Antegrade Method Research Articles

Short- and long-term outcomes of antegrade versus retrograde approaches in patients undergoing percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BackgroundChronic Total Occlusion (CTO) involves severe coronary artery blockage that impairs blood flow and affects 15–20 % of patients undergoing coronary angiography and over 40 % with diabetes or heart failure. Percutaneous Coronary Intervention (PCI) is used to restore blood flow in such cases. The retrograde approach, developed due to lower success with the antegrade method in complex cases, improves outcomes but increases complications. This meta-analysis compares the efficacy and safety of both approaches to guide clinical practice. MethodsA comprehensive literature search was conducted on PubMed, Embase, Google Scholar, and Scopus until June 5, 2024, to find studies comparing antegrade and retrograde approaches in CTO-PCI patients. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using R software (version 4.4.1), with significance set at p < 0.05. Random-effects models were used for all analyses. ResultsOur analysis included 22 observational studies with 49,152 CTO-PCI patients: 35,844 in the antegrade arm and 13,308 in the retrograde arm. The antegrade approach showed significantly lower risks of in-hospital outcomes, including mortality [RR: 0.45; p < 0.001], myocardial infarction [RR: 0.37; p < 0.001], major adverse cardiovascular events [RR: 0.34; p < 0.001], and cerebrovascular events [RR: 0.50; p = 0.011]. Long-term outcomes, such as all-cause mortality [RR: 0.71; p = 0.157] and myocardial infarction [RR: 0.76; p = 0.438], were comparable between both approaches. ConclusionThe antegrade technique shows better outcomes and procedural advantages over retrograde revascularization, though long-term outcomes are similar. Further studies, especially randomized controlled trials are needed to confirm these findings.

Ventricular versus atrial side ablation for treatment of atrioventricular accessory pathways: a randomized controlled clinical trial.

The earliest atrial (A)/ventricular (V) activation potentials, or fused A/V potentials, are commonly used as ablation targets for atrioventricular (AV) accessory pathways (APs). However, these targets can be achieved in a relatively wide area of the heart around AV rings at both atrial and ventricular sides. The aim of this study is to analyze the height of intracardiac A and V waves and their correlation to find the most appropriate side for successful delivery of radiofrequency energy, atrial or ventricular edge. Ninety patients diagnosed with orthodromic AV re-entrant tachycardia (AVRT) or Wolff-Parkinson-White syndrome were enrolled. Local atrial/ventricular (A/V) amplitude potentials with the earliest activation or fused AV potentials were measured. Patients were randomly assigned into two groups with a 2:1 ratio. In group 1, ablation was done at the site where A was greater than V. In group 2, V was greater than A. Primary endpoint was success at first attempt, achieving antegrade AP conduction block, AV block during right ventricle pacing, or AVRT termination with no AP conduction. Fifty-one patients (56.7%) were male. Thirty patients had an ablation at an atrial site (A > V) and 60 at a ventricular site (V > A). Ablation was more successful at the ventricular site (87% vs 100%, P = 0.011). All 30 patients in the atrial arm and 71% of the ventricular group underwent ablation via the antegrade method. Success of catheter ablation of APs is higher where V > A (ventricular site of AP), indicating the priority of the ventricular edge of the mitral ring for a better outcome.

Application of modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer patients

