Antegrade Route Research Articles

Comparison Between Histidine-Tryptophan-Ketoglutarate Cardioplegia and Cold Blood Cardioplegia for Myocardial Protection in Tetralogy of Fallot Patients Undergoing Surgical Repair: A Randomized Clinical Trial

ObjectivesThis study was conducted to compare the efficacy of histidine-tryptophan-ketoglutarate (HTK) cardioplegia and cold blood cardioplegia (CBC), especially for postoperative right ventricle (RV) function after Tetralogy of Fallot (TOF) repair. DesignRandomized, double-blinded, parallel group, controlled, clinical trial. SettingAin Shams University Hospitals.) ParticipantsA total of 100 children (1-5 years-old) scheduled for TOF repair. InterventionsPatients were allocated (double blinded one: one allocation ratio), to either HTK Group that received HTK cardioplegia (30 ml/kg by antegrade route) or CBC Group that received cold blood cardioplegia with blood to Ringer solution (4:1) in volume of 20 ml/kg. Measurements and Main ResultsThe HTK group showed a statistically significant reduction of the vasoactive inotropic score on admission to pediatric intensive care unit (13.0±4.1) in comparison to CBC (15.5±5.4) with P-value of 0.011 but after 24 hours Vasoactive-Inotropic Score was comparable. Lactate level during the first 24 hours in HTK group (6.2±0.7) mmol/l and (6.9±0.4) mmol/l in CBC group with P-value < 0.0001. Serial troponin measurements were lower in the HTK group (1.49 ± 0.45) in comparison to the CBC group (1.69 ± 0.18) with P-value of 0.005 at the first 72 hours postoperatively. Postoperative echocardiographic assessment of RV function by mean of tricuspid annular plane systolic excursion and myocardial performance index were better in HTK than CBC (P-value<0.05). ConclusionsHTK cardioplegia may offer better cardiac protection to pediatric patients undergoing TOF repair than our institutional standard CBC with better recovery for the hypertrophic RV.

Polyp Endotherapy for Multiple Jejunal Lipomas Presenting as Small Bowel Intussusception: “Loop and Let Go Technique”

AbstractA 46-year-old woman presented with abdominal pain, vomiting, and intermittent constipation for the last 2 days. She had similar history of recurrent symptoms for the last 6 months. Abdominal examination showed mild central abdominal tenderness and generalized abdominal fullness and no palpable mass. A diagnosis of intestinal obstruction was considered. Nasogastric aspiration was performed with intravenous (IV) antibiotics and IV fluids. Computed tomography (CT) scan of the abdomen showed “bowel in bowel” or “target” sign appearance of jejunum with a submucosal hypodense lesion (suggestive of lipoma) acting as the lead point. There were two more submucosal lipomas of sizes approximately 3 cm each in the distal jejunal loops. A diagnosis of jejunal lipomas causing small bowel intussusception was made. The patient improved with conservative management. Exploratory laparotomy was planned with an intent to resect the small bowel. The patient did not provide consent for the same and so the option of enteroscopy-guided polyp endotherapy was offered to the patient. An antegrade single balloon enteroscopy was done (SIF-Q180, Olympus Medical Systems, United States). Three submucosal lesions with smooth overlying mucosa were noted in the mid and distal jejunum consistent with lipomas. The base of the lesions was ligated tightly using endoloop to make them ischemic and detach. Notable changes in color and mucosal appearance were noted after the application of endoloop. Since all the lipomas detected on cross-sectional radiologic imaging have been tackled via antegrade route, a retrograde enteroscopy was not attempted further. After 2 days, the patient was discharged in stable condition. Follow-up cross-sectional imaging at 3 months showed no residual lipomas, and she remained symptom-free at the end of 6 months.

Retrograde Peroneal Artery Approach to Treat Infra-Inguinal Arterial Chronic Total Occlusions: A Multicentre Experience and Technical Considerations.

Background/Objectives: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. Methods: We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. Results: Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). Conclusions: Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.

Role of Novel Motorized Enteroscopy in the Evaluation of Small Bowel Diseases: A Systematic Review and Meta-analysis.

