Distal Lesions Research Articles

712 In-stent restenosis: how optical coherence tomography can make the difference

Abstract Aims Patient male, 38 years old, affected by hypercholesterolaemia, carotid atherosclerosis, in 2014 NSTEMI (bivascular coronary artery disease treated by angioplasty and implantation of a medicated stent in the ostial and proximal tract of the right coronary artery). In September 2021 the patient went to the emergency room of our hospital for chest pain, that comes during physical exertion, with a spontaneous regression. We performed blood tests that showed phase rise of the Hs-TNI (>25 000 ng/dl). The ECG showed lateral sub-endocardial ischemia and the transthoracic echocardiogram a slight reduction in ejection fraction with hypochinesia of the inferior and inferior-lateral wall. After collegial discussion, it was decided to perform a coronary angiography. Methods and results The coronary angiography showed the left coronary artery free from stenosis, with a collateral circle towards the right coronary; the right coronary showed an ostial and proximal critical in-stent restenosis with patency of the stent in the middle segment, total occlusion of the distal segment. It was decided to treat the right coronary. A guide wire was pushed into to the right coronary with difficulty and, after recanalization of the vessel, an optical coherence tomography (OCT) was performed. The OCT pointed out a homogeneous widespread neointima into the stent and an extraluminal fibrous-calcified plaque in the ostial proximal segment, which caused likely the stent under-expansion and then the stent fracture. We proceeded with angioplasty and stent implantation of the distal lesion. Due to the mechanism underlying critical in-stent restenosis (fracture of the stent) of the ostial proximal segment, we first proceed with a pre-dilatation of the lesion and then with a stent in stent implantation. Post-dilatation with a non-compliant balloon at high atm. Eventually, we found out a detail not visible before due to the ostial stenosis: the protrusion of some millimeters of the previously implanted stent in the ascending aorta; this was the cause of the difficulty in advancing the angioplasty material throughout the procedure. As a result, we had no complications. Conclusions Intracoronary imaging has stronger evidences to guide the percutaneous revascularization, especially for in-stent restenosis. Evaluation by OCT can highlight the mechanism of in-stent restenosis (biological causes/mechanical causes) and consequently it can guide the most appropriate method to perform percutaneous revascularization.

Treatment of chronic isolated distal tibiofibular syndesmosis injury. Literature update and case report using autologous semitendinous graft reconstruction

Isolated distal tibiofibular syndesmosis lesions are rare and can be easily missed. Diagnosis and treatment of chronic disruption is not easy, with limited published data. Surgical treatment of chronic syndesmosis injury is challenging as there is no international consensus on the optimal management. Diagnosis and treatment are still controversial and poorly discussed in literature. PubMed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1990 to December 2020 to identify studies relating to treatment of isolated chronic syndesmosis injury and 17 articles were identified. We found 5 studies reporting on the results of autologous semitendinosus tendon graft in chronic syndesmosis reconstruction. We describe the case of a 47-year-old man who sustained an isolated distal tibiofibular syndesmotic injury of his right ankle that was initially missed. The patient was diagnosed at 6 months after a motocross accident and underwent reconstruction of syndesmosis with semitendinous autologous tendon associated with debridement of the fibrosous scar tissue in the anterior tibial fibular area (with preservation of the anterior sleeve) and subsequent reinsertion with transosseous stitches in the fibular bone. We used a quadricortical screw to stabilize syndesmosis definitively. After 1 month, the reduction failed because of transyndesmosic screw breakage and the patient underwent another surgery. We removed the broken screw and then used a suture button to stabilize syndesmosis permanently. The literature review and clinical case seem to suggest that reconstruction of the distal tibiofibular syndesmosis with autogenous tendon for chronic syndesmosis injury determines a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The autologous semitendinosus tendon graft may be an appropriate and promising reconstruction target in the treatment of chronic syndesmosis injury.

Double Crush Syndrome of the Upper Extremity.

The double crush hypothesis originally proposed that compression of a peripheral nerve at a proximal site increases its susceptibility to additional distal lesions. The etiology of double crush syndrome is likely multifactorial as mechanical, systemic, pharmacologic, or environmental factors may increase a patient's susceptibility to this syndrome. To date, there remains no standardized definition of double crush syndrome, and there is no consensus on its exact pathophysiology or diagnostic criteria. Patients with double crush syndrome should be counseled that surgical repair may produce inferior outcomes compared with those who are treated for isolated entrapment neuropathies.