To explore the effectiveness of the modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer (LABC) patients. Between January 2016 and June 2019, 64 unilateral LABC patients were admitted. All patients were female with an average age of 41.3 years (range, 34-50 years). The disease duration ranged from 6 to 32 months (mean, 12.3 months). The diameter of primary tumor ranged from 4.8 to 14.2 cm (mean, 8.59 cm). The size of chest wall defect ranged from 16 cm×15 cm to 20 cm×20 cm after modified radical mastectomy/radical mastectomy. All defects were reconstructed with the modified designed bilobed latissimus dorsi myocutaneous flaps, including 34 cases with antegrade method and 30 cases with retrograde method. The size of skin paddle ranged from 13 cm×5 cm to 17 cm×6 cm. All the donor sites were closed directly. In antegrade group, 2 flaps (5.8%, 2/34) showed partial necrosis; in retrograde group, 6 flaps (20%, 6/30) showed partial necrosis, 5 donor sites (16.7%, 5/30) showed partial necrosis; and all of them healed after dressing treatment. The other flaps survived successfully and incisions in donor sites healed by first intention. There was no significant difference in the incidence of partial necrosis between antegrade and retrograde groups ( χ 2=2.904, P=0.091). The difference in delayed healing rate of donor site between the two groups was significant ( P=0.013). The patients were followed up 15-30 months, with an average of 23.1 months. The appearance and texture of the flaps were satisfactory, and only linear scar left in the donor site. No local recurrence was found in all patients. Four patients died of distant metastasis, including 2 cases of liver metastasis, 1 case of brain metastasis, and 1 case of lung metastasis. The average survival time was 22.6 months (range, 20-28 months). The modified designed bilobed latissimus dorsi myocutaneous flap can repair chest wall defect after LABC surgery. Antegrade design of the flap can ensure the blood supply of the flap and reduce the tension of the donor site, decrease the incidence of complications.

Choice of X-ray surgical tactics for the treatment of venogenic erectile dysfunction in patients with pelvic varicose veins

The aim of the study was to develop an interventional approach for X-ray endovascular occlusion of the periprostatic plexus veins in patients with venogenic erectile dysfunction by systematizing X-ray phlebographic images obtained by standard dynamic pharmacocavernosography and dynamic multispiral computed cavernosography.Materials and methods. A comprehensive examination was carried out in 192 patients with venous erectile dysfunction. The age of the patients ranged from 19 to 66 (36.5 ± 0.73) years. The indication for occlusion of the veins of the periprostatic plexus was a combination of erectile dysfunctions on the IIEF-5 scale from 5 to 20 points and pathological venous drainage from the proximal cavernous bodies of the penis.Results. According to the Doppler ultrasound of the scrotum organs, TRUS of the prostate and the veins of the periprostatic plexus, all patients were diagnosed with pelvic varicose disease as a simultaneous combination of varicose veins of the gonadal veins and veins of the pelvic organs. Standard dynamic pharmacocavernosography was performed in 96 patients with erectile dysfunction. Pathological venous drainage was detected in 79 patients: proximal type - in 68 (86.0 %) of cases, distal type - in 4 (5.1 %) of cases and mixed type - in 7 (8.9 %) of cases. Periprostatic plexus vein occlusion was performed in 20 patients with venogenic erectile dysfunction with proximal pathological venous drainage. Complete disappearance of complaints of erectile dysfunction 6 months after X-ray surgical occlusion of the periprostatic plexus veins was noted in 81.0 % of cases (an increase in the index on the IIEF-5 scale from 12.7 ± 0.9 to 19.8 ± 0.9 points). The discrepancy between the data on the presence of venous leakage according to the results of standard pharmaco-Doppler sonography and the data on its absence according to the results of dynamic pharmacocavernosography in 19 patients determined the indications for dynamic multispiral computed pharmacocavernosography. The implementation of dynamic multispiral computed pharmacocavernosography made it possible to improve the visualization of variants of pathological venous outflow into the periprostatic venous plexus and the veins of the small pelvis from the cavernous bodies of the penis and to offer our own X-ray anatomical classification.Conclusion. The most common type of pathological venous drainage is its proximal type (86.0 % of cases). X-ray surgical occlusion of the veins of the periprostatic plexus is an effective method for the treatment of venogenic erectile dysfunction. Visualization of X-ray phlebographic images of the small pelvis during dynamic multispiral computed cavernosography with 3D reconstruction surpasses the results of standard dynamic pharmacocavernosography in the diagnosis of proximal, distal and mixed types of pathological venous drainage from the corpora cavernosa of the penis. Dynamic multispiral computed pharmacocavernosography with 3D reconstruction allows to determine the shape of the pathological venous drainage of the proximal type and determines the choice of antegrade or retrograde method of X-ray endovascular occlusion of the peripheryprostatic plexus veins in patients with venogenic erectile dysfunction.