Motorized spiral enteroscopy (MSE) has recently been introduced for small bowel evaluation. In this systematic review and meta-analysis, we aim to evaluate the safety and efficacy of MSE for evaluation of small bowel diseases. A literature search was performed in Embase, PubMed, Medline databases for studies evaluating MSE between January -2010 and October-2022. The primary outcome of the study was diagnostic yield with MSE. Secondary outcomes included technical success, procedure duration, depth of maximum insertion (DMI), rate of pan-enteroscopy and adverse events. 10 studies with 961 patients [581 (60.5%) males] were included in the analysis. 1068 MSE procedures were performed by antegrade route in 698, retrograde route in 215 and bidirectional in 155 patients. Technical success was achieved in 94.9% (95% CI 92.9% to 96.4%) procedures. The pooled diagnostic yield of MSE was 73.7% (95% CI 70.7% to 76.4%). Pooled rate of pan-enteroscopy by antegrade route was 21.9% (95% CI 18.1% to 26.1%), retrograde route was 6.9% (95% CI 2.4% to 18.3%) and combined route was 61.2% (95% CI 52.4% to 69.3%). Pooled rate of major adverse events was 1.9% (95% CI 1.2% to 3.2%). MSE is a safe and effective tool for evaluating small bowel disorders. High diagnostic yield and low rate of adverse events make it a potential alternative to balloon enteroscopy. However, comparative trials are required in the future.

Route of Administration for UGN-101 and Impact on Oncological and Safety Outcomes

BackgroundUGN-101 can be used for chemoablation of low-grade upper tract urothelial carcinoma (UTUC). The gel can be administered via a retrograde route through a ureteral catheter or an antegrade route via a nephrostomy tube. ObjectiveTo report outcomes of UGN-101 by route of administration. Design, setting, and participantsWe performed a retrospective review of 132 patients from 15 institutions who were treated with UGN-101 for low-grade UTUC via retrograde versus antegrade administration. Outcome measurements and statistical analysisSurvival outcomes are reported per patient. Treatment, complications, and recurrence outcomes are reported per renal unit. Statistical analysis was performed for primary endpoints of oncological response and ureteral stricture occurrence. Results and limitationsA total of 136 renal units were evaluated, comprising 78 retrograde and 58 antegrade instillations. Median follow-up was 7.4 mo. There were 120 cases (91%) of biopsy-proven low-grade UTUC. Tumors were in the renal pelvis alone in 89 cases (65%), in the ureter alone in 12 cases (9%), and in both in 35 cases (26%). Seventy-six patients (56%) had residual disease before UGN-101 treatment. Chemoablation with UGN-101 was used in 50/78 (64%) retrograde cases and 26/58 (45%) antegrade cases. A complete response according to inspection and cytology was achieved in 31 (48%) retrograde and 30 (60%) antegrade renal units (p = 0.1). Clavien grade 3 ureteral stricture occurred in 21 retrograde cases (32%) and only six (12%) antegrade cases (p < 0.01). Limitations include treatment bias, as patients in the antegrade group were more likely to undergo endoscopic mechanical ablation before UGN-101 instillation. ConclusionsThese preliminary results show a significantly lower rate of stricture occurrence with antegrade administration of UGN-101, with no apparent impact on oncological efficacy. Patient summaryWe compared results for two different delivery routes for the drug UGN-101 for treatment of cancer in the upper urinary tract. For the antegrade route, a tube is inserted through the skin into the kidney. For the retrograde route, a catheter is inserted past the bladder into the upper urinary tract. Our results show a lower rate of narrowing of the ureter (the tube draining urine from the kidney into the bladder) using the antegrade route, with no difference in cancer control.

