Difference In Procedure Time Research Articles

Sa1315 EFFECTIVENESS AND SAFETY OF PER ORAL ENDOSCOPIC MYOTOMY IN ACALASIA COMPARING ANTERIOR AND POSTERIOR APPROACH IN A REFERENCE CENTER

Achalasia is an esophageal primary motor disorder, characterized manometrically by the incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. Heller's myotomy is the gold standard therapie, but per oral endoscopic myotomy (POEM), with similar clinical and manometric success, is considered a safe alternative, the submucosal wall approach possible anterior or posterior esophagus depending on operator experience. As gastroesophageal reflux disease (GERD) is its main complication, there is few evidence about wich approach is safer and more effective. To describe in patients with achalasia who undergo POEM the manometric characteristics, pre and post procedure clinics with 6-month follow-up and compare the effectiveness and complications in anterior and posterior approach. We include patients with a diagnosis of achalasia virgins to treatment, candidates for POEM with anterior or posterior approach at the Hospital 1ero de Octubre ISSSTE in Mexico City from 2016 to 2018. We exclude patients with previous endoscopic and surgical treatment and other esophageal motor disorders. At the 6-month follow-up, we evaluated clinical response (Eckardt <3), manometric (integral relaxation pressure IRP <15 mmHg), endoscopy esophagitis (Los Angeles Classification), questionnaire of symptoms of gastroesophageal reflux (GERD Q> 8 points) and 24-hour pH-metry (Demeester> 14.7). Descriptive statistics were used; For difference of proportions between the 2 techniques in non-parametric variables X2and for parametric variables t of student; The statistical package SPSS V.22 was used and a p value of less than 0.05 was considered statistically significant. 51 patients were included, 21 with type II achalasia (41.2%); Average age of 59.3 years (25-88 years), 32 women (62.7%). Baseline Eckardt score of 9, baseline IRP of 35.7 mm Hg. Anterior approach in 29 cases (56.9%). The average procedure time was 62.3 minutes (range 34-118), the anterior technique with 60.3 minutes (p=0.348). In the follow-up clinical and manometric response of 90.2% in both groups, without significant differences between them. The most frequent adverse event was subcutaneous emphysema in 11 cases (21.6%), with a greater tendency in posterior approach 31.8% (p=0.114); In 4 patients perforations without difference between approaches (p=0.417) resolved with endoscopic management. Esophagitis was diagnosed in 15 cases (29.4%), positive pH-metry by Demeester in 33.3% of cases without significant differences. POEM is a safe procedure in both approaches (anterior or posterior), with no differences in procedure time and adverse events. We obtained a clinical and manometric success in the similar follow-up between groups, without finding significant differences in the presence of GERD by clinic, endoscopy and 24-hour pH-metry.

Su1298 ENDOSCOPIC ULTRASOUND (EUS) GUIDED FINE-NEEDLE BIOPSY (FNB) IS COST-EFFECTIVE AND TIME SAVING OVER FINE-NEEDLE ASPIRATION (FNA) FOR TISSUE ACQUISITION OF PANCREAS AND INTRA-ABDOMINAL MASS LESIONS