A Novel Surgical Method for Treating Symptomatic Incomplete Atypical Femoral Fracture using Percutaneous Elastic Intramedullary Nailing.

Purpose:To introduce the principles and procedure of percutaneous elastic intramedullary nailing (PEIN) as a treatment for symptomatic incomplete atypical femoral fracture (SIAFF).Methods:From October 2014 to April 2019, 6 cases of SIAFF were treated with PEIN. Two pre-bent 4-mm stainless-steel nails were used to apply compressive force to the fracture site. The antegrade method was used for proximal fractures and the retrograde method for middle and distal femoral fractures. The femoral bowing angle in the coronal and sagittal planes, and the time required for callus formation and union, were evaluated on plain radiographs in both planes. Thigh pain, tenderness, and complications were also assessed.Results:The mean operating time was 65.00 ± 22.64 min. No case progressed to complete atypical fracture. In one case, fracture occurred around the point of nail entry after the patient fell from a chair on postoperative day 7. The incomplete fracture lines were united in 5 cases, after excluding one case with a complication. The time taken to confirm endocortical callus formation, fracture line disappearance, and clinical union was 2.11 ± 0.53, 6.45 ± 4.10, and 6.45 ± 3.65 months, respectively.Conclusions:PEIN is a quick, simple but effective treatment for SIAFF that considers the fracture mechanism and is applicable to cases with severe femoral bowing.Level of evidence:Level IV, case series.

Preoperative biliary drainage for malignant biliary obstruction: to drain or not to drain? And if drain, in what way?

On the basis of the conducted literary search, a number of conclusions can be drawn. When performing preoperative biliary drainage (PBD), it is necessary to have a clear understanding: why is this procedure performed (severe liver failure, cholangitis, long preoperative preparation is required due to comorbid status, neoadjuvant chemotherapy is necessary, etc.)? Routine use of PBD is impractical. In the presence of indications for PBB in perihilar cholangiocarcinoma, percutaneous decompression is preferable, in periampullary tumors, endoscopic. Moreover, both methods can be alternative (for example, in case of technical failure of the first priority). There is also no convincing evidence of the superiority of metal stents over plastic ones for PBD (except in cases of long-term preoperative preparation or neoadjuvate treatment) for periampular tumors. To date, a decrease in overall survival and a higher incidence of implantation metastases have not been proven when using the antegrade PBD method. Large multicenter studies are required with differentiation of patients according to the nosological principle in order to more accurately understand the place of each method, as well as to determine clear indications for PBD and those clinical situations when its implementation is impractical.

Comparison of Clinical Outcome of Transcatheter Closure of Ventricular Septal Defect Using Antegrade and Retrograde Approaches

INTRODUCTION: Transcatheter device closure became a trending treatment for ventricular septal defect for perimembranous and muscular type with satisfactory results and low morbidity rates. In most centers, the procedure is performed using antegrade method or transvenous approach. In adult patients, recent studies of transcatheter VSD closure via retrograde or transarterial approach have been successful. However, in pediatric patients, this kind of approach have insufficient data available. This study aims to compare the clinical outcome of transcatheter device closure of ventricular septal defect using antegrade and retrograde approaches among patients of our institution from January 2013 to July 2018. METHODS: To compare the outcomes of two approaches, we retrospectively evaluated early and mid-term results of device closure for VSD in 72 patients divided into 2 groups (A and B) composed, respectively, of 37 patients (antegrade) and 35 patients (retrograde). RESULTS: Procedure time between groups with group A 39.2+13.8 min and with group B 27.3+10.8 min (p&lt;0.0001) were found to be significant. There is a significant difference in clinical outcome between the groups with number of complications in group A is 10 (27%) and in group B is 2 (5.7%). Antegrade patients were more likely to have complications compare to retrograde patients with a p-value of 0.027. Embolization of the device was the early adverse events observed on both groups. Data from midterm follow-up showed that, in antegrade group, new onset valvular insufficiency and residual shunts were more frequent. CONCLUSION: Both therapeutic approaches for transcatheter device closure of VSD were immediately safe and effective but retrograde approach is less likely to have complication compared to antegrade procedure. Patients must be accurately selected before choosing VSD device closure approach; operator skills and experience still have a large impact on success rate for this procedure. KEYWORDS: Ventricular septal defect, VSD device closure, retrograde approach, antegrade approach

