Procedural Complication Rates Research Articles

Efficacy and safety of flow diverters in retreatment of recurrent intracranial aneurysms-A systematic review and meta-analysis.

Treatment of recurrent intracranial aneurysms after their initial therapy has been a significant challenge in the field of neurointervention. Recently flow diverters stents are widely used for treating intracranial aneurysms. In this systematic review and meta-analysis, we assessed the safety and efficacy of flow diverter in treating recurrent or recanalized intracranial aneurysms. This meta-analysis is reported following the PRISMA 2020 guidelines. We conducted a systematic review of literature in the PubMed, Embase, Web of Sciences, and Scopus databases. Pooled prevalence and the corresponding 95% are calculated from extracted data using a random-effect model. The systematic literature search included 21 studies involving 411 patients, with 135 (32.8%) being male and 276 (67.2%) being females with a total number of 447 aneurysms. The overall rate of adequate occlusion was 90.67% (95% CI: 84.23%-94.65%), and the rates were comparable between the surgery (93.48%), coiling (91.78%), and stenting (85.77%) groups. The overall pooled rate of complete occlusion was 81.80 (95% CI: 71.14%-89.13%). On doing a subgroup analysis, the complete occlusion rates were 89.68%, 84.39%, and 73.47% for the surgery, coiling, and stenting groups, respectively. The overall mortality rate and achieving modified Rankin scale score of 0-2 was 1.28% (95% CI: 0.45%-3.64%) and (95% CI: 89.92%-97.84%), respectively. No significant heterogeneity is noted in the included studies. Flow diverter stents are an effective and safe method for retreating recurrent or residual intracranial aneurysms with a high rate of complete and adequate occlusion. The rate of mortality, intracerebral hemorrhage, and overall and procedural complications following using flow diverters for intracranial aneurysms is low.

EP502 - Outcome of 5 years of endoscopic oesophageal stenting: a retrospective analysis

Abstract Background Oesophageal endoscopic stenting has a wide range of indications however dysphagia and use in cancer of the oesophagus is by far the most common, being the 14th most common cancer in the UK, despite advances in diagnosis and therapy with patients often presenting at advanced stages of the disease. Greater than 50% of presentations are at an advanced stage of disease where resection is often not possible and palliation is required. Palliation often is a potential combination of palliative chemotherapy, radiotherapy and endoscopic stenting to control the disease burden and improve symptoms. One of the most limiting palliative symptoms is dysphagia for which oesophageal stenting has become the standard of treatment showing immediate results. However, intra/post procedural complication rates can be high leading to: oesophageal perforation, mediastinitis, aspiration pneumonia, failed stent insertion or slippage. Method A retrospective analysis of 97 patients who underwent oesophageal stenting, in a 5 year time period between 2018-2023 in the Dumfries Royal Infirmary, a large district general hospital. Patients electronic notes were retrospectively analysed for patient characteristics, indication for stenting, early complications, successful hospital discharge and mortality. Conclusion The retrospective study demonstrated oesophageal stenting is a relatively safe procedure with a low mortality and the majority of patients being discharged from hospital. However, complications are not uncommon and patients should be properly counselled; on the risks, benefits and also food habits to prevent bolus.

Prehospital Cricothyrotomy: A narrative review of technical, educational, and operational considerations for procedure optimization

BackgroundDefinitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure. ObjectiveReview and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies. DiscussionTechnical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of EMS Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed. ConclusionsBy focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.

Transjugular mesenteric-caval shunt for portal vein cavernous transformation with recurrent variceal bleeding: preliminary results.

This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding. This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes. The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20-36 mmHg) to a postoperative value of 6 mmHg (range 4-11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7-18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality. The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation. TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option. Performing TIPS in patients with portal vein cavernoma is complex due to the requirement for recanalization of the occluded portal vein. Creating a mesenteric-caval shunt through a transjugular approach is a feasible technique. Establishing a TMCS provides a means to manage life-threatening complications arising from portal vein cavernoma.

Management of airway complications following lung transplantation: first interventional bronchoscopy report from Türkiye.