EUS-FNA with on-site cytologic evaluation (OSE) has been the gold standard for tissue acquisition of pancreatic and intra-abdominal mass lesions (IAML). Recently, EUS-FNB or core biopsy has been shown to have equivalent diagnostic yield (DY) compared to EUS-FNA with OSE, but the differences in per patient cost and procedural time remain unclear. As such, we sought to compare per patient cost and procedural time between EUS-FNB and EUS-FNA for pancreatic masses and IAML. We performed a retrospective cohort study of EUS procedures for tissue sampling of solid pancreatic and IAML from 2013 to 2018. Patients were stratified into two subgroups: 1) EUS-FNB and 2) EUS-FNA with OSE. Patients who underwent both FNA and FNB were excluded. Primary outcomes included per patient costs and median procedure time. Costs were estimated using the Medicare cost to charge ratio and divided into procedural, anesthesia related, and pathology costs, as well as total cost. Total procedure time was defined as time from patient arrival into endoscopy suite until patient arrival in the recovery unit. Secondary outcomes included DY and rate of adverse events (AE). Cost data was analyzed using bivariate analysis to detect differences between groups. Multivariate logistic regression was used to identify differences in procedural time (SAS, v.9.4). A total of 305 patients underwent EUS-guided tissue acquisition (170 FNA and 135 FNB) for pancreas lesions and 333 patients (64 FNA and 269 FNB) for IAML. Procedural data between groups including needle passes, needle gauge, and AE are shown in Table 1. The DY of EUS-FNB was superior to EUS-FNA for pancreas (99.3% vs 94.7%, p=0.05) and IAML (98.5% vs 84.4%, p<0.01). EUS-FNB had a 30% shorter median procedure time compared to EUS-FNA for pancreatic lesions (50m [IQR: 41-64] vs 75m [IQR:59-101], p<0.01) and 33% shorter median procedure time compared to EUS-FNA for IAML (53m [IQR: 44-64] vs 75m [IQR: 59-101], p<0.01, Table 2). Mean procedure costs for FNA of pancreas lesions were $144 greater than FNB (p<0.01) while mean pathology costs of FNA were $107 lower than FNB (p<0.01) as FNB specimens were more likely to undergo additional tissue staining compared to FNA (43% vs 9%, p<0.01). There was no significant difference in procedure cost for FNA compared to FNB for IAML. EUS-FNB significantly reduces procedure time for tissue sampling with higher diagnostic yield compared to EUS-FNA with OSE for both pancreas and IAML. Marginal increase in pathology costs for EUS-FNB over EUS-FNA is best explained by better samples, enhancing tissue staining and diagnosis. In aggregate, EUS-FNB dominates EUS-FNA as there was no significant difference in total per patient costs. EUS-FNB should be considered first line for tissue acquisition in all cases where immediate diagnosis does not impact patient care.Table 2Procedure Time and Cost of EUS-FNB compared to EUS-FNA with OSE for Pancreatic and Intra-abdominal Mass LesionsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Saline-Air Hysterosalpingo-Contrast Sonography Is Equivalent to the Modified Hysterosalpingogram Following Hysteroscopic Sterilization.

To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization. This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared. Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P < 0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P > 0.05) or maximum pain scores (2.3 vs 3.1, P > 0.05) for the mHSG compared with SA-HyCoSy. Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.

Mechanical Thrombectomy for Tandem Vertebrobasilar Stroke: Characteristics and Treatment Outcome.

Background and Purpose- Tandem vertebrobasilar strokes are not well-known causes of posterior circulation stroke. The purpose of this study was to investigate the characteristics and outcome of mechanical thrombectomy in patients with tandem vertebrobasilar stroke. Methods- Acute basilar artery occlusion patients with tandem vertebral artery (VA) stenosis/occlusion who underwent mechanical thrombectomy were retrospectively analyzed. Concomitant tandem VA steno-occlusion was defined as severe stenosis/occlusion of the extracranial VA with impaired flow. Clinical/angiographic characteristics, recanalization rate, procedure time, and clinical outcome were evaluated with comparisons according to the treatment strategy. Results- Tandem vertebrobasilar occlusion was identified in 24.6% (55 of 224) of the acute basilar artery occlusion patients. Overall successful recanalization and good clinical outcome was achieved in 87.2% (48 of 55) and 30.9% (17 of 55) of the patients. There were no significant differences in procedure time, recanalization rate, and clinical outcome in comparisons of the VA access route selection or angioplasty of the tandem VA lesion. Two patients developed short-term recurrent basilar artery occlusion when angioplasty of the tandem VA lesion was not performed. Good clinical outcome was more likely with lower baseline National Institutes of Health Stroke Scale score (odds ratio, 0.87 [95% CI, 0.787-0.961]; P=0.006) and short onset-to-recanalization time (odds ratio, 0.993 [95% CI, 0.987-0.999]; P=0.03). Conclusions- Tandem vertebrobasilar occlusion may be a frequent pathological mechanism of posterior circulation stroke. Good outcome may be achieved by strategic choice of the access route and selective angioplasty of the tandem VA lesion.

Does Intravenous Thrombolysis Influence the Time of Recanalization and Success of Mechanical Thrombectomy during the Acute Phase of Cerebral Infarction?