Comparative outcomes of antegrade open radical prostatectomy with electrosurgical devices versus retrograde technique without devices

Aim: In this study we compared outcome of antegrade and retrograde radical prostatectomy with new homeostasis devices.Material and Methods: Present study includes retrograde view of prospective recorded data between January 2006 and January 2016 in two different centers.The antegrade technique was applied to 67 cases with the Thunderbeat and the retrograde technique was performed as described by Reiner and Walsh before include with early division of the urethra.Demographic data,operative data (tPSA, ISUP, DM, etc.) and post-operative data (transfusion, hospitalization, surgical margin positivity, stenosis, etc.) were evaluated.Results: There was no difference in terms of demographic status.Incontinence resolved in 29patients in the antegrade group(%43) and resolved in 32patients in the retrograde group(%64) (p=0.012). Erectile dysfunction was observed in 28 patients in the first group(41%) and in 18 patients in the second group(36%) (p=0,359).There was a statistical difference in terms of surgical margin positivity in favor of the antegrade group for these results(p=0.003). Transfusion was required by 11 patients (16%) with the antegrade technique and in 9 patients (18%) with the retrograde technique (p=0.055).There was no difference in terms of anastomosis stenosis and operation duration (p=0.357 and p=0.108).Conclusion: In our study,the antegrade method was shown to be an easier method with less hemorrhage,more reliable preservation of the neurovascular bundle and adding Thunderbeat to the procedure was found to add to the ease of surgery.

A new and easy technique of double-J stenting after retroperitoneal laparoscopic ureterolithotomy: A discussion of other techniques

Aim:To summarize a new and easy technique of double-J stent (DJ stent) placement after retroperitoneal laparoscopic ureterolithotomy (RLU).Materials and Methods:RLU for upper and upper half of mid ureteric stones was performed successfully in 172 patients during the 8-year period between March 2011 and February 2019. In all the cases, a ureteric DJ stent was successfully placed by this new technique. A small-bore antral puncture needle is inserted into the retroperitoneal space to push down a DJ stent with a guidewire into the lower ureter. The tip of the antral puncture needle is manipulated to bring it near the ureterotomy site for easy insertion of the stent. The whole stent is pushed down leaving only the upper end in the ureterotomy area. Then, the guidewire is removed and the upper end is pushed up slowly into the renal pelvis.Results:DJ stents were successfully inserted by this technique in all the 172 cases. In most cases, the stent could be placed in <3 min (range between 2 and 8 min). In two patients, the upper end failed to fully coil in the renal pelvis, but as the stent was passed beyond the ureterotomy site, it served its purpose of an internal drain. None of our cases had any urinary leak. Stents were removed cystoscopically after 6–12 weeks.Conclusion:This technique provides an easy, fast, and safe antegrade method of inserting a DJ stent after RLU.

Placement of double-J stent in patients with malignant ureteral obstruction: antegrade or retrograde approach?

To determine whether antegrade or retrograde methods should be preferred for double-J stent placement in patients with malignant ureteral obstruction (MUO). The medical records of patients treated for MUO in the Urology and Interventional Radiology Clinic, Konya Training and Research Hospital, were reviewed retrospectively. Patients with benign aetiology were excluded from the study. Reports of the procedures, ultrasonography findings, computed tomography (CT), angiography, and pyelography images and the follow-up records of patients with MUO were assessed. A total of 111 patients and 114 ureteral stenting treatments were included in the study; 63 (55.3%) were operated on using the antegrade ureteral stenting (AUS) method, whereas 51 (44.7%) were operated on using the retrograde ureteral stenting (RUS), method, and the characteristics of these groups were evaluated. The presence of hydroureteronephrosis and ureteral tortuosity were determined. Overall success rates were found to be 95.2% using the AUS method and 47.1% using the RUS method. The technical success of the antegrade method was significantly higher in patients with or without tortuosity (respectively: p=0.005, Z shape p=0.001, pigtail shape p=0.035″). The technical success of the antegrade method was significantly higher in patients with hydroureteronephrosis (p=0.001). The AUS technique should be the first choice for double-J stent placement in patients with MUO.