Multicentric Chordoma With Initial Resection by Bilateral Transcondylar Approach: 2-Dimensional Operative Video.

Chordoma is a rare skull base tumor with malignant behavior.1-3 It invades locally with high recurrences, metastasizes distally, and seeds after interventions.1-4 Chordoma exemplifies the malignant progression doctrine as it accumulated genetic mutations. The natural history of untreated disease is 2.4 yr on average survival.5 Best tumor control is achieved by radical resection, followed by high doses radiation. Multicentric chordoma is an ill-defined challenging entity extremely rare in the literature. However, chordoma is known for distal metastasis, particularly to the lungs, iatrogenic cerebrospinal fluid (CSF) dissemination with drop metastasis, or surgical implantation. A subset of patients present with synchronous or metachronous regional or distal neuraxial lesions associated with the initial chordoma. Patients presenting with multicentric bony axial lesions and no extra-axial metastases point toward the multicentric chordoma concept rather than local, hematogenous, or CSF spread.6-12 Biopsy of these multicentric lesions can show a spectrum of abnormalities ranging from benign notochordal tumor to chordomas confirming the multicentric hypothesis.9 We present a patient who underwent a bilateral transcondylar approach for giant craniovertebral junction chordoma and then treated with radiation and a second lesion at the C6 transverse foramen. Six years later, she presented with a chordoma at the petrous apex. The patient consented to surgery and to the publications of her image. The participants and any identifiable individuals consented to publication of his/her image. Image at 1:39 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.

Abstract 10961: Integrated Coronary Vascular Disease Diagnosis System Based on Two-Step Neural Network Algorithm Trained by Synthetic Model and Patient Biometric Features

Introduction: Fractional flow reserve (FFR) is the golden standard that determines whether coronary artery disease (CAD) surgery is necessary or not. Invasive FFR uses pressure wire to obtain the pressure ratio of proximal and distal lesion. However, the burden from high cost and time due to invasive process makes it difficult to perform diagnosis. To overcome these limitations, FFR can be measured non-invasive through CFD analysis based on geometry models obtained from observational equipment such as coronary computer tomography (CT). However, obtaining this FFR value consumes considerable time and computer resources in the process of vessel shape extraction and CFD. In this study, we propose a non-invasive artificial intelligence-based FFR prediction technology. Methods & Results: The algorithms used in this paper were separated into two steps. The first algorithm is to compute flow features from geometric features trained by synthetic models and CFD analysis. In the second step, we trained classification algorithms and regression algorithms using the flow properties obtained from the first step and patient biometric information. Classification algorithms are used to determine whether to invasive operate, and regression algorithms are used to predict FFR values. The algorithms used are 6 machine learning and 2 neural networks. To improve the performance of the algorithms, outlier data were removed through the IQR method. Among the classification algorithms, random forest had the best accuracy of 80.1%, and in the regression algorithm, artistic neural network had the lowest mean absolute error of 0.04. Furthermore, we analyze the algorithm performance within the gray zone to prove that the algorithm can provide guidance in the case of uncertain situations. Conclusions: Algorithms learned in a two-step manner determined whether the lesion need a surgery or not and predicted the FFR value. In particular, we presented guidelines for building FFR prediction algorithms with good prediction performance.

Abstract 12565: Rotational Atherectomy in the Left Coronary System

It′s known that the Left Coronary Artery stenosis has greater mobility and mortality compared to the rest of the coronary tree, due to its size since the formation of plaques has a disseminated distribution, greater volume and severity of calcification. The use of rotational atherectomy (RA) has proven to be an effective tool to facilitate the sub-expansion of stents in atheromatous calcified lesions. We present a case study where plaque modification is performed by atherectomy and angioplasty in the Left Coronary system.A 62 years old female patient diagnosed with diabetes mellitus 2, systemic arterial hypertension and dyslipidemia. Antecedent of coronary angiography 10 days prior to admission due to chest pain and dyspnea, where found trivascular disease of left dominance with diffuse calcified lesion. She was programmed for RA with ROTABLATOR and ROTAWire system. It started by advancing the microcatheter on the angioplasty guide and exchanging for ROTAWIRE 0.009”. Subsequently, the 1.5 mm abrasive bur was advanced, rotating up to 6 times in the proximal and middle segment of the Anterior Descending Artery, proceeding to predilate with balloon noting a non-dilatable distal lesion, a 1.25 mm abrasive bur was passed, rotating up to 3 times, and it was decided to perform balloon predilatation and placement of spliced stents.Continuing with Circumflex Artery, an intermediate 0.014” Zinguer guide was advanced to the distal segment, spliced stents were placed in the proximal segment and it was dilated with a balloon to optimize results. It was decided to exchange guides and predilated the artery ostium, then it was decided to advance the stent using the Culotte bifurcation technique and a proximal optimization of the stent with a balloon was performed.Finally, a post-dilation was performed in the Anterior Descending Artery and the Left Coronary Trunk with a balloon to optimize a successful result (Figure 1), with no dissection image or thrombus. Final flow TIMI 3, TMP 3.