Objectives: Mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusion. Recanalization time is a key factor in the treatment of AIS. It has previously been suggested that intravenous thrombolysis (IVT) may be associated with a shorter recanalization time. The aim of our study was to investigate whether IVT or other factors could be associated with shorter or longer MT procedure times. Methods: We performed a retrospective analysis of a local cohort of patients treated by MT. We collected procedure time (puncture to recanalization and clot visualization to recanalization), demographic data, localization of the thrombus, antithrombotic treatment at arrival, IVT infusion, and stroke subtype at discharge according to the TOAST classification. We planned to analyze the full cohort and the successful revascularization subgroup. Results: There was no difference in procedure times between patients who received IVT and those who did not. In the successful revascularization subgroup, patients presenting with cardioembolic stroke had a significantly shorter time between clot visualizations and revascularization than the other patients (41 vs. 56 min, p = 0.024), but this was not the case in the full cohort. Also in the successful revascularization subgroup, the revascularization time was 76 vs. 61 min (p = 0.075) in patients presenting with tandem occlusion vs. the others, but there was no difference between these groups in the full cohort. Conclusions: There was no difference in terms of procedure times in patients treated by IVT and MT vs. patients treated by MT alone either in the full cohort or in the successful revascularization subgroup. The data from the successful revascularization subgroup may be useful for studying revascularization times, provided that data from procedures that were stopped prematurely by the operator due to the length of time since symptom onset is removed.

Lymphatic Decompression Concomitant With Fontan/Kreutzer Procedure: Early Experience.

To present a strategy for identifying patients at risk of lymphatic failure in the setting of planned Fontan/Kreutzer completion, allowing a tailored surgical approach. Since January 2017, clinical evaluation before performance of the Fontan/Kreutzer procedure included T2-weighted magnetic resonance imaging (MRI) lymphangiography. Thoracic lymphatic abnormalities were categorized using a scale of I to IV according to progression of severity. Patients with severe lymphatic abnormalities (types III and IV) underwent Fontan/Kreutzer with lymphatic decompression via connection of the left jugular-subclavian junction containing the thoracic duct to the systemic atrium (group A). Thirteen patients were enrolled. Magnetic resonance imaging showed type I abnormalities in four cases (30.7%), II in four (30.7%), III in two (15.3%), and IV in three (23.3%). Patients in types III and IV underwent a Fontan/Kreutzer with lymphatic decompression (group A, n = 5), while patients in types I and II underwent a fenestrated extracardiac Fontan/Kreutzer procedure without lymphatic decompression (group B, n = 8). Preoperatively, there were no differences in age, weight, ventricular dominance (right vs left), superior vena cava pressure, incidence of chylothorax after previous superior cavopulmonary anastomosis (Glenn), or need for concomitant procedures at Fontan/Kreutzer completion. There were no differences in procedural times between the groups, nor were there differences in mortalities and Fontan/Kreutzer takedowns. There were no statistically significant differences in early and late morbidity between the two groups with the exception of total volume of effusions output postoperatively. At median follow-up of 18 months (range, 4-28 months), all patients in group A are in New York Heart Association class 1 with no differences between groups in arterial oxygen saturation. Lymphatic decompression during Fontan/Kreutzer procedure was successfully performed in patients identified by MRI as predisposed to lymphatic failure. A larger cohort of patients and longer follow-up are required to determine the efficacy of this approach in preventing early- and long-term Fontan/Kreutzer failure.

Abstract No. 595 Percutaneous radiologic gastrostomy in obese versus nonobese patients

Prior studies showed that percutaneous endoscopic gastrostomy (PEG) is generally safe in obese patients; however, limited data is available for percutaneous radiologic gastrostomy (PRG). The purpose of this study is to compare the safety and efficacy of PRG in obese vs. nonobese patients. This is an IRB-approved retrospective study of 136 patients (M:F, 88:48; mean age 63.7 years, range 21-94) who underwent PRG with or without gastropexy at a single academic medical center between 2015 to 2018. Body mass index (BMI) ≥ 30 kg/m2 was defined as obese. Patient demographics, indications, technical success, major/minor complications, and procedural variables were analyzed. Thirty-two (23.5%) patients were obese (average BMI 34.6 kg/m2; range, 30 to 50). Overall technical success in obese group was 93.8% vs. 98.1% in nonobese group. In the obese vs. nonobese group, major complications, including death-related to PRG (0%), injury to adjacent structures (0%), bleeding (0%), or peritonitis (3.3%), were not significantly different. Minor complications, including tube occlusion (3.3%), tube dislodgement (3.3%), and superficial skin infection (3.3%) were also not significantly different. There were no significant differences in procedure time, fluoroscopy time, or contrast volume. However, mean peak skin dose (PSD) was significantly increased in the obese group vs. nonobese group (378.1 ± 599.7 mGy vs. 121.8 ± 308.5 mGy; P = 0.0002). PRG is a safe procedure in obese patients without significant difference in major or minor complications, procedure time, fluoroscopy time, or contrast volume. However, PRG is associated with increased radiation dose with obese patients; therefore, optimal methods of radiation protection should be utilized.