Our modified technique of combined antegrade-vein graft cardioplegia infusion versus conventional antegrade method in coronary artery bypass grafting. A randomized clinical trial

BackgroundTo determine the efficacy of antegrade cardioplegia supplemented with venous graft perfusion in patients scheduled for coronary artery bypass grafting (CABG). Methods223 consecutive patients scheduled for isolated CABG were randomized to receive either continuous crystalloid cardioplegia via vein grafts on completion of each distal anastomosis plus intermittent blood cardioplegia through aortic root (group 1, n = 110) or antegrade blood cardioplegia alone (group 2, n = 113). Two groups were similar in terms of preoperative patients' and procedural characteristics. The primary end-points were low output syndrome (LOS) variables. ResultsThe inotrope and intra-aortic balloon pump demand during weaning were significantly higher in the control group (31.8% vs. 20%, p = 0.043 and 7.9% vs. 1.8%, p = 0.034 respectively). Postoperative level of potassium and arterial base excess (BE), stood in the normal range in both groups, despite significant inter-group differences. Peak serum level of myocardial injury biomarkers (CK, CK-MB, and cTnI) at 12 h following operation, though markedly greater in the group 2, did not reach the cut-off point of myocardial necrosis. Postoperative arrhythmia was more commonly encountered in the control group (p = 0.045).The duration of ventilation and hospital stay were considerably longer in the group 2. In a subgroup with LVEF<30%, the length of ICU stay was more prolonged in the control group, as well (p = 0.0145). The significant differences among groups regarding LOS parameters were more remarkable in the two high-risk subgroups (LVEF<30%, left main coronary stenosis). ConclusionsGiven the better postoperative cardiac performance, we recommend this method to all CABG candidates, particularly in higher-risk patients.

Combined anterograde and retrograde method exposing porta hepatis for the treatment of intrahepatic cholangiocarcinoma invading porta hepatis

Objective To explore the surgical safety and clinical efficacy of combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis. Methods The retrospective descriptive study was conducted. The clinicopathological data of 3 patients with left intrahepatic cholangiocarcinoma invading porta hepatis who were admitted to the Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine from February 2015 to May 2016 was collected. All the 3 patients underwent left hemihepatectomy combined with caudate lobectomy after preoperative lab and imaging examinations and the evaluations of liver function and residual liver volume. The surgical procedures followed as: anterograde dissection of porta hepatis, exposure of hilar plate, left hemihepatectomy combined with caudate lobectomy, right artery resection and reconstruction, hilar cholangioplasty and bilioenteric anastomosis. Observation indicators included: (1) surgical situations: operation time, time of hepatic artery anastomosis and volume of intraoperative blood loss; (2) postoperative pathological examinations; (3) postoperative situations: postoperative complications (biliary fistula, hemorrhage, abnormal liver function, gastroplegia) and postoperative chemotherapy; (4) follow-up: postoperative patients′ survival and carcinoma occurrence. Follow-up was performed to by outpatient examination up to December 2016. The follow-up included clinical symptoms such as abdominal pain, chills, fever and jaundice, liver function and tumor marker examination, and color ultrasound Doppler or abdominal enhanced computed tomography (CT) was performed to detect carcinoma recurrence. Measurement data was represented as average (range). Results (1) Surgical situations: all the 3 patients underwent successful left hemihepatectomy combined with caudate lobectomy using combined antegrade and retrograde method exposing porta hepatis, including 1 combined with right hepatic artery resection and reconstruction, without perioperative death. The average operation time, average time of hepatic artery anastomosis and average volume of intraoperative blood loss of 3 patients were 493 minutes (range, 430-570 minutes), 11 minutes and 526 mL (range, 450-600 mL), respectively. (2) Postoperative pathological examination showed 3 patients were diagnosed with cholangio-carcinoma, 2 with nerve bundles invaded and 2 with No.12 lymph node metastasis, with negative margins of bile duct and hepatic artery. (3) Postoperative situations: 3 patients are not complicated with biliary fistula and gastroplegia. One patient with postoperative liver dysfunction after right artery resection and reconstruction underwent anti-infection, hepatoprotection and anti-hepatic encephalopathy therapies, and then was improved and discharged from hospital at 4 weeks postoperatively. The other 2 patients recovered steadily without complications such as hypohepatia, and then respectively discharged from hospital at 17 and 20 days postoperatively. All the 3 patients underwent chemotherapy of gemcitabine combined with S-1 for 8 courses at week 4 or 5 postoperatively. (4) Follow-up: all the 3 patients were followed up for 7-20 months, with good general conditions and normal liver function and without cholangitis symptoms. One patient received right artery reconstruction, and CT reexamination at postoperative month 3 showed fine imaging of right hepatic artery. There was no sign of carcinoma recurrence. Conclusion The combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis can increase the radical resection rate and surgical safety. Key words: Biliary neoplasms, perihilar; Intrahepatic cholangiocarcinoma; Combined anterograde and retrograde method exposing porta hepatis; Artery reconstruction