Evolution of the Crush Technique for Bifurcation Stenting.

Bifurcation lesions are frequently encountered, associated with greater procedural complexity and consequently are at higher risk for restenosis and stent thrombosis. Early trials in bifurcation percutaneous coronary intervention favored a provisional stenting approach, but contemporary randomized trials have highlighted potentially superior outcomes using a double-kiss crush technique in unprotected distal left main stem bifurcation lesions. Although the evidence is greatest for double-kiss crush, many operators favor a mini-crush or nano-crush single-kiss approach. In this review, the authors describe the iterations of the crush technique and the evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Ureteral access sheath-related injuries vs. post-operative infections. Is sheath insertion always needed? A prospective randomized study to understand the lights and shadows of this practice

ObjectiveTo compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion. Patients and methodsIn this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication. ResultsThe evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P = 0.03). ConclusionsUAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections. Clinical Trial Registration Number (ISRCTN registry number)55546280.

Surgical treatment of metastatic bone disease of the distal extremities.

Metastatic bone disease of the distal extremities, also known as acrometastasis, is very rare. Thus, there is very limited information regarding the clinical manifestations and methods of surgical treatment. The current available literature shows that acrometastases are often encountered in the context of advanced disease and are thus associated with poor patient survival. As metastatic bone disease is generally uncurable, the goal of surgical treatment is to provide the patient with good function with as few complications as possible. In this article, we discuss the clinical manifestation of acrometastases, the methods of surgical intervention, and the expected clinical outcome. Non-surgically managed pathological fractures generally remain ununited; therefore, conservative treatment is reserved for patients with poor general condition or dismal prognosis. The current evidence suggests that in lesions of the lower arm and leg, osteosynthesis (plate and screw fixation or intramedullary nail) is the most common method of reconstruction, whereas local excision or amputation are more commonly used in cases of more distal lesions (such as ankle, foot and hand). Following surgery most patients receive adjuvant radiotherapy, even though its role is poorly documented. Close collaboration between orthopedic surgeons and medical oncologists is necessary to improve patient care and treatment outcome. Further studies are needed in order to provide stronger clinical evidence and improve decision-making, in an effort to optimize the patients’ quality of life and avoid the need for revision surgery.

Complications of balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease according to the classification proposed by the 6th world symposium on pulmonary hypertension