Abstract TMP4: Impact of Bridging Therapy With Intravenous Thrombolysis Prior to Mechanical Thrombectomy in Patients With Large Vessel Occlusion- Insights From the STAR Registry

Introduction: Clinical trials have proven the safety and efficacy of mechanical thrombectomy (MT) with intravenous alteplase (tPA) compared to tPA alone in patients presenting with large vessel occlusion (LVO). The impact of tPA prior to MT on procedural metrics, successful revascularization, symptomatic hemorrhage and long-term functional outcome has not been established from large scale real-world studies. In this study we evaluate the impact of tPA prior to MT on procedural times, immediate and long-term outcomes. Methods: The STAR registry combined prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe and Asia. Patients who received mechanical thrombectomy with or without intravenous tPA prior to MT were included in these analyses. Baseline characteristics, procedural time, successful revascularization (TICI ≥ 2B), symptomatic intracranial hemorrhage (PH2), and long-term functional outcomes were compared between the two groups. Results: Total of 1869 patients were included in this analysis. Of those, 907 received tPA prior to MT. Baseline features and outcomes are summarized in table 1. There were more white patients in the non-tPA group, and more patients in this group had atrial fibrillation and hyperlipidemia; otherwise there were no differences in baseline features between the two groups. Median NIHSS on admission was 16 in both groups, median ASPECTS was 9 in the tPA group versus 8 in the non-tPA group, p=0.208. Patients in the tPA group had higher rate of successful revascularization, lower number of revascularizations attempts and were more likely to achieve excellent long-term functional outcome. There was no difference in procedural time, rate of symptomatic hemorrhage or length of hospital stay. Conclusion: Bridging therapy with intravenous tPA prior to mechanical thrombectomy may facilitate MT and yield to better long-term functional outcome.

Abstract WP8: Procedural Times and First Pass Tici-3 With Direct Aspiration vs Retrievable Stents vs for Treatment of Large Vessel Occlusion Stroke: A Systematic Review and Meta-Analysis

Introduction: Randomized trials of direct aspiration (ADAPT) vs retrievable stent (RS) did not show a difference in 90-day outcomes. We searched existing literature for differences in reperfusion times and success between the two techniques. Methods: We performed a systematic review to identify relevant articles in electronic databases and references. Studies comparing ADAPT vs RS and reporting the procedural details and outcomes were included. Random-effect meta-analysis was performed to compare the procedural duration and outcomes. Results: We screened 8578 abstracts and 864 full-text articles. Analysis of 16 studies (2182 ADAPT and 2786 RS patients) reveals no difference in procedural time (D=-5.37 min shorter with ADAPT, 95% CI -19.78 to 9.04; p=0.46), successful reperfusion rate defined as TICI 2b or higher (OR=1.38 in favour of RS, 95% CI 0.98 to 1.96; p=0.07), first pass TICI3 rates (OR=1.29 in favour of RS, 95% CI 0.92 to 1.82; p=0.14) and number of device passes (OR=0.03, 95% CI -0.18 to 0.24; p=0.79). Good functional outcome was also similar (OR=0.89, 95% CI 0.78 to 1.02; p=0.08), as mortality (RR=1.07, 95% CI 0.95 to 1.2; p=0.28), and ICH (RR=1.23, 95% CI 0.99 to 1.52; p=0.06) Conclusions: Existing endovascular techniques appear equally efficient in current literature. Fig. 1. OR forest plot of for successful reperfusion. Fig. 2. Mean D forest plot for groin to reperfusion time.