Lung transplantation is the treatment of last resort for many chronic lung diseases. Airway complications (AC) following lung transplantation, such as bronchial stenosis, dehiscence, malacia, and fistula, account for frequent hospital admissions, additional treatment costs, decreased quality of life, and reduced survival rates. Beyond surgical and medical preventive efforts, interventional bronchoscopy (IB) can be used in the management of these complications. The aim of the study is to evaluate the efficacy of IB on the management of AC following lung transplantation. A retrospective analysis was done using the data of lung transplant patients with AC referred to the interventional pulmonology unit between December 2012 and December 2019. From a total of 116 lung transplants, the data of 14/116 (12%) patients and 14/220 (6.3%) anastomoses in the same lung transplant group with AC requiring IB were analyzed. In these 14 patients, the diseases leading to lung transplantation were interstitial lung diseases (ILD) (50.0%), bronchiectasis (28.6%), pulmonary arterial hypertension (PAH) (7.1%), chronic obstructive pulmonary disease (COPD) (7.1%), and COPD + bronchiectasis (7.1%). Airway stenosis was the most common airway complication, and it developed mostly in the right bronchial system.The 14 patients underwent 27 total sessions of IB with an average of 2-3 per patient. Airway patency was successfully achieved in 74.1% of the procedures. Mechanical dilatation with a balloon and/or a rigid tube was the most preferred procedure (81.5%). Permanent airway patency was achieved in eight (57.4%) patients. No early complications were encountered (0%). The late complication rate was 48.1%. The most frequent late complication was restenosis, which cannot be directly attributed to IB. IB is safe to perform on lung transplant patients with AC. It has low procedural complication rates and can be performed repeatedly. Because of the high rate of restenosis, interventional pulmonologists should find out treatment modalities with lower rates of restenosis.

Pre-Cut Papillotomy Versus Endoscopic Ultrasound-Rendezvous for Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis.

Various endoscopic techniques are employed to achieve biliary cannulation when confronted with difficult biliary access. Every procedure carries its own risk in terms of bleeding, infection, pancreatitis, and cholangitis. Our meta-analysis aimed to compare pre-cut papillotomy and endoscopic ultrasound (EUS)-rendezvous in terms of technical success rates, and post-procedure pancreatitis and bleeding. We conducted a systematic review and meta-analysis of studies that compared pre-cut papillotomy and EUS-rendezvous. The primary outcome was technical success by achieving biliary cannulation. Secondary outcomes were postoperative pancreatitis and bleeding. A random-effects model was used to calculate the risk ratios (RRs) and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Our meta-analysis included four studies comparing pre-cut papillotomy and EUS-rendezvous. The studies included 13,659 total endoscopic retrograde cholangiopancreatography (ERCP) procedures, of whom 1,004 patients underwent alternate biliary cannulation procedures due to difficult biliary cannulation. The mean age of the study population was noted to be 49.5 years and males represented 53.3% of the total participants. Both procedures were similar in terms of technical success (RR: 0.95, 95% CI (0.88, 1.02)). No difference was found between rates of post procedure pancreatitis (RR: 1.82, 95% CI (0.80, 4.15)) and post procedure bleeding (RR: 2.80, 95% CI (0.67, 11.66)). There was no difference in technical success of procedure or post-procedure complications such as pancreatitis and bleeding between pre-cut papillotomy and EUS-rendezvous technique. More randomized controlled trials (RCTs) are needed to compare both procedural techniques and complications rates. However, currently, both procedures are equally effective and safe during difficult biliary cannulation in the hands of experienced endoscopists.

Angiographic Features of Meningiomas Predicting Extent of Preoperative Embolization.

Preoperative embolization is used as an endovascular adjunct to surgical resection of meningiomas. However, there is no standardized system to assess the efficacy or extent of embolization during the embolization procedure. We sought to establish a purely angiographic grading system to facilitate consistent reporting of the outcome of meningioma embolization and to characterize the anatomic and other features of meningiomas that predict the degree of devascularization achieved through preoperative embolization. We identified patients with meningiomas who underwent preoperative cerebral angiography and subsequent resection between 2015 and 2021. Demographic, clinical, and imaging data were collected in a research registry. We defined an angiographic devascularization grading scale as follows: grade 0 for no embolization, 1 for partial embolization, 2 for majority embolization, 3 for complete external carotid artery embolization, and 4 for complete embolization. Eighty consecutive patients were included, 60 of whom underwent preoperative tumor embolization (20 underwent angiography with an intention to treat but ultimately not embolization). Embolized tumors were larger (59.0 vs 35.9 cc; P = .03). Gross total resection, length of stay, and complication rates did not differ among groups. The distribution of arterial feeders differed significantly across tumors in a location-specific manner. Both the tumor location and the identity of arterial feeders were predictive of the extent of embolization. Anterior midline meningiomas were associated with internal carotid (ophthalmic, ethmoidal) supply and lower devascularization grades (P = .03). Tumors fed by meningeal feeders (convexity, falcine, lateral sphenoid wing) were associated with higher devascularization grades (P < .01). The procedural complication rate for tumor embolization was 2.5%. Angiographic outcomes can be graded to indicate the extent of tumor embolization. This system may facilitate consistency of reported angiographic results. In addition, arterial feeders vary in a manner predicted by tumor location, and these patterns correlate with typical degrees of devascularization achieved in those tumor locations.