Abstract Introduction Balloon pulmonary angioplasty (BPA) is a complex procedure and not risk free. In an attempt to standardize reports of BPA complications in the several centers, a classification of complications was proposed by the task force on chronic thromboembolic hypertension (CTEPH) in the 6th World Symposium on Pulmonary Hypertension (WSPH). Purpose To determine the prevalence of BPA complications according to the classification of 6th WSPH and to identify its predictors. Methods Detailed procedural and technical aspects were collected for consecutive patients (pts) with inoperable, residual/recurrent chronic thromboembolic disease, undergoing BPA at a single institution from December/2017 to December/2020. Per procedure logistic regression analysis was used to evaluate the predictive variables for complications. Results A total of 76 BPA sessions in 15 pts were performed (mean age 63.2±14.0 years; 60.0% women; 86.7% CTEPH). Mean pulmonary artery pressure and pulmonary vascular resistance before the first BPA session were 33.1±13.3 mmHg and 4.8±3.2 woods unit, respectively (73.3% of pts under vasodilator therapy). Femoral access was used for all pts. Mean vessels treated per procedure were 4.3±1.9 (324 vessels in total). Webs, subtotal occlusions, ring-like stenosis and total occlusions were noted in 215 (66.4%), 58 (17.9%), 31 (9.6%) and 20 (6.2%) treated vessels, respectively. We performed 21 pressure-wire-guided sessions (27.6%). Intravascular imaging was used in 6 procedures (7.9%). Average time of fluoroscopy was 60.3±14.0 minutes and volume of contrast 273.0±73.0 mL per session. Procedure-related adverse events occurred in 25.0% of the interventions (27.6% in the first two years vs 16.7% in the last two). Pulmonary artery vascular injuries were noted in 6 BPA vessels (7.9% per procedure and 1.9% per treated vessel): haemoptysis in all, but perforation was only detected angiographically in 3 of them (balloon inflation was performed for 2 distal perforations, and 1 perforation sealed without any intervention). Vascular dissection in distal lesions occurred in 4 cases (5.3%) with no need of transcatheter or surgical procedures. We had 3 lung injuries, all grade 2. None of the pts required oral intubation or mechanical ventilation. Extra-pulmonary complications were illustrated in table. Importantly, there was no peri-procedural death. The occurrence of vascular or lung injuries was 0% in pressure-wire-guided BPA versus 14.5% in non-guided (p=0.098). Multivariate analysis revealed that age (OR 1.05; CI 1.01–1.10; p=0.030) was the only independent predictor of complications. Conclusions In our experience, BPA can be safely performed in inoperable, residual or recurrent CTEPH or CTED pts, with 25% minor procedural-related complications but no major adverse event. Age was the strongest factor related to the occurrence of complications. Funding Acknowledgement Type of funding sources: None.

Intralesional TTI-621, a novel biologic targeting the innate immune checkpoint CD47, in patients with relapsed or refractory mycosis fungoides or Sézary syndrome: a multicentre, phase 1 study

Intravenous TTI-621 (SIRPα-IgG1 Fc) was previously shown to have activity in relapsed or refractory haematological malignancies. This phase 1 study evaluated the safety and activity of TTI-621 in patients with percutaneously accessible relapsed or refractory mycosis fungoides, Sézary syndrome, or solid tumours. Here we report the clinical and translational results among patients with mycosis fungoides or Sézary syndrome. This multicentre, open-label, phase 1 study was conducted at five academic health-care and research centres in the USA. Eligible patients were aged 18 years or older; had injectable, histologically or cytologically confirmed relapsed or refractory cutaneous T-cell lymphoma (CTCL) or solid tumours; Eastern Cooperative Oncology Group performance status of 2 or less; and adequate haematological, renal, hepatic, and cardiac function. TTI-621 was injected intralesionally in a sequential dose escalation (cohorts 1-5; single 1 mg, 3 mg, or 10 mg injection or three 10 mg injections weekly for 1 or 2 weeks) and in expansion cohorts (cohorts 6-9; 2 week induction at the maximum tolerated dose; weekly continuation was allowed). In cohort 6, patients were injected with TTI-621 in a single lesion and in cohort 7, they were injected in multiple lesions. In cohort 8, TTI-621 was combined with pembrolizumab 200 mg injections per product labels. In cohort 9, TTI-621 was combined with the standard labelled dose of subcutaneous pegylated interferon alpha-2a 90 μg. The primary endpoint was the incidence and severity of adverse events. The study is registered with ClinicalTrials.gov, NCT02890368, and was closed by the sponsor to focus on intravenous studies with TTI-621. Between Jan 30, 2017, and March 31, 2020, 66 patients with mycosis fungoides, Sézary syndrome, other CTCL, or solid tumours were screened, 35 of whom with mycosis fungoides or Sézary syndrome were enrolled and received intralesional TTI-621 (escalation, n=13; expansion, n=22). No dose-limiting toxicities occurred; the maximum tolerated dose was not established. In the dose expansion cohorts, the maximally assessed regimen (10 mg thrice weekly for 2 weeks) was used. 25 (71%) patients had treatment-related adverse events; the most common (occurring in ≥10% of patients) were chills (in ten [29%] patients), injection site pain (nine [26%]), and fatigue (eight [23%]). No treatment-related adverse events were grade 3 or more or serious. There were no treatment-related deaths. Rapid responses (median 45 days, IQR 17-66) occurred independently of disease stage or injection frequency. 26 (90%) of 29 evaluable patients had decreased Composite Assessment of Index Lesion Severity (CAILS) scores; ten (34%) had a decrease in CAILS score of 50% or more (CAILS response). CAILS score reductions occurred in adjacent non-injected lesions in eight (80%) of ten patients with paired assessments and in distal non-injected lesions in one additional patient. Intralesional TTI-621 was well tolerated and had activity in adjacent or distal non-injected lesions in patients with relapsed or refractory mycosis fungoides or Sézary syndrome, suggesting it has systemic and locoregional abscopal effects and potential as an immunotherapy for these conditions. Trillium Therapeutics.

Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate.

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

S2129 Who’s the Father?: The Duality of Esophageal Spindle-Cell Squamous Carcinoma

Introduction: Spindle-cell squamous carcinoma (SpCC) is an extremely rare variant of SCC previously described in literature with a series of confounding names as a result of its intriguing yet confusing origin. Furthermore, the rarity of SpCC along its dual cellular component has led to diagnostic challenges of this highly aggressive entity. Herein a curious case of an African American male with atypical chest pain diagnosed with spindle-cell squamous carcinoma of the esophagus. Case Description/Methods: A 53-year-old male with history of tobacco and alcohol abuse presented to ER with atypical chest pain and questioning revealed epigastric pain, worsening heartburn, weight lost, and difficulty swallowing since 3 months ago. EKG without evidence of acute ischemia. Physical exam and labs unremarkable. CT chest with evidence of mid-to-distal esophageal distention with associated distal nodular lesion of 1.5 cm in size. EGD revealed distal esophageal bulky polypoid lesion. Biopsy suggested spindle cell malignancy, yet inconclusive due to scant amount of tissue. Second EGD with evidence of friable lesion obstructing 75% of esophageal lumen. Biopsy revealed expression of P40, P63, Ck5/6 and morphology suggestive of SpCC. Patient referred to Oncology service and chemotherapy-radiotherapy started with remission of disease. A year later patient presented with severe dysphagia. Initial EGD negative for strictures, tumor, or fistula. Bronchoscopy negative for fistulization. Due to worsening dysphagia, patient re-admitted and CT chest concerning for fistulous tract. New EGD demonstrated tracheoesophageal fistula at 31 cm and AGILE stent placed with improvement of dysphagia. Discussion: SpCC is a rare subtype of SCC but with similar risk factors such as tobacco use and alcohol consumption. The spindle cell component simulating a sarcoma and a non-specific clinical presentation precludes a correct diagnosis. Our patient initially presented with atypical chest pain, and review of systems revealed symptoms of progressive dysphagia and weight loss which guided the diagnosis. A second biopsy performed, and several immunohistochemistry tests confirmed the presence of both a carcinomatous and sarcomatous component. As a result, our case is an example of one of the rarest malignancies affecting the esophagus and its complications. It also highlights the importance of a thorough history taking, adequate tissue sampling, use of staining techniques to reach a correct diagnosis, as well as incorporation of innovative medical devices.Figure 1.: Spindle-cell squamous carcinoma lesion with tracheoesophageal fistula complication and subsequent Agile Stent placement.

S326 Potential Modifiers and Different Cut-offs in Diagnostic Accuracy of Fecal Immunochemical Test in Detecting Advanced Colon Neoplasia: A Diagnostic Test Accuracy Meta-Analysis

Introduction: Fecal Immunoglobulin Test (FIT) has been advocated as the first line of screening for colorectal cancer in several jurisdictions. Most studies have focused on colorectal cancer as the outcome of interest. Our goal was to quantify the diagnostic accuracy of different threshold of fecal immunochemical testing as compared to colonoscopy for detection of colonic advanced neoplasia and potential modifiers using proper Cochrane methodology. Methods: A comprehensive electronic search was performed for studies on FIT using colonoscopy as reference standard, to detect advanced neoplasia. Cochrane methodology was used to perform a diagnostic test accuracy meta-analysis. Diagnostic accuracy of different cut-offs of FIT including 25, 50, 75, 100, 150 and 200 ng/mL were calculated separately. Meta-regression analysis was also performed to detect potential a priori modifiers including age, location of tumour, time from FIT to colonoscopy. Results: 24 studies were included with no evidence of publication-bias. Sensitivity of FIT did not decrease with lowering the cut-off although specificity increased in higher cut-offs. Commonly used cut-offs of 50 ng/mL, 75 ng/mL and 100 ng/mL for FIT provided sensitivity of 39%, 36%, 27% and specificity of 92%, 94%, 96%, respectively. The sensitivity and specificity of FIT were 31 (26-36)% and 95 (94-96)%, respectively for distal lesions and 20 (13-27)% and 95 (94-96)%, respectively for proximal lesions (P=0.16). These numbers were 18 (3 - 33)% and 97 (96 - 98)%, respectively in those older than 50 as compared to 10 (1 - 19)% and 98 (97 - 99)%, respectively, for those under 50 (P=0.47). Meta-regression analysis did not show any significant predictability for location of the study (Asian versus non-Asian, P=0.06), inclusion of patients with unclear or high risk (P=0.14), time gap from FIT to colonoscopy (P=0.09) and risk of bias (high or unclear as compared to low) criteria in diagnostic accuracy of FIT (P=0.82). Conclusion: Sensitivity of FIT might have been overestimated in previous studies focusing on colorectal cancer as compared to advanced neoplasia and it seems to be independent of age, location of neoplasia or cut-offs contrary to some previous studies. Lowering the cut-off will reduce diagnostic odds ratio by increasing specificity but without any effect on sensitivity.Figure 1.: SROC of diagnostic accuracy of colonoscopy and different cut-offs of FIT.Table 1.: Diagnostic test accuracy of FIT for most used cut-off.