Correlation of Post-Operative Outcomes in patients undergoing CABG Receiving Antegradecardioplegia alone Versus Combined Antegrade Plus Retrograde Cardioplegia: A Prospective Review

Aim: To compare the mean ejection fraction and cardiac enzymes level in patients with Ischemic heart disease undergoing elective coronary artery bypass graft surgery (CABG) having antegrade blood cardioplegia versus antegrade plus retrograde Cardioplegia. Study design: Randomized Controlled Trial Place and duration: This study was performed from 7th February, 2020 to 7th August, 2020 at the Cardiac Surgery Department, PIC, Jail Road, Lahore. Methodology: After receiving informed consent, all patients undergoing CABG were enrolled in this study. In order to compare the mean ejection fraction and cardiac enzyme levels between patients who had antegrade blood cardioplegia and those who had antegrade plus retrograde cardioplegia, preoperative, intraoperative, and postoperative characteristics were recorded into the predesigned proforma. Results: The total number of patients 72 was enrolled in this study who were divided into two groups. There were 36(50%) patients of who have given Cardioplegia through antegrade route while CABG and 36(50%) patients who have given Cardioplegia through antegrade plus retrograde route while CABG in this study. According to Table 1, the mean age of the patients in Group A was 51.86±9.35 years, whereas the mean ages of the participants in Group B 52.92±7.70 years. There were 26(72%) male and 10(28%) females in Group A and 30(83%) male and 6(17%) females in Group B. The mean BMI in Group A was 25.65±5.18 and 25.02±3.97 in Group B. There were 35(97%) hypertensive and 1(3%) non hypertensive patients in Group A and B respectively. Similarly, there were 33(92%) diabetic and 3(8%) non diabetic patients in Group A and 28 (78%) diabetic and 8(22%) non diabetic patients were in Group B. There were 26(72%) smokers and 10(28%) non- smokers in Group A and 24 (67%) smokers and 12(33%) non-smokers in this Group B. Practical Implication: The comparison of CKMB(IU/L) levels in Antegrade route group and antegrade plus retrograde group baseline and after 48 hours shows insignificant p-values of 0.17 and 0.12 respectively which shows that there is no significant difference in CKMB levels regarding these two routes chosen for giving Cardioplegia to patients undergoing coronary artery bypass grafting. Conclusion: Although both required additional surgical manoeuvres, however, the antegrade and antegrade plus retrograde cardioplegia approaches were equally effective and safe. Prior research demonstrated that multiple infusions offer superior protection to either antegrade or retrograde cardioplegia alone. Keywords: Coronary artery Bypass grafting surgery, Antegrade route, Retrograde Route, Antegrade plus Retrograde route.

Ultrasound-guided retrograde tibial access through chronically occluded tibial arteries: a last resort recanalization technique.

PURPOSE We aimed to demonstrate the feasibility of ultrasound (US)-guided retrograde tibial access through chronically occluded tibial arteries as a bailout endovascular recanalization procedure in patients with critical limb ischemia (CLI). METHODS Fifty-one CLI patients with failed conventional antegrade tibiopedal recanalization required retrograde tibiopedal access in the same session. In all of these patients, the target tibial artery was chronically occluded in at least the distal half of the cruris. Access attempts were made under real-time US by a single operator experienced in image-guided vascular access procedures. Fluoroscopy was used only as an adjunct during advancement of a 0.018 inch guidewire. If access to the artery was successful by the retrograde route, the occluded artery was usually predilated with a 2 mm balloon, and the standard endovascular treatment was mostly performed through the antegrade route. RESULTS Patients had athereosclerosis (n=35) or Buerger's disease (n=32) and presented with Rutherford category IV and category V. Successful placement of a guidewire in the occluded artery lumen was achieved in 81% of all patients, whereas, treatment success, i.e. angiographic demonstration of in-line flow at the end of procedure, was achieved in 49%. No significant procedure-related complications were observed. Of 33 limbs with initially successful endovascular treatment, 6 required minor and 1 required major amputation during follow-up. CONCLUSION US-guided retrograde access through completely occluded tibial arteries is difficult but feasible. Half of the tibial arteries that could not be recanalized otherwise were converted to successful recanalization by this method.

Safety and efficacy of the novel motorized power spiral enteroscopy: A single-center experience.