Temporary Declines and Demand Resurgence: Gender-Affirming Surgery Volume and Complication Trends During and After the COVID-19 Pandemic.

The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period. The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications. Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications. GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19. During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Comparison between Remotely Supported Nurse-led Electro-Anatomic Mapping and Standard Onsite Engineer Support for Electrophysiological Procedures.

Catheter ablations of complex cardiac arrhythmias are currently guided by electro-anatomic mapping systems. The aim of this study was to compare two different approaches: remotely supported nurse-led electro-anatomic mapping with standard onsite engineer support. In this retrospective observational study, 166 patients with complex and non-complex procedures were included. 82 patients benefited from electro-anatomic mapping with remotely supported nurse-led mapping (mean age: 62±16years), while the approach for 84 patients was with standard onsite engineer support (mean age: 56±19 years). Procedural characteristics, acute results and complication rates were compared between both groups and showed similar results.Complex and non-complex procedures were conducted in both groups, including left atrial and ventricular procedures. As ventricular tachycardia and accessory pathway ablations were more frequently conducted with standard onsite engineer support, we separately analyzed the largest subgroup, 105 patients with atrial fibrillation, left atrial flutter and left atrial tachycardia. Patients in this subgroup had comparable baseline characteristics, procedure times and procedural success. Nevertheless, there were longer ablation times and more utilization of fluoroscopy in the onsite group, most likely due to more complex procedures. Our results underline the practicality of remotely supported nurse-led electro-anatomic mapping. The latter approach proved to be a safe alternative to onsite engineer support. Due to its advantages, particularly for insular settings, it will likely play a greater role in the future.

Cracking the Code of Coronary Calcium: One-year Clinical Outcomes of Intravascular Lithotripsy in All-comers and Two Complex Cohorts

Background: Severe coronary calcifications are commonly encountered in real-world populations and in left main (LM) disease, heightening complication risks including stent underexpansion. Although intravascular lithotripsy (IVL) appears safe, longer-term data in high-risk populations are lacking. The aim of this study was therefore to examine 1-year IVL outcomes for severely calcified lesions in two complex cohorts: LM stenosis and underexpanded stents (UES) during stent implantation. Methods: A registry study was carried out to examine major adverse cardiovascular events (MACEs) (MI, target vessel revascularisation [TVR], cardiac mortality). The LM and UES subgroups were compared with their counterparts in the non-LM and de novo lesion subgroups, respectively. Results: The study involved 102 participants (median age, 70 years, 68% male), and the cardiovascular burden was high (diabetes, 72%; dialysis, 18%; prior MI, 43%, median left ventricular ejection fraction, 45%). Many participants presented acutely (acute coronary syndrome, 36%; decompensated heart failure, 13%) and had complex anatomies (triple-vessel disease, 77%). The cardiovascular burden was higher in the LM and UES subgroups than in the non-LM and de novo lesion subgroups, but the rates of procedural complications and 30-day MACEs were low and were not significantly different. The 1-year MACE rate was higher in the LM group than in non-LM (29% versus 10%, p=0.042), but was non-significant after adjusting for baseline variables (OR 3.08; 95% CI [0.87–10.9]); the rates of 1-year MI, TVR and mortality did not differ from non-LM. In the UES group, 1-year MACE rate (17% versus 13%, p=0.500) was similar to that for de novo lesions. Conclusion: The preliminary data suggest that the use of IVL is reasonable when encountering stent underexpansion due to severe coronary calcifications during stent implantation. The 1-year MACE rate was higher in calcific LM stenosis, probably due to greater comorbidity burden and acute presentations.

Diagnostic yield of percutaneous, ultrasound-guided, fine needle aspirates of the gastrointestinal wall: a retrospective analysis of 152 samples.