The importance of proximal optimization technique with intravascular imaging guided for stenting unprotected left main distal bifurcation lesions: The Milan and New-Tokyo registry.

This study evaluated the 5-years outcomes of intracoronary imaging-guided proximal optimization technique (POT) for percutaneous coronary intervention (PCI) in patients with unprotected left main distal bifurcation lesions (ULMD). The long-term effects of POT with intracoronary imaging guide in PCI for ULMD have been unclear. Between January 2005 and December 2015, we identified 1832 consecutive patients who underwent DES implantation for ULM distal bifurcation lesions. Of them, 780 (56.1%) patients underwent POT with intravascular imaging guidance (optimal expansion group). Residual 611 (43.9%) patients did not undergo either POT or intravascular imaging or both (suboptimal expansion group). Analysis using propensity score adjustment was performed. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target lesion revascularization (TLR), and myocardial infarction. TLF rate at 5 years was significantly lower in optimal expansion group than that in suboptimal expansion group [adjusted HR 0.65, 95% CI (0.48-0.87), p= 0.004]. Cardiac mortality was significantly lower in optimal expansion group than that in suboptimal expansion group [adjusted HR 0.46, 95% CI (0.27-0.79), p= 0.004]. The multivariable analysis identified POT with intravascular imaging guide [adjusted HR 0.65, 95% CI (0.48-0.87), p= 0.004] as an independent predictor of TLF. Intravascular imaging guided POT was strongly associated with the reduced risk of TLF at 5 years after PCI for ULMD, mainly driven by reducing cardiac mortality.

Сomputed tomography in assessing the severity of patients with chronic thromboembolic pulmonary hypertension

Objective. To evaluate the role of computed tomography in the assessment of chronic thromboembolic pulmonary hypertension (CTEPH) severity. Design and methods. We included 41 patients. Chest dual-energy CT-computed tomographic angiography was performed according to the standard protocol and in some cases Dual Energy mode was used. The patients were divided into 2 groups: with proximal and distal types of pulmonary artery lesions. Results. Quanadli index and Score index showed a significant negative correlation with the value of cardiac output (CO) (r = –0,591, p < 0,05; r = –0,531, p < 0,001, respectively), mixed venous blood saturation (SvO2) (r = –0,457, p = 0,065; r = –0,595, p < 0,001, respectively). For the Score index, significant negative correlations were established with both the CO value: r = –0,531, p < 0,001, the SvO2 r = –0,595, p < 0,001, and with the N-terminal pro-B type natriuretic peptide (NTproBNP) value (r = –0,537, p = 0,003). Correlations are also found in the analysis within the compared groups. The Quanadli index correlated with the mean pressure in the pulmonary artery in the group with the proximal type of lesion (r = 0,825, p = 0,012). Pulmonary artery aneurysms were detected in 39 % (n = 16) patients. There was a positive correlation between the presence of a pulmonary artery aneurysm and the functional class of CTEPH (r = 0,526, p = 0,007) in patients with the distal lesion. Conclusions. Quanadli and Score indices are promising tools for CTEPH severity assessment.