ObjectiveEvaluation and management of small bowel disorders have always been challenging due to the limitations of the existing technology. Motorized power spiral enteroscopy (PSE) is an innovative new technique that offers easier, faster, and more complete small bowel evaluation with the ability to perform therapeutics. We aimed to evaluate the safety and efficacy of PSE in various indications.MethodsRetrospective analysis of prospectively collected data of consecutive patients, who underwent PSE at a tertiary care center. Primary outcome measures were technical success rate, pan‐enteroscopy rate, diagnostic and therapeutic yield, and the secondary outcomes measures were the depth of maximal insertion, median insertion time, and adverse events.ResultsFifty‐four patients (mean age of 49.38 ± 16.26 years) underwent PSE for small bowel evaluation. Technical success rate was 95.55% (antegrade route) and 93.10% (retrograde route). Pan‐enteroscopy rate is 46.29% and antegrade enteroscopy to the cecum was achieved in eight patients. Overall diagnostic and therapeutic yields were 85.18% and 30.76%, respectively. The most common findings were ulcero‐stricturing lesions (51.92%) followed by vascular lesions (9.61%). The most common histopathologic diagnosis was Crohn's disease in 29.62%. Median depth of maximal insertion was 400 cm (range 150–550 cm; antegrade route) and 180 cm (range 50–350 cm; retrograde route). The median insertion time to depth of maximal insertion was 70 min (range 30–110 min; antegrade route) and 45 min (range 20–70 min; retrograde route). PSE‐associated major adverse events occurred in one patient and minor adverse events were seen in 48.14%.ConclusionPSE is a safe and effective modality for the evaluation of small bowel disorders with a high diagnostic yield.

Retrograde use of the Outback re-entry catheter in complex infrainguinal arterial recanalizations.

Retrograde recanalizations gained increasing recognition in complex arterial occlusive disease. Re-entry devices are a well-described adjunct for antegrade recanalizations. We present our experience with retrograde, infrainguinal recanalizations using the Outback re-entry catheter in challenging chronic total occlusions. We report data from a retrospective multicenter registry in complex retrograde recanalizations. Eligibility criteria included retrograde infrainguinal use of the Outback re-entry catheter where both conventional antegrade and retrograde recanalizations had been unsuccessful. Procedural outcomes included technical success (defined as successful wire passage and delivery of adjunctive therapy with<30% residual stenosis), safety (periprocedural complications, eg, bleeding, vessel injury, or occlusion of the artery at the re-entry site, and distal embolizations), and clinical outcome (amputation-free survival and freedom from clinically driven target lesion revascularization [cd-TLR]). Forty-five consecutive patients underwent retrograde, infrainguinal recanalization attempts with the Outback re-entry catheter between February 2015 and August 2020. Thirty (67%) patients had a history of open vascular surgery in the index limb. In four patients, recanalizations were even more challenging due to previous surgical removal and/or ligation of the proximal segment of the superficial femoral artery. The retrograde access site of the Outback catheter was the femoropopliteal segment in 31 (69%) patients and crural vessels in 14 (31%) patients. The re-entry target sites were as follows: common femoral artery in 31 (69%) patients, superficial femoral artery in 9 (20%) patients, popliteal artery in 1 patient, and below-the-knee arteries in 2 patients. In four patients, the needle of the re-entry device was targeted to an inflated balloon, inserted via the antegrade route. The Outback re-entry catheter was placed via a 6-French sheath in 19 (42%) cases and sheathless in 26 (58%) cases. Technical success was achieved in 41 (91%) patients There were two instances of distal embolizations and three bleeding episodes. Amputation-free survival was 100% at 30days, and after 12months, freedom from cd-TLR was 95% at 30days and 75% at 12months of follow-up. Female sex was an independent predictor for cd-TLR at 12months of follow-up. Retrograde use of the Outback re-entry catheter in infrainguinal chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed.

Objective Content Validation of the Hemodynamic and Technical Parameters of the OrpheusTM Cardiopulmonary Bypass Simulator.