The aim was to assess the technical success of percutaneous ultrasound-guided fine needle aspirates of gastrointestinal wall lesions and evaluate predictors of success. Secondary aims included comparing the cytological diagnosis with histopathology, evaluating the utility of concurrent locoregional lymph node cytology and assessing the procedure's complication rate. Gastrointestinal wall cytology from 75 dogs and 70 cats obtained between 2018 and 2023 were reviewed and categorised as successful (resulting in a diagnostic cytology report) and accurate (resulting in the correct diagnosis when compared to histopathology). Unsuccessful fine needle aspirates, not submitted for cytology, were not recorded. Variables recorded included animal signalment, lesion and lymph node's appearance on ultrasound, size, location, number of smears submitted and experience of the ultrasonographer. One hundred and fifty-two reports were analysed. Eighty-eight (58%) were successful: three normal epithelium, 21 inflammatory processes and 64 neoplasms. Variables associated with increased technical success included description of a mass, higher number of slides submitted and thickness of gastrointestinal lesion on ultrasound. Comparison with histopathology, performed for 17 lesions, showed discrepancies in eight, complete agreement in seven and partial in two. Eighty-four loco-regional lymph nodes were sampled, of which, 67 were successful (80%) and 52 brought additional clinical information (supporting GI wall cytology or diagnosing neoplasia not identified on GI wall cytology). No complication strictly attributable to gastrointestinal wall sampling was reported but when possibly related, death of the patient occurred in 2.5% of cases. Ultrasound-guided fine needle aspirate of gastrointestinal wall had moderate accuracy and was unsuccessful in 42% of cases, but technical success increased when sampling mass lesions, thicker intestinal layers and submitting more slides.

Initial Experience with a New Self-Expanding Open-Cell Stent System with Antithrombotic Hydrophilic Polymer Coating (pEGASUS Stent) in the Treatment of Wide-Necked Intracranial Aneurysms.

We report our initial experience with endovascular embolization of intracranial aneurysms using this new self-expanding open-cell stent system (pEGASUS stent system) with the antithrombogenic hydrophilic polymer coating. We retrospectively reviewed all patients treated with stent-assisted coiling or the Woven EndoBridge device using the pEGASUS stent system between September 2022 and June 2023. Demographic, clinical, and angiographic data were analyzed as well as short-term follow-up, including procedural complication rates and aneurysmal occlusion rates using the Raymond-Roy occlusion classification (RROC). Twelve patients with 12 wide-necked intracranial aneurysms were treated with the pEGASUS stent system, including 2 acutely ruptured aneurysms embolized in an emergency setting. The treated aneurysms were located at the anterior communicating artery (25.0%), the basilar artery (50.0%), the middle cerebral artery (16.7%), and the internal carotid artery (8.3%). All stents were deployed successfully. Immediate complete aneurysmal occlusion (RROC class I) was achieved in 83.3% (10/12) and near-complete occlusion (RROC II) in 16.7% (2/12). No periprocedural complications occurred in patients treated in the elective setting. A single case of intraoperative in-stent thrombus formation occurred during the treatment of an acutely ruptured basilar aneurysm and was resolved with intravenous Tirofiban. No other periprocedural complications occurred. Eleven out of 12 patients were available for follow up (mean 7.4 months). Complete aneurysmal occlusion without in-stent stenosis (ISS) was seen in 10 patients (90.9%). One patient (9.1%) showed aneurysmal reperfusion (RROC IIIb) with asymptomatic moderate ISS. Our initial results demonstrate that the pEGASUS stent system appears to be a safe and effective device for stent assisted embolization of wide-necked intracranial aneurysms. More data is necessary to evaluate long-term follow-up.

Percutaneous Closure of Post-myocardial Infarction Ventricular Septal Rupture-experience From a Resource-limited Setup From Eastern Part of India