Abstract WP14: Higher Aspiration Force Improves Technical Outcomes in ADAPT Thrombectomy for Ischemic Stroke

Introduction: Aspiration thrombectomy using the direct aspiration at first pass technique (ADAPT) has been shown to be non-inferior to stent-retriever thrombectomy in ischemic stroke trials. Favorable outcomes after ADAPT are dependent on successful recanalization and lower number of aspiration attempts. We investigated the impact of aspiration force on technical and clinical outcomes of ADAPT by modulating two underlying determinants, the aspiration catheter size and the reperfusion pump power. Methods: We performed a retrospective analysis of patients undergoing ADAPT thrombectomy between 01/2018 and 02/2019. Patient treated using ADAPT were included irrespective of age, onset to groin or whether thrombolytic therapy was administered. Patient demographics and outcomes were reviewed from patient charts and thrombectomy procedure notes. Patients were dichotomized based on the reperfusion pump used (MAX, 28.5 inHb power vs ENGINE, 29.2 inHg power) and further split into the different reperfusion catheters used. Results: This study included 194 patients who underwent ADAPT thrombectomy during the study period with mean age of 69, and of which 48% were females. Comparing patients treated with two different reperfusion pumps, ENGINE (N=73) and MAX (N=118), similar rates of favorable outcomes measured by 90-day modified Rankin score (mRS) were observed. However, patients in the ENGINE groups had significantly shorter procedure time (20 vs 27 min, p&lt;0.05), lower number of aspiration attempts (1.9 vs 2.2 p&lt;0.05), and low rates of rescue stent retriever therapy (14% vs 33%, p&lt;0.05). The use of ENGINE was an independent predictor of shorter procedure time (p&lt;0.05) and lower rates of symptomatic hemorrhage (p&lt;0.1) compared to MAX pump. There was no significant difference in procedure time and rates of functional outcomes among patients undergoing ADAPT using different sizes of large bore catheters ACE 60, ACE68 and Jet 7. Conclusion: Success of ADAPT thrombectomy is dependent on successful aspiration of the occluding clot, and is dependent on the aspiration force. Higher aspiration forces can be achieved by increasing the power of reperfusion pump leading to better technical outcomes without increased complication rates.

Use of smart glasses for ultrasound-guided peripheral venous access: a randomized controlled pilot study.

ObjectiveSmart glasses can provide sonographers with real-time ultrasound images. In the present study, we aimed to evaluate the utility of smart-glasses for ultrasound-guided peripheral venous access.MethodsIn this randomized, crossover-design, simulation study, 12 participants were recruited from the emergency department residents at a university hospital. Each participant attempted ultrasound-guided peripheral venous access on a pediatric phantom at intervals of 5 days with (glasses group) or without (non-glasses group) the use of smart glasses. In the glasses group, participants confirmed the ultrasound image through the lens of the smart glasses. In the non-glasses group, participants confirmed the ultrasound image through the display viewer located next to the phantom. Procedure time was regarded as the primary outcome, while secondary outcomes included the number of head movements for the participant, number of skin punctures, number of needle redirections, and subjective difficulty.ResultsNo significant differences in procedural time were observed between the groups (non-glasses group: median time, 15.5 seconds; interquartile range [IQR], 10.3 to 27.3 seconds; glasses group: median time, 19.0 seconds; IQR, 14.3 to 39.3 seconds; P=0.58). The number of head movements was lower in the glasses group than in the non-glasses group (glasses group: median, 0; IQR, 0 to 0; non-glasses group: median, 4; IQR, 3 to 5; P<0.01). No significant differences in the number of skin punctures or needle restrictions were observed between the groups.ConclusionOur results indicate that smart-glasses may aid in ensuring ultrasound-guided peripheral venous access by reducing head movements.

Evolution of Fenestrated Stent-Graft Design in Early Versus Late Experience with Fenestrated Stent-grafts