The utilization of simulators for training is increasing in the professions associated with cardiac surgery. Before applying these simulators to high-stakes assessment, the simulator's output data must be validated. The aim of this study is to validate a Cardiopulmonary Bypass (CPB) simulator by comparing the simulated hemodynamic and technical outputs to published clinical norms. Three Orpheus™ CPB simulators were studied and compared to a published reference of physiologic and technical metrics that are managed during clinical CPB procedures. The limits of the simulators user modifiable variables were interrogated across their full range and the results were plotted against the published clinical norms. The data generated with the simulator conforms to validated clinical parameters for patients between 50 and 110 kg. For the pre- and post-CPB periods, the independent variables of central venous pressure (CVP), heart rate (HR), contractility, and systemic vascular resistance (SVR) must be operated between the limits of 7 and 12 mmHg, 65 and 110 beats/min, 28% and 65%, and 6 and 32 units respectively. During full CPB the arterial pump flows should be maintained between 3.5 and 5.5 LPM and SVR between 18 and 38 units. Validated technical parameters during cardioplegia delivery are expected at solution flow rates between 250 and 400 mL/min and 100 and 225 mL/min for antegrade and retrograde delivery routes, respectively. We have identified the limits for user-modifiable settings that produce data conforming to the physiologic and technical parameter limits reported in the peer reviewed literature. These results can inform the development of simulation scenarios used for high stakes assessments of personnel, equipment, and technical protocols.

Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature

Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route.Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed.Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8–27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0–2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome.Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.

Use of Lifetech™ Konar-MF, a device for both perimembranous and muscular ventricular septal defects: A multicentre study

BackgroundThe objective of this study was to evaluate the safety and efficacy of transcatheter closure of ventricular septal defects (VSD) using the LifeTech™ multifunctional occluder device (MF-Konar). MethodsClinical features and demographic characteristics and follow-up findings were evaluated retrospectively from three centers. ResultsMF-Konar was used in 98 patients. The median age and weight of the patients were 3.8 years (range 5.4 months–50 years) and 15.3 kg (range 5.5–80 kg), respectively. The mean fluoroscopy time was 13.7 ± 8.2 min (range 3.4–42.6 min). Procedural success was obtained for 96 out of 98 patients (98%). In 54 out of 98 patients, closure was performed via the antegrade route. Major complications occurred in four patients (embolization in two, complete heart block in one, and device dislocation needing surgical treatment in one). All of the complications were treated successfully, and there was no mortality. Mild residual flow in eight patients (8%), new onset tricuspid valve insufficiency in one (moderate), and new onset aortic valve insufficiency in one (mild) were observed during a mean follow-up duration of 224 ± 149 (10–515) days. Minor rhythm disturbances were observed in eight patients. ConclusionsTranscatheter closure of VSDs in selected patients using the LifeTech MF-Konar device seems effective. Its advantages are softer design, use of both an antegrade and retrograde approach, and an advanced smaller delivery system. Increasing the number of usage and the experience will provide more accurate data and low complication rates.

Intermittent Antegrade Warm Blood Cardioplegia: What Is Next?

The introduction of warm heart surgery was a radical change in the concept of myocardial protection. In 1992, we applied a protocol for intermittent antegrade warm blood cardioplegia (CPL), which acquired some popularity for its simplicity and effectiveness. The possibility to deliver the warm blood CPL intermittently using the antegrade route attracted the attention of the scientific world, as the surgical procedure was less complicated. In this report, our aim is to focus on the changes that the protocol underwent over time and the reasons why these changes were made.

The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy.

Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.

Limb revascularization of peripheral artery disease in the developing countries: Earliest 1-year experience from Northwestern Nigeria

Purpose:The purpose of the study is to present the preliminary audit and challenges of earliest cases of balloon angioplasty from Northwestern Nigeria.Materials and Methods:We present our first 25 cases of peripheral angioplasty in Northwestern Nigeria. The clinical diagnosis of peripheral artery disease was confirmed with Doppler ultrasound and angiography. Angioplasty was done either through femoral or brachial artery approaches. The patients were monitored for minimum of 6 months with serial clinical and Doppler ultrasound examinations.Results:Our patients consist of 19 males and 6 females. Their ages ranged from 20 to 80 years with a mean of 54 ± 17.5 years. There were 13 hypertensive and 15 diabetic patients while 5 patients have co-morbidities of diabetes and Hypertension. Although femoral antegrade route is the common access for angioplasty (14 out of 25), seven patients who were treated through the left brachial artery, six of them had either Type C or D aortoiliac disease in addition to distal lesions. At follow-up, 36% had limb amputation while one patient died a day after the procedure. Out of nine patients who had amputation, six are diabetic.Conclusion:Although more than half of them had improved blood flow with healing ischemic ulcers and reducing claudications, still substantial number of our patients often present late with severe peripheral artery disease. As a result, we had to resort to cumbersome arterial access and high amputation rate.