Background: Post-infarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of an acute myocardial infarction (AMI). It results in 90% - 95% mortality within two months of diagnosis without any kind of intervention. Given high surgical mortality, transcatheter closure has emerged as a potential strategy as an alternative to high-risk surgical closure. Indian data on percutaneous device closure of post-AMI-VSR is limited hence we report our resource-limited single-centre experience with different kinds of occluder devices for closure of post-AMI VSR. Methods and results: In this single-centre, retrospective, cohort study, patients who underwent transcatheter closure of post-MI VSR between 2018 and 2024 at Health World hospitals, in Durgapur, West Bengal, were included. The primary outcome was a mortality rate of 30 days. The study population was eleven primary cases of post-MI VSR. The mean age of the population was 61 years. The majority of the patients had anterior wall MI (54.5%) and the remaining had inferior wall MI. Different kinds of devices (ASO, PostMI VSD device, Konar MFO) were used to close VSR. Successful closure was performed in 9 patients (81%) with minimal residual shunt in 2 patients. Out of 9 cases 3 patients expired, one was lost to follow up and the rest are doing well at 30 days follow-up. Conclusion: Transcatheter closure of PMIVSRs can be performed with different kinds of devices with high technical success, relatively low procedural complication rates, and 30 days survival even in a resource-limited setup as an alternative to high-risk surgical closure.

Long-Term Effectiveness of Vestibulectomy for the Treatment of Vulvodynia: A Retrospective Cohort Study.

To evaluate the effectiveness and complication rate of vestibulectomy for vulvodynia. A retrospective cohort study in a teaching and university hospital analyzing patients with vulvodynia with insufficient response to conservative treatment who underwent a vestibulectomy. Data from 114 consecutive vestibulectomy procedures done between September 2009 and October 2018 were retrospectively analyzed. All procedures were performed by the same surgeon.The primary outcome was difference in pain scale (6-point Q-tip test, Nociceptive Rating Scale) between preoperative consultation, postoperative visit, and last follow-up consultation. The secondary outcome was surgical complications, such as wound dehiscence and hematoma. Complete data were available for 80 patients. There was a significant reduction in median pain scores of between 65% and 80% on all 6 evaluated vestibular points during Q-tip tests. The median follow-up was 21 months, ranging from 1 to 92 months (interquartile range [IQR]). Overall, 75% of patients needed no further treatment at the end of the follow-up period. In 22.6% (18/80), a limited wound dehiscence was noted. No other complications were reported nor were there any cases of worsening of the complaints. In this retrospective cohort study, a significant pain reduction occurred after vestibulectomy in patients who were not responding to conservative treatment. The complication rate of this surgical procedure is low. Vestibulectomy seems to be an effective technique for management of vulvodynia.

The Value of Adjunctive Left Atrial Posterior Wall Isolation on Clinical Outcomes in Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis.

Although pulmonary vein isolation (PVI) remains the mainstream way of atrial fibrillation (AF) ablation. The left atrial posterior wall (LAPW) may contributes to the development of AF as an arrhythmogenic substrate. The efficacy of additional left atrial posterior wall isolation (LAPWI) beyond PVI is in AF patients remains undefined. This study explored the influence of posterior wall isolation (PWI) on clinical outcomes in AF patients. PubMed, EMBASE, and Cochrane Library databases were searched for studies comparing the outcomes of AF with and without PWI. The efficacy outcomes were recurrence of all atrial arrhythmia (AA), atrial fibrillation (AF), and atrial flutter (AFL)/atrial tachycardia (AT). The safety outcomes were mainly focused on procedural adverse events. A total of 16 studies (7 randomized controlled trials (RCTs), 3 prospective studies and 6 retrospective analyses) with 3340 AF patients were enrolled (1550 patients in PVI with PWI group and 1790 in PVI alone group). 12 studies included persistent atrial fibrillation patients, 3 studies with paroxysmal AF patients and 1 study with paroxysmal AF and persistent AF concurrently. Mean follow-up period was 16.56 months. In AF patients, adjunctive PWI obviously reduced the recurrence of all atrial arrhythmias (risk ratio (RR) 0.78 [95% CI 0.64-0.95], = 79%, p = 0.01) and the recurrence of AF (RR 0.68 [95% CI 0.53-0.88], = 75%, p = 0.004); Meanwhile, additional PWI left no impact substantially on lower recurrence of AFL/AT (RR 1.23 [95% CI 0.94-1.60], = 49%, p = 0.12). The results seemed to be no significant differences in occurrence rate of procedural complications between the PVI only and PWI+PVI (RR 1.19 [95% CI 0.80-1.79], = 0%, p = 0.39). In subgroup analyses, the benefit of adjunctive PWI compared with PVI only was more distinct in persistent AF group and cryoballoon ablation group. Notably, adjunctive PWI with radiofrequency ablation may induce a slight increase of recurrent AFL/AT compared with PVI only (RR 1.56 [95% CI 1.02-2.39], = 30%, p = 0.04). Compared with PVI alone, additional PWI to PVI appeared to be associated with decreased recurrence of AF and atrial arrhythmias without an increased occurrence of procedural complications, especially in persistent AF patients. Cryoballoon ablation seemed more suitable for PWI compared with radiofrequency ablation. More RCTs are needed to verify the conclusion.