How to Avoid Damaging the Terminal Branches of the Medial Antebrachial Cutaneous Nerve and the Medial Brachial Cutaneous Nerve During Operations Involving the Medial Elbow?

Objective: Medial elbow incision is obligatory for cubital tunnel syndrome surgical treatment. However, the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) are likely to be harmed using the current incision technique. The aim of this study was to seek a new incision to avoid damaging the branches of MACN and MBCN during the operation for cubital tunnel syndrome. Methods: Ten fresh frozen cadaver upper extremities and 20 clinical cases (elbows) were analyzed. A conventional incision and a new incision were used in the cadaveric specimens and the clinical cases, respectively. The medial epicondyle was set as the reference landmark to quantify the location of the terminal branches, with the elbow at full extension. The numbers of the terminal branches and their locations were noted for MACN and MBCN, and the locations of the posterior branch of the MACN were recorded in the elbow medial incision. Results: The average numbers of MACN’s posterior terminal branches were 2.6 ± 1.6 and 4.4 ± 2.4 in the cadaveric specimens and clinical cases, respectively. The average number of MBCN’s terminal branches was 2 ± 0.87 in the cadaveric specimens. The MACN’s posterior terminal branches were located at 19 and 45 mm, respectively, measuring from the medial epicondyle. And the posterior branch of MACN was always located in between the medial epicondyle and the basilic vein, and the average distance was 10 ± 6 mm to the medial epicondyle. We could preserve all the MBCN’s terminal branches in the new incision. The MACN’s posterior terminal branches could be perfectly exposed by the use of the antegrade dissection technique, finding the MACN’s posterior branch in advance. Conclusions: The new elbow medial incision technique could reduce the risk of injuring the terminal branches from the MBCN. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. An antegrade method of dissection can effectively identify and avoid the injury to the terminal branches of the MACN in the elbow medial incision.

Retrograde transcatheter closure of ventricular septal defects in children using the Amplatzer Duct Occluder II