Introduction: Fenestrated grafts (FEVAR) are being increasingly used for the treatment of short-necked, juxtarenal, and suprarenal aortic aneurysms.The number of fenestrations in FEVAR depends on the desired proximal landing zone. Standard 2x FEVAR fitting two fenestrations for the renal arteries and a scallop for the superior mesenteric artery (SMA) has been the configuration first used in the treatment of short necked and some juxtarenal AAA. For more complex anatomy with extension of disease at the level of renal arteries or higher, a stent-graft configuration fitting 3 or 4 fenestrations (3x/4x FEVAR) for the renal arteries, the SMA and the celiac trunk became later available in order to achieve adequate proximal sealing. With the aim to create a longer sealing zone for durability, several large volume centers use increasingly more complex devices with 3 or 4 fenestrations. This study aims to compare the fenestrated stent-graft configuration and outcomes in early vs late experience in a single center setting. Methods: All patients undergoing elective implantation of fenestrated grafts between January 2010 and April 2018 in our center were included. Data were collected prospectively. Patients were divided in early (first half of the time period) and late experience (second half of the time period). Stent-graft complexity, length of the proximal sealing zone, operative data and outcomes were compared between the two groups. Results: 454 patients (412 male, mean age 72.5 ± 8 years) were included. Mean follow-up was 20 months. In the late group, complex grafts with 3 or 4 fenestrations were used more often (early 30% vs late 81%, p< 0.001) and the created proximal sealing zone longer (early 28 mm vs late 43 mm, p< 0.001). Less contrast volume was used in the late group (early 152 ml vs late 130 ml, p< 0.001), with no differences in procedure time, blood loss or fluoroscopy time (p>0.05). Despite the increased graft complexity, no differences were found in technical success, mortality, spinal cord ischemia or vessel patency rates. Conclusion: Length of proximal sealing and number of targeted vessels have increased over time in patients undergoing FEVAR in our center. This increase in graft complexity and aortic coverage was not associated with more perioperative complications or worse outcomes during follow-up. Studies with longer follow-up are needed to assess the impact of these changes on FEVAR durability. Disclosure: Nothing to disclose

MT4 COST ANALYSIS OF INTEGRATED VERSUS CONVENTIONAL OPERATING ROOMS

Integrated operating rooms allow for surgical staff to control all relevant equipment from the sterile field as different systems/technologies are functionally linked through a single touchpad. Thereby it potentially reduces inappropriate workflow and saves time. This study compared resource use and costs of the integrated operating room (IOR) and conventional operating room (COR). Surgical departments with an IOR and COR that performed comparable surgeries were identified to be included in the study. A hospital perspective was applied to compare resource use and costs of the two operating rooms (OR). Field studies and unstructured interviews were conducted to identify activities and resources that varied in the OR set-up. Time consumption during identified procedures was extracted from the clinical system at the hospital. Independent t-test was used to estimate the statistical difference in mean time between the two alternatives. Technology costs were estimated based on procurement data for the past 3 years at the hospital. Costs common to both IOR and the COR were not included. The department of heart, lung and vascular surgery and the department of gastrointestinal surgery at Aarhus University Hospital in Central Denmark Region were included. During the study period a total of 1,192 surgeries of selected types were performed in the ORs. We found no statistically significant differences in procedure time or staff cost between IOR and COR. The cost analysis revealed incremental costs of an IOR varying from investment costs of 93,290 EUR corresponding to an equivalent annual cost of 11,909 EUR for the simplest solution to investment costs of 151,007 EUR corresponding to an equivalent annual cost of 19,483 EUR for a more comprehensive solution. The study found no difference in procedure time or staff costs between the IOR and the COR. The IOR was associated with varying incremental costs dependent of the integrated solution.

Use of Prospective Radiobrachial Angiography in Transradial Cardiac Catheterization and Intervention

ObjectivesThis study examined the utility of prospective radiobrachial angiography (pRBA) in transradial coronary angiography and intervention as a method for reducing procedural complications. BackgroundA growing body of evidence has supported the transradial approach (TRA) as superior to the transfemoral approach (TFA) due to advantages such as reduced bleeding and improved outcomes in high-risk patients. However, TRA has a higher failure rate than TFA, and has seen slow rates of adoption among United States operators. MethodsThis was a retrospective, single center, case-control analysis of coronary angiography procedures, performed by two experienced operators at the University of Chicago Medical Center between October 28, 2015 and July 21, 2017. Operator 1 began using pRBA during the study, whereas Operator 2 used pRBA in all TRA procedures. There were 567 patients stratified into three groups based on operator and pRBA use. Comparisons of procedural outcomes for Operator 1 before and after adoption of pRBA, and of outcomes between Operator 1 and Operator 2 were made. ResultsUse of pRBA was associated with reduced overall procedural complication rates (2.5% versus 10.4%, p = 0.004), driven primarily by reflexive radiobrachial angiography (rRBA) after resistance or pain was encountered (8.6% versus 0.0%, p = 0.0001) for Operator 1. A slight reduction in contrast associated with pRBA for Operator 1 was noted, but no difference in procedural time, radiation dose, or additional equipment used across groups was found. No significant difference in adverse procedural outcomes between the pRBA groups of Operator 1 and Operator 2 were observed. In patients with radiobrachial variants in anatomy, use of pRBA was associated with shorter times to cross anatomic lesions, shorter procedure times, reduced use of extra catheters, and less perforations and crossovers compared to patients requiring rRBA. Lack of pRBA was associated with higher procedural complications (hazard ratio 1.08, 95% CI, 1.03–1.13, p = 0.004). ConclusionpRBA may be a useful tool for mitigating procedural complications, reducing time needed to cross difficult radiobrachial anatomy, and reducing the need to utilize additional equipment in TRA. pRBA may offer operators a tool to improve outcomes and increase adoption of this approach.