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery

Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.

New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement.

Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.

Clinical Outcomes and Electrolyte Balance Factors in Complex Cardiac Operations in Adults; Del Nido® Versus Custodiol® Cardioplegia Solutions: A Randomized Controlled Clinical Trial

Background: Cardioplegia is used for protection of myocardium during cardiac operations. Del Nido (DN) and Custodiol cardioplegia solutions are used for prolonged protection of the myocardium during cardiopulmonary bypass (CPB). Custodiol cardioplegia (CC) solution is gaining popularity for myocardial protection during cardiopulmonary bypass. Objectives: This study aimed to compare the effects of Custodiol with another cardioplegia solution, Del Nido, on myocardial protection during cardiopulmonary bypass. Methods: In a randomized controlled clinical trial, forty patients were randomly allocated to DN and Custodiol (CC) groups. Patients in both groups received a normal anesthesia protocol. For cardioplegia, in the DN group, the DN solution was administered every 90 minutes by the antegrade route. In the Custodiol group, the Custodiol solution was administered in the same way at the beginning of the cardioplegia. Demographic information, blood chemistry parameters and other related perioperative and postoperative clinical indices were recorded. Results: Frequency of female patients was 14/21 (66.66) in the DN and 12/19 (63.15) in the CC group (P = 0.816), age was 57.14 ± 12.48 years in the DN and 59.47 ± 11.96 years in the CC group (P = 0.551), weight was 70.95 ± 9.56 kilograms in the DN and 69.63 ± 7.64 kilograms in the CC group (P = 0.635), CPB time was103.19 ± 23.43 minutes in the DN versus 97.36 ± 16.7 minutes in the CC group (P = 0.376), and cross-clamp time was 73.76 ± 19.66 minutes in the DN and 83.95 ± 16.14 minutes in the CC group (P = 0.083). Blood chemistry and blood gas analysis revealed a similar trend between the two groups in these parameters (P > 0.05) except for higher sodium levels after cardioplegia (P = 0.016) and end of CPB (P = 0.002), potassium levels after cardioplegia (P = 0.029), and bicarbonate anions at the end of bypass (P = 0.03) in the custodiol group. Conclusions: In conclusion, CC and DN offer effective myocardial protection during cardiopulmonary bypass. It is recommended to restrict the use of CC in patients susceptible to electrolyte disturbances. © 2018, Author(s).

Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding.

Background/aims The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE. Methods A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE. Results A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1; P = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 – 4.6; P = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 – 4.9; P = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 – 8.1; P = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 – 6.8; P < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 – 6.1; P < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors. Conclusions Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review.

1: ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization.Strong recommendation, high quality evidence.However, the optimal timing for taking purgatives is yet to be established. 2: ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients.Strong recommendation, moderate quality evidence. 3: ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions.Strong recommendation, low quality evidence. 4: ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices.Weak recommendation, low quality evidence. 5: ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician.Strong recommendation, moderate quality evidence. 6: ESGE recommends observation in cases of asymptomatic capsule retention.Strong recommendation, moderate quality evidence.In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice.Strong recommendation, moderate quality evidence. 1: ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended.Strong recommendation, low quality evidenceThe choice between different settings also depends on sedation protocols.Strong recommendation, low quality evidence. 2: ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols.Weak recommendation, low quality evidence. 3: ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route.Strong recommendation, moderate quality evidence.If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred.Strong recommendation, low quality evidence.In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach.Strong recommendation, low quality evidence. 4: ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal.Strong recommendation, low quality evidence.ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal.Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion.Strong recommendation, low quality evidence. 5: ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE.Strong recommendation, moderate quality evidence.Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications.Strong recommendation, high quality evidence.