Patient factors associated with unplanned sedation after intra-articular lidocaine for shoulder dislocation

BackgroundRecent evidence suggests that intra-articular lidocaine (IAL) is an appropriate analgesic alternative to intravenous sedation (IV sedation) during shoulder dislocation reduction, however little is known about patient factors associated with IAL failure and need for subsequent IV sedation. Avoiding crossover is important, as repeated reduction attempts have been previously shown to increase the rate of procedural complications. ObjectivesTo identify patient level factors associated with crossover from IAL to IV sedation and associated complication rates and operational impacts. MethodsThis retrospective observational cohort study evaluated the patient characteristics associated with crossover to unplanned IV sedation after IAL among adult patients undergoing ED reduction of an isolated, acute anterior shoulder dislocation from 2013 to 2021 in an urban, academic hospital system. Univariate analysis and multivariate logistic regression were used. ResultsIn total, 630 participants were identified who received IAL or procedural sedation. Of these, 182 (28.9 ​%) received IAL of whom 49 (26.9 ​%) subsequently required unplanned IV sedation. Participants had 1.205 (95 ​% CI 1.030, 1.418) fold increase in odds of unplanned sedation for every 10-year increase in age. Crossover to IV sedation was associated with greater rates of adverse events, ED length of stay, and quantity of opioids received compared to either IAL or IV sedation alone. ConclusionsParticipants with unplanned IV sedation after IAL had more adverse events than those who received either method alone. Older age was associated with unplanned sedation after IAL. Prospective studies are needed to further define patient factors likely to contribute to failure of IAL.

Left atrial appendage closure in patients with atrial fibrillation and haemodialysis: outcomes from an international, multicentric registry

Abstract Background Atrial fibrillation (AF) patients receiving haemodialysis (HD) face increased bleeding risks, so the net benefit of stroke prophylaxis by oral anticoagulation (OAC) is ill defined. Left atrial appendage closure (LAAC) might serve as a suitable alternative to OAC for stroke prevention in this high-risk cohort. Objective To determine the safety and clinical efficacy of LAAC in HD patients with AF. Methods In an international multi-center (n=9) registry, the clinical details were compiled from all HD+AF patients who underwent LAAC. Results The cohort included 147 patients: age 72.6 ± 10.4 yrs, 73% male, CHA2DS2-VASc 4.5 ± 1.5, HAS-BLED 4.7 ± 1.2, prior stroke/TIA 22,5%, prior major bleed 57,8%. The pre-LAAC anticoagulation regimen was heterogeneous with a wide array of at least 12 different combinations of medications utilized. A total of 149 procedures were performed and LAAC was successful in 98% (146 of 149), with a median procedure time of 43 (30-66) minutes. The most common device was Watchman (61%), followed by Amulet (23,3%). The rate of major complications was 5,4% (8), same as the rate of minor complications (5,4%), leading to an overall complication rate of 10,7% (16/149) including one fatal bleed the day after implantation, 4 (2.7%) cardiac tamponades of which 3 were treated with pericardiocentesis and one surgery, and 2 device dislodgements requiring percutaneous retrieval followed by successful reimplantation. Most patients were discharged on DAPT (61,6%). At a median of 61 days follow-up, imaging was performed in 83% of patients, revealing: only 2 (1.7%) peri-device leaks ≥5 mm, and no DRT. Subsequently, anticoagulation was shifted to SAPT so that SAPT emerged as the predominant anticoagulation regimen representing 165,9 patient years (py) of usage followed by DAPT (41,8 py). Over the follow-up of 222,9 py, the incidence of ischemic stroke was 0,9% per year (2 strokes in total), reflecting an 88% relative risk reduction (p&amp;lt;0,001) compared with the calculated stroke rate of 7,4% for patients with a similar CHA2DS2VASc score and no anticoagulation. Similarly, the rate of major bleeding events (defined as BARC score ≥3) was 4,5% per year, signifying a 55% relative risk reduction (p=0,023) compared to the expected rate of patients on VKA therapy, based on a comparable HAS-BLED score. Event tough time on SAPT was nearly four times longer than on DAPT, the number of major bleeding events was similar (SAPT: 5; DAPT: 4). Conclusion In light of these findings LAAO emerges as a promising solution for this unique patient cohort. By mitigating the risks of both bleeding complications associated with anticoagulation and the threat of stroke in the absence of anticoagulation, LAAO represents a well-balanced and effective therapeutic strategy for these individuals. However, the procedural complication rate was elevated compared to that observed in other LAAC cohorts, and requires further study.