P1919The assessment of the application and the efficacy of pulmonary vein isolation with cryoballoon for non-paroxysmal atrial fibrillation

Abstract Background Pulmonary vein isolation (PVI) using second generation cryoballoon (CB) ablation has become an established treatment for paroxysmal atrial fibrillation (PAF) patients. On the other hand, PVI with radiofrequency (RF) has been an established treatment for non-PAF patients, in addition to PAF patients. Purpose The data on second generation CB ablation for non-PAF patients is limited. We assessed the application of PVI with CB for non-PAF patients and compared the outcomes of success rate, radiational time, and procedural time. Methods A total of 2632 AF patients (age 64±10; 1873 males) underwent initial PVI from September 2014 to June 2018. Second-generation CB was employed to 1587 patients (CB-PAF: 80%, CB-non-PAF: 20%) and RF using irrigation-tip catheter was employed to other 1045 patients (RF-PAF: 40%, RF-non-PAF: 60%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p&lt;0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using ISP infusion and rapid atrial pacing. Results AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB-non-PAF 66.3%, RF-non-PAF 69.8%; log-rank p=0.297). There was significantly difference in procedural time (CB-non-PAF 132±56min, RF-non-PAF: 189±52min, p&lt;0.001), and radiation time (CB-non-PAF: 47±40min, RF-non-PAF: 75±31min, p&lt;0.001). The percentage of patients with non-PV foci was significantly higher in CB group (CB-non-PAF 41%, RF-non-PAF 54%, p&lt;0.001), and after excluding the patients with non-PV foci, AF free survival rate was almost equivalent in both group (2-years Kaplan-Meier event rate, CB-non-PAF 75.4%, RF-non-PAF 78.8%; log-rank p=0.577). On the other hand, in patients in CB, AF free survival rate was significantly superior in PAF group (2-years Kaplan-Meir event rate, CB-PAF 83.3%, CB-non-PAF 65.2%; log-rank p&lt;0.001). There was significantly difference in procedural time (CB-PAF: 117±47min, CB-non-PAF: 132±56min, p&lt;0.001), and radiation time (CB-PAF: 38±22min, CB-non-PAF: 46±27min, p&lt;0.001). The percentage of patients with non-PV foci was significantly higher in non-PAF group (CB-PAF 30%, CB-non-PAF 41%, p&lt;0.001), and after excluding the patients with non-PV foci, AF free survival rate was also significantly superior in PAF group (2-years Kaplan-Meier event rate, CB-PAF 85.1%, CB-non-PAF 69.8%; log-rank p&lt;0.001). Conclusions For non-PAF patients with PV triggers, PVI with CB might be non-inferior to PVI with RF. Our study showed the efficacy of CB in terms of the shortening of procedural time, and the reduction of radiational exposure. PVI with CB for non-PAF patients was inferior to that for PAF patients.

2 Hydrogen Peroxide-Assisted Endoscopic Necrosectomy vs. Standard Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis: A Multi-Center Retrospective Comparative Study

