1.9-mm 0-degree needle arthroscope in a randomized blinded fashion. The grading of drill tracts was performed on postoperative CT. Specificity, sensitivity, positive and negative predictive values, and time to assign endoscopic grade were investigated. Postoperative CT confirmed 43 nonbreached tracts, 7 medial breaches (partial/full), and 5 lateral breaches (partial/full). One tract was excluded because of guide misplacement. Intraosseous endoscopy was successfully performed in the remaining 55 drill tracts. Sensitivity to detect medial and lateral breaches was 71.4% and 60.0%. Negative predictive value was 93.1%. Specificity was 94.2%. Positive predictive value for detection of medial and lateral breaches was 83.3% and 54.5%. Median (range) time to assign an endoscopic grade was 118 (30 to 486) seconds. Intraosseous endoscopy of pedicle drill tracts may be a useful adjunct technique during pedicle screw/pin placement in dogs.

Clinical and Hemodynamic Features of Aneurysm Rupture in Coil Embolization of Intracranial Aneurysms.

Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our institution. The inclusion criterion was extravasation or coil protrusion during CE. Postoperative data were used to confirm rupture points, and computational fluid dynamics (CFD) analysis was performed to assess hemodynamic characteristics, focusing on maximum pressure (Pmax) and wall shear stress (WSS). IPR occurred in six aneurysms (1.3%; three ruptured and three unruptured), with a dome size of 4.7 ± 1.8 mm and a D/N ratio of 1.5 ± 0.5. There were four aneurysms in the internal carotid artery (ICA), one in the anterior cerebral artery, and one in the middle cerebral artery. ICA aneurysms were treated using adjunctive techniques (three balloon-assisted, one stent-assisted). Two aneurysms (M1M2 and A1) were treated simply, yet had relatively small and misaligned domes. CFD analysis identified the rupture point as a flow impingement zone with Pmax in five aneurysms (83.3%). Time-averaged WSS was locally reduced around this area (1.3 ± 0.7 [Pa]), significantly lower than the aneurysmal dome (p < 0.01). Hemodynamically unstable areas have fragile, thin walls with rupture risk. A microcatheter was inserted along the inflow zone, directed towards the caution area. These findings underscore the importance of identifying hemodynamically unstable areas during CE. Adjunctive techniques should be applied with caution, especially in small aneurysms with axial misalignment, to minimize the rupture risk.

Cap-assisted snare capture technique for resection of fibrotic large polyps

Background and AimsEndoscopic mucosal resection (EMR) of non-lifting or fibrotic polyps may pose challenges, especially when the snare fails to capture flat or depressed fibrotic areas. We present “cap-assisted snare capture” technique using the distal attachment clear cap as an adjunct to EMR for the resection of residual fibrotic tissue. MethodsThree consecutive patients referred for EMR of colonic laterally spreading tumors were included in this case series. Prior to EMR referral, biopsy or attempt for resection of these lesions was not performed. The fibrotic residual tissue after EMR was resected using distal attachment clear cap at tip of adult colonoscope, by placing a soft braided hot snare around the fibrotic tissue and suctioning of tissue into the distal attachment cap while simultaneously closing snare. The suction was released and snare capture of targeted tissue was confirmed prior to snare resection of tissue. The resected site was evaluated for perforation and bleeding prior to closure with clips. ResultsThree presented cases demonstrate the effectiveness of the “cap-assisted snare capture” technique in resecting residual fibrotic tissue and highlights the safety and efficacy of this technique in challenging EMR scenarios (video). There was no perforation, significant bleeding or major adverse events. Conclusions“Cap-assisted snare capture” is a simple technique to assist with resecting fibrotic adenomatous tissue that cannot be captured with conventional snare closure. Its simplicity, use of standard equipment, and effectiveness makes it a valuable adjunct technique in difficult EMR procedures. Larger cohort studies are needed to validate the safety and efficacy of this technique.

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.