Long-term outcomes of ventricular tachycardia ablation in patients with ischemic and non-ischemic cardiomyopathy: a propensity-score matched analysis

Abstract Background Catheter ablation (CA) has been shown to be effective in the treatment of ventricular tachycardia (VT). Although some observational data suggest that patients with non-ischemic cardiomyopathy (NCIM) have less favorable clinical outcomes when compared to those with an ischemic etiology (ICM), direct comparisons are scarcely reported. We aimed to compare the outcomes of VT ablation in a propensity score-matched population of ICM or NICM patients. Methods Single-center observational registry including 246 consecutive patients with ischemic (ICM, N=166) and non-ischemic cardiomyopathy (NICM, N=80) who underwent drug-resistant VT ablation from 2012 to 2023. A propensity score (PS) was used to match patients in a 1:1 fashion according to the following variables: age, sex, left ventricular ejection fraction (LVEF), NYHA class, electrical storm (ES) at presentation, and previous endocardial VT ablation. The outcomes of interest were VT-free survival and all-cause mortality. Results The PS yielded two groups of 71 patients each (mean age 63±10 years, 92.3% male, mean LVEF 35±10%, 35.9% with ES at presentation, and 23.2% with previous ablation), well matched for baseline characteristics. Those with NICM were more likely to undergo epicardial or combined VT ablation (43.7% vs. 9.9%, P&amp;lt;0.001). The procedural complication rate was low (4.9%, N=7) and similar between groups (P&amp;gt;0.05). During a median follow-up of 27 (IQR 15–45) months, patients with NICM had a significantly lower VT-free survival (53.5% vs. 69.0%, log-rank P=0.037), although there were no differences regarding all-cause mortality (22.5% vs. 16.9%, log-rank P=0.245) – Figure. Multivariate analysis identified NICM (HR 2.34 [95% CI 1.32–4.14], P=0.004), NYHA class III/ IV (HR 2.11 [95% CI 1.11–4.04], P=0.024), and chronic kidney disease (HR 2.23 [95% CI 1.25–3.96], P=0.006), as independent predictors of VT recurrence. Non-inducibility of any VT immediately after ablation was associated with significantly lower rates of VT recurrence (22.8%/ year vs. 42.4%/ year, log-rank P=0.03). Conclusion NCIM patients are at increased risk of VT recurrence after ablation, although long-term mortality was similar to ICM in a propensity-matched cohort. Non-inducibility of any VT after CA is associated with better outcomes.Figure

Not too old to be treated: electrophysiological study and catheter ablation in eldery patients