Compression neuropathies of the forearm: anatomy, clinical features and management

The upper limb consists of four major parts: a girdle formed by the clavicle and scapula, the arm, the forearm and the hand. Peripheral nerve lesions of the upper limb are divided into lesions of the brachial plexus or the nerves arising from it. Lesions of the nerves arising from the brachial plexus are further divided into upper (proximal) or lower (distal) lesions based on their location. Peripheral nerves in the forearm can be compressed in various locations and by a wide range of pathologies. A thorough understanding of the anatomy and clinical presentations of these compression neuropathies can lead to prompt diagnosis and management, preventing possible permanent damage. This article discusses the aetiology, anatomy, clinical presentation and surgical management of compressive neuropathies of the upper limb.

Shoulder Pain - Dodgeball

HISTORY: 39-year-old right-handed man presented to clinic for right shoulder pain. Symptoms were present for 4-5 months prior and began several days after playing in a dodgeball tournament. There was no trauma or clear inciting event. Pain was localized to the top of the right shoulder and worse with reaching across the body and with overhead activities. The 3-4 weeks prior to presenting to clinic he noticed a lump and swelling over the top of the shoulder and clavicular region that was not painful to touch. His pain was rated overall 3/10 intensity. PHYSICAL EXAM: Full range of motion of the shoulder in abduction, flexion without pain. Negative empty can test, Hawkins and Neers tests on the right. Speeds test negative on the right. Fullness and bony prominence noted at the distal clavicle on the right shoulder. No focal tenderness at the AC joint. Mild discomfort with scarf test on the right. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular joint sprain 2. Acromioclavicular joint arthralgia 3. Distal clavicle osteolysis 4. Osteoid osteoma. TESTS AND RESULTS: Ultrasound right shoulder: Cortical irregularity of the distal right clavicle. XR right shoulder: Distal clavicular ill-defined lytic lesion with apparent cortical breakthrough superiorly and possibly inferiorly. MRI right shoulder: Indeterminate 3.6 cm expansile enhancing lesion with fluid. Biopsy right clavicle with USP6 genotype testing: consistent with an aneurysmal bone cyst FINAL/WORKING DIAGNOSIS: Aneurysmal bone cyst in the distal clavicle TREATMENT AND OUTCOMES: 1. Patient referred to orthopedic oncology and underwent biopsy 2. Underwent aspiration of aneurysmal bone cyst with injection of doxycycline 3. 2 months post-operatively continued to have pain and tightness in the shoulder 4. 5 months post-operatively reported resolution in shoulder pain and improved mobility, interval sclerosis noted of aneurysmal bone cyst on imaging

Vascular skin manifestations in patients with severe COVID-19 in intensive care units: a monocentric prospective study.

BackgroundVarious skin manifestations have been reported during the coronavirus disease 2019 (COVID-19) pandemic. Among these are acral vascular skin lesions in non-severe patients, but few studies have focused specifically on patients with severe COVID-19 admitted to the intensive care unit (ICU).ObjectivesWe aimed to assess the frequency of acral vascular skin manifestations (AVSM) in patients admitted to the ICU based on systematic dermatological examination.Materials & MethodsWe conducted a clinical, observational and prospective study in the ICU of Lille University Hospital (France). All adult patients with RT-PCR-confirmed severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) infection were included on May 5th and 6th, 2020.ResultsA total of 39 patients with severe COVID-19 were examined (34 males and five females; median age: 61 [55–59]). We observed AVSM in 11/39 patients (28%) including five with acral necrotic lesions, three with haemorrhagic blisters, one with acral live-doid rash, and one with erosive distal lesions. Chilblain or chilblain-like lesions were not seen, unlike ambulatory or non-severe patients described in the literature. There was no difference regarding the median length of stay in the ICU, initial symptoms of COVID-19 or baseline characteristics, except for a lower BMI in patients with AVSM. All patients had biological coagulation abnormalities (e.g. higher levels of fibrinogen or D-dimers), but there was no difference between patients with and without AVSM.ConclusionAVSM are infrequent and heterogenous and seem to be non-specific to patients with severe SARS-CoV-2, and possibly unrelated to COVID-19. The pathophysiology of AVSM described during the COVID-19 pandemic is not fully elucidated.

Lesiones relacionadas con la vaina de acceso ureteral frente a infecciones postoperatorias. ¿Es siempre necesaria la inserción de la vaina de acceso? Estudio prospectivo aleatorizado para comprender las luces y sombras de esta práctica

ObjectiveTo compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion. Patients and methodsIn this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication. ResultsThe evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P=.03). ConclusionsUAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections.Clinical Trial Registration Number (ISRCTN registry number): 55546280.