To describe the technique and results of transcatheter closure of ventricular septal defects (VSDs) by a modified retrograde transarterial approach using the new Amplatzer Duct Occluder II (ADO II). Transcatheter device closure of ventricular septal defects (VSDs) by antegrade method is well established, but a challenging procedure. We describe a retrograde technique that obviates the need for arteriovenous looping. This is a prospective study from a single center. Between April 2009 and February 2010 13 children were identified for closure of various types of perimembranous and muscular VSDs using the ADO II device. All had met the criteria for surgical closure. Following left ventricular angiogram two were excluded as technically nonfeasible. The median age was 48 months (range 15-78). The median weight was 14 kg (range 7.5-20). The device was successfully deployed in the 11 selected children by the method described. The follow-up evaluation included chest roentgenogram, ECG, and echocardiogram on day 1, at 6 weeks, at 3, 6, and 12 months. The immediate and follow up complete closure rates were 73 and 82%, respectively. The median fluoroscopic time was 14 min (range 8.2-45). There were no procedure related complications. All patients were doing well at median follow up of 10 months; none showing any conduction abnormality. Transcatheter retrograde device closure of selected cases of Ventricular Septal Defects using the Amplatzer Duct Occluder II is simple and appears safe in the short term and can be completed within a short fluoroscopic time.

A Comparison between the Anterior and Posterior Approach to US-guided Shoulder Articular Injections for MR Arthrography

Purpose: To assess the feasibility of ultrasound-guided shoulder joint injections by the anterior and posterior approaches for performing a MR arthrography. Materials and Methods: Between April 2007 and June 2008, 28 patients underwent ultrasound-guided intra-articular contrast injections for a MR arthrography. This study was approached using the antegrade method. As well, all injections were performed by one radiologist. The patient selection criteria for the anterior and posterior approaches were randomly for the anterior approach and alternatively for the posterior approach. Each approach included 13 cases and each were injected by the anterior or posterior approaches exclusively . The patients were classified into three groups as follows: 1) the successful intra-articular injection group, 2) the small leakage group, and 3) the injection failure group. Results: Of the 15 patients that underwent the anterior approach, two were unsuccessful for the MR arthrography. Whereas, two other cases experienced small leakage. The two failed MR arthography cases using the anterior approach were later injected using the posterior approach. The 15 patients subjected to the posterior approach to perform a MR arthrogram were successful in all cases, without any leakage. Conclusion: The ultrasound-guided intra-articular injections were feasible with a high success rate by both the anterior and posterior approaches. However, better results were achieved from the posterior approach than the anterior approach in this study.

Antegrade and retrograde endoscopic approach in the establishment of a neo-esophagus: a novel technique

Although total obstruction or secondary atresia of the esophagus is extremely rare, high-grade strictures are not uncommon. The retrograde approach was previously described to achieve dilation when the conventional antegrade method fails. Gastroenterology laboratory in a tertiary referral center. A 30-year-old man with congenital T-cell immunodeficiency had complete esophageal obstruction after a severe episode of cryptococcal meningitis that required prolonged nasogastric intubation. For the next 3 years, he had daily episodes of regurgitations and several hospitalizations for aspiration pneumonia. A barium study revealed a dilated megaesophagus, with no contrast reaching to the stomach. Initially, a new track was created by using access from above and below the obstruction. This was followed by placement of a self-expandable silicone stent after allowing sufficient time for the new track to mature. Restoration of esophageal continuity, which allowed resolution of the patient's aspiration pneumonia and resumption of oral feeding. Complete esophageal obstruction after prolonged nasogastric intubation is a rare but serious complication. A novel endoscopic approach can be used to restore esophageal continuity, minimize complications, and avoid major reconstructive surgeries.

Antegrade and Retrograde Endoscopic Approach in the Establishment of a Neo-Esophagus

Background Although total obstruction or secondary atresia of the esophagus is extremely rare, high-grade strictures are not uncommon. The retrograde approach was previously described to achieve dilation when the conventional antegrade method fails. Setting Gastroenterology laboratory in a tertiary referral center. Patient A 30-year-old man with congenital T-cell immunodeficiency had complete esophageal obstruction after a severe episode of cryptococcal meningitis that required prolonged nasogastric intubation. For the next 3 years, he had daily episodes of regurgitations and several hospitalizations for aspiration pneumonia. A barium study revealed a dilated megaesophagus, with no contrast reaching to the stomach. Intervention Initially, a new track was created by using access from above and below the obstruction. This was followed by placement of a self-expandable silicone stent after allowing sufficient time for the new track to mature. Main Outcome Measurements Restoration of esophageal continuity, which allowed resolution of the patient's aspiration pneumonia and resumption of oral feeding. Conclusions Complete esophageal obstruction after prolonged nasogastric intubation is a rare but serious complication. A novel endoscopic approach can be used to restore esophageal continuity, minimize complications, and avoid major reconstructive surgeries.