Abstract Background The number of elderly patients referred for electrophysiological study (EPS) and catheter ablation (CA) is increasing. These patients are thought to have more complications due to age and comorbidity. Purpose The aim of our study was to evaluate the safety (EPS and CA) and acute success (CA) in a group of elderly patients (age ≥75 years old). Methods Between August 2020 and September 2023, consecutive elderly patients (32.7% older than 80 years) underwent EPS alone or EPS and CA at our center. Left atrial thrombus was ruled out performing transesophageal echocardiography when indicated. Anticoagulation (ACO) was not interrupted. Femoral veins, arteries and transeptal punctures were performed under ultrasound guidance. A navigation system was used for all CA procedures, except for pulmonary vein isolation, which was performed with a cryoballoon. We analysed procedural complications related to EPS and CA and the acute success of CA procedures. Results A total of 104 patients undergoing EPS±CA (79.9±4.6 years, 41.3% female, 75% HTA, 67.3% diabetes type 2, 19.4% COPD, 20.2% chronic renal disease, 25% structural heart disease, CHA2DS2VasC score 3.6±0.8, IMC 27.3±4.5 kg/m2, weight 72.3±13.6 kg, LVEF 52.7±10.8%, 31% history of atrial fibrillation (AF), 47.1% on ACO, 38.5% bundle-branch block, 34.6% first-degree atrioventricular block, 4.8% implanted pacemaker or ICD) were included. Indications for referral (Figure 1) were typical atrial flutter (TAF, 34.6%), atrioventricular nodal reentrant tachycardia (AVNRT, 26.9%), study of syncope (11.5%) atypical atrial flutter or atrial tachycardia (AAF/AT, 10.6%), AF (8.6%, 6 patients for AV node ablation, 3 for pulmonary vein isolation), ventricular tachycardia or ectopy (VT or VE, 5.7%), orthodromic reentrant tachycardia (ORT, 1.9%). 2 patients had TAF and AVNRT, treated in the same procedure. Acute success was achieved in 100% of AF, 94.6% of TAF, 89.6% of AVNRT, 66% of VT/VE, 50% of ORT, 45% of AAF/AT. There were 4 complications (2.9%) in 3 patients, all during the CA procedure: an AV block during an AVNRT ablation, another AV block during an ischaemic septal VT ablation, a femoral artery pseudoaneurism in the same patient (femoral artery approach), and a dislocation of the electrodes from a previous pacemaker during an AT ablation. None of the patients undergoing EPS alone had complications. Weight was the only variable associated with the development of complications (mean difference= -19.8, 95% CI(-38.9-0.7); p=0.04), being higher in those with than in those without complications (91.5±2.2 vs 71.6±13 Kg),(Table 1). Conclusions EPS and CA procedures in elderly patients with multiple comorbidities are safe and effective. Acute success and complication rates of CA procedures are substrate-dependent and similar to those reported in the literature for younger patients. We conclude that age is not a barrier to the study and treatment of arrhythmias.

Near-zero fluoroscopy technique for cardiac electronic device implantation: long-term outcomes

Abstract Introduction Radiation hazards are a major concern for both patients and staff. We have previously described a near-zero fluoroscopy technique for cardiac electronic device implantation. In this study, we aimed to investigate the long-term safety of this technique and compare outcomes and procedural metrics with a conventional approach in a larger population. Methods Low-dose fluoroscopy technique. Radiation exposure during fluoroscopy is directly proportional to the time the unit is activated. Typically, the pedal switch is depressed for at least a few seconds per imaging sequence in order to visualize "live" movements of either the leads during their positioning or the needle during a fluoroscopy-guided puncture of the subclavian vein. Our technique consists of setting a low frame rate per second (0.5-3.75fps) and momentarily triggering the foot pedal switch only to obtain screenshots of the position of the leads/needle. Use of live electrograms to assist spatial awareness of lead position (e.g. Atrial, Coronary Sinus, Ventricular signals) acts as an adjunct to guidance. Study design We included consecutive patients undergoing permanent pacemaker (PPM) or cardiac defibrillator (ICD) implant at our center from July 2018 to December 2022 using the near-zero fluoroscopy technique. Procedures were performed by three operators (AC, MD, MF). Cumulative radiation dose was measured using dose-area product (DAP). We assessed procedure success and complication rate during long-term follow-up. We compared the procedural metrics and outcomes with a cohort of patients with PPM or ICD implanted in our centre by senior operators, using a traditional fluoroscopic approach. Propensity score was adopted to match baseline characteristics between the study and control group. Results The total population consisted of 412 patients (74.2±13.9 years, 60.9% male). We included 206 who underwent PPM or ICD implantation using the low-dose fluoroscopy technique, and 206 matched-control. A PPM or ICD was successfully implanted in all patients. Fluoroscopy time and DAP were significantly lower in the low-dose fluoroscopy group, mean 2.3±2.0 seconds versus 258.4±252.1 seconds (P&amp;lt;0.001) and 3.4±3.5 µGym2 versus 29.8±55.4 µGym2 (P&amp;lt;0.001), respectively. Mean procedure time was 49.0±20.8 minutes in the low fluoroscopy group and 65.7±26.8 minutes in the control group (P&amp;lt;0.001). Median frame per second setting was 0.5 in the low-dose cohort. After a mean follow-up of 441±470 days, the rate of complications was identical across groups (2.4%, p = 1.0). Conclusion This near-zero dose fluoroscopy technique is effective and safe, enabling a 10x reduction in radiation exposure during device implant. Modification of traditional implant and imaging techniques can provide material reductions in fluoroscopy dose to even below that for a standard PA chest radiograph.