INTRODUCTION: Endoscopic necrosectomy has emerged as the preferred treatment modality for walled off pancreatic necrosis (WON). Standard endoscopic necrosectomy can be tedious and time consuming, employs sharp instruments in vascular cavities, and does not provide for microdebridement. Hydrogen peroxide (H2O2) lavage has been reported in small series; however, there have been no comparative studies on its safety and efficacy in the management of WON. METHODS: We performed a retrospective chart review of all cases undergoing endoscopic transmural management of WON at 9 major medical centers in the US from November 2011 to August 2018. Cystogastrostomies were performed using lumen apposing metal stents (LAMS). Patients who underwent cystogastrostomy without necrosectomy were excluded. Clinical success was defined as resolution of the WON by imaging within 6 months, without requiring non-endoscopic drainage procedures or surgery. RESULTS: A total of 296 patients underwent cystgastrostomy and 206 patients underwent one or more necrosectomies. Clinical success was achieved in 171/192 (89.1%) of those with follow-up data at 6 months. In terms of patients, 122 (59.2%) patients had at least one H2O2 necrosectomy (H2O2 group), and 84 (40.8%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group (n = 107 (95.5%) vs 63 (79.7%), P &lt; 0.001). On multivariate logistic regression, the use of hydrogen peroxide (OR 17.4, 95% CI: 2.9–103, P = 0.002) was associated with higher clinical success rates (Table 2). During a mean follow up of 278 days, 29 complications occurred: bleeding (n = 18), perforation (n = 5), respiratory complication (n = 3), and sepsis (n = 3). One death was presumed to be procedure related (splenic pseudoaneurysm rupture day 8; standard necrosectomy group). A total of 394 necrosectomies were performed. Comparing necrosectomy procedures with and without H2O2 (n = 209 vs 185), there was no difference in procedure time (72.5 ± 39.6 vs 72 ± 44.2, P = 0.936), post-procedural bleeding (8 vs 10, P = 0.45), perforation (3 vs 2, P = 1), infection (1 vs 2, P = 0.6) or overall complication rate (n = 15 (7.1%) vs 14 (7.6%), P = 1) (Table 3). CONCLUSION: In this multicenter retrospective cohort study, H2O2 necrosectomy appeared to be safe and effective with a higher clinical success rate and equivalent rates of bleeding, perforation, death, and overall complications relative to standard necrosectomy.

Safety and feasibility of ultrasound-guided placement of peripherally inserted central catheter performed by neurointensivist in neurosurgery intensive care unit.

We evaluated the safety and feasibility of ultrasound-guided peripherally-inserted central venous catheters (PICC) by a neurointensivist at the bedside compared to fluoroscopy-guided PICC and conventional central venous catheter (CCVC). This was a retrospective study of adult patients who underwent central line placement and were admitted to the neurosurgical intensive care unit (ICU) between January 2014 and March 2018. In this study, the primary endpoint was central line-induced complications. The secondary endpoint was initial success of central line placement. Placements of ultrasound-guided PICC and CCVC performed at the bedside if intra-hospital transport was inappropriate. Other patients underwent PICC placement at the interventional radiology suite under fluoroscopic guidance. A total of 191 patients underwent central line placement in the neurosurgery ICU during the study period. Requirement for central line infusion (56.0%) and difficult venous access (28.8%) were the most common reasons for central line placement. The basilic vein (39.3%) and the subclavian vein (35.1%) were the most common target veins among patients who underwent central line placement. The placements of ultrasound-guided PICC and CCVC at the bedside were more frequently performed in patients on mechanical ventilation (p = 0.001) and with hemodynamic instability (p <0.001) compared to the fluoroscopy-guided PICC placement. The initial success rate of central line placement was better in the fluoroscopy-guided PICC placement than in the placements of ultrasound-guided PICC and CCVC at the bedside (p = 0.004). However, all re-inserted central lines were successful. There was no significant difference in procedure time between the three groups. However, incidence of insertional injuries was higher in CCVC group compared to PICC groups (p = 0.038). Ultrasound-guided PICC placement by a neurointensivist may be safe and feasible compared to fluoroscopy-guided PICC placement by interventional radiologists and CCVC placement for neurocritically ill patients.

Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance

PurposeTo compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). Materials and methodsA retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. ResultsRadiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. ConclusioniTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.

Safety and quality of endovascular therapy under general anesthesia and conscious sedation are comparable: results from the GOLIATH trial

BackgroundThe “General or Local Anesthesia in Intra-Arterial Therapy” (GOLIATH) trial compared infarct growth and outcome in patients undergoing endovascular therapy (EVT) under either general anesthesia (GA) or conscious sedation (CS)....

Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video)

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities. This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assistedESD (RESD) in an exvivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload. Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P< .0001). The perforation rate was higher in the ESD group (60% vs 30%, P= .18). Total procedure time (34.1 vs 88.6 min, P= .001) and dissection time (27.8 vs 79.4 minutes, P= .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P= .01). RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.