Retrograde intramedullary nailing of femoral shaft fractures. A prospective study

Antegrade intramedullary nailing is seen as a most effective method in the management of femoral fractures. However, complications may arise due to the surgical approach.Can these disadvantages be avoided by using a retrograde approach? In a prospective study 70 femoral fractures in 62 patients were stabilised using a long intramedullary nail by a retrograde approach. We were able to re-examine 50 patients (57 fractures) 13,3 (3-36) months after the operation. Apart from one non-union by infection, all fractures healed in time. Flexion of the knee joint was within a normal ROM in 81% of shaft fractures 12 months or more after the operation, as was the case in 44% of distal fractures. A inhibition of extension was not found in any patient. Two patients had a femoral shortening of up to one centimeter. We observed no rotational malalignment of more than 5 degrees. The clinical results were excellent in 89% of shaft fractures, and in 50% of supra-/diacondylar fractures. In 18 cases a nail removal was already performed, thereby allowing an arthroscopic follow-up inspection of the knee joint. No knee pathology due to nailing was found in either case. Our results show the advantages of retrograde intramedullary nailing in comparison to the antegrade method.

Heterogeneous distribution of cardioplegic solution in pigs

Septal dyskinesia in the left ventricle is detected frequently in many patients after open-heart surgery. The present study was designed to determine whether the antegrade delivery of cardioplegic solution to the regional wall categorized in echocardiography is homogeneous, and whether the distribution to the septal wall differs from that to the lateral wall in the absence of coronary artery disease. To assess these hypotheses quantitatively, radioactive microspheres were mixed into the cardioplegic solution and infused by an antegrade method in eight normal pigs. The cardioplegic distribution to the septal wall was significantly less than to the lateral wall close to the base of the left ventricle (P<0.05). Therefore, antegrade perfusion of cardioplegic solution was non-uniformly distributed to the regional and transmural wall of normal pig hearts. Absence of functional correlation was a limitation of this study. However, these findings suggest that inadequate protection of the ventricular septum by antegrade cardioplegia might be an explanation for the abnormalities of septal wall motion after open-heart surgery.

Low-power laser therapy for gastrointestinal neoplasia.

The purpose of this study was to evaluate changes in the degree of neoplasia-induced stenosis and clinical symptoms before and after therapy with a contact low-power neodymium yttrium aluminum garnet (Nd:YAG) laser. Fifty patients with pathologically proven gastrointestinal (GI) neoplasia were studied; 21 with benign lesions and 29 with malignant tumors. The low-power contact Nd:YAG laser was applied toward the lesion, using an antegrade method as the scope was moved circumferentially and downward along the length of the lesions, step-by-step. The energy of the laser was 20W, with a duration of 1 to 2 min for each shot. Either the tumor was eradicated completely, or the neoplasia-induced stenosis was recanalized by laser via the endoscope. All benign lesions were completely remitted by laser therapy. The clinical symptoms in the 29 patients with malignant GI neoplasia showed a significant improvement (P < 0.001; Wilcoxon matched-pairs signed-rank test, one-tailed) after laser therapy in comparison with the symptoms before treatment. Malignant GI stenosis treated by laser resulted in recanalization in 93.1% of the 29 patients. Unfortunately, in 1 patient with gastric cancer, the disease progressively worsened after treatment. One of 3 patients with early cancer of the stomach who received laser therapy was found to have distant metastasis 2 years later. A patient with esophageal cancer developed an esophagobronchial fistula that was not a direct complication of the laser effect. Four patients with malignancies died of cancer progression during the 2 years of follow-up. We conclude that the low-power contact laser is a safe, convenient method for the treatment of both benign and malignant tumors. Patients with advanced obstructive lesions have a better quality of life after laser therapy.