Femoral Site Research Articles

Reconstruction of the anterior cruciate ligament: a historical view.

Management of anterior cruciate ligament (ACL) tears has continuously evolved since its first description in approximately 170 A.D. by Claudius Galenus of Pergamum and Rome. The initial immobilization using casts was replaced by a variety of surgical and conservative approaches over the past centuries. The first successful case of ACL repair was conducted by Mayo Robson in 1885, suturing cruciate at the femoral site. In the nineteenth century, surgical techniques were focused on restoring knee kinematics and published the first ACL repair. The use of grafts for ACL reconstruction was introduced in 1917 but gained popularity in the late 1900s. The introduction of arthroscopy in the 1980s represented the greatest milestones in the development of ACL surgery, along with the refinements of indications, development of modern strategies, and improvement in rehabilitation methods. Despite the rapid development and multitude of new treatment approaches for ACL injuries in the last 20 years, autografting has remained the treatment of choice. Compared to the initial methods, arthroscopic procedures are mainly performed, and more resistant and safer fixation devices are available. This results in significantly less trauma from the surgery and more satisfactory long-term results. The most commonly used procedures are still patellar tendon or hamstring autograft. Additionally, popular, but less common, is the use of quadriceps tendon (QT) grafts and allografts. In parallel with surgical developments, biological reconstruction focusing on the preservation of ACL remnants through the use of cell culture techniques, partial reconstruction, tissue engineering, and gene therapy has gained popularity. In 2013, Claes reported the discovery of a new ligament [anterolateral ligament (ALL)] in the knee that could completely change the treatment of knee injuries. The intent of these modifications is to significantly improve the primary restriction of rotational laxity of the knee after ACL injury. Kinematic studies have demonstrated that anatomic ACL reconstruction and anterolateral reconstruction are synergistic in controlling pivot displacement. Recently, there has been an increased focus on the application of artificial intelligence and machine learning to improve predictive capability within numerous sectors of medicine, including orthopedic surgery.

Lateral Extra-articular Tenodesis: The Onlay Technique

Tibial anterolateral rotary instability associated with anterior cruciate ligament (ACL) tears is a well-documented and difficult problem with a long history of solutions. The lateral extra-articular tenodesis (LET) has undergone multiple refinements in technique, largely focusing on the femoral site insertion using either an interference screw versus a staple for adequate fixation. In this article, we present an improved technique using a suture anchor as an alternative to a staple or an interference screw with secure fixation to insert the LET graft onto the femur. This technique diminishes the chance of ACL tunnel–LET drilling convergence, minimizes the footprint required for adequate graft fixation, and allows the surgeon to dial in the correct tension necessary for adequate augmentation of an ACL reconstruction.

Predictors of Bleeding after Percutaneous Coronary Intervention

Background: Acute coronary syndrome patient outcomes have been improved using early invasive techniques. The aim of this study was to investigate the incidence, location, and severity of bleeding in PCI-treated cases to identify patient risk profiles and increased bleeding occurrences.
 Methods: This prospective observational study evaluated percutaneous coronary angiography in 80 patients with hypertension and diabetes mellitus who planned to undergo primary or elective PCI. The cases were separated into 2 groups; those who reported bleeding (n=11) and those who did not (n=69). All patients underwent physical examination, laboratory evaluation, 12-lead electrocardiography, and PCI.
 Results: In univariate regression analysis, age (OR: 1.09, 95% CI: 1.009 – 1.192), female gender (OR: 4.32, 95% CI: 1.157 – 16.131), history of peripheral arterial disease (OR: 7.31, 95% CI: 1.585 – 33.742), and femoral site of vascular access (OR: 9.6, 95% CI: 2.263 – 40.721) were independent predictors of major bleeding after PCI. In multivariate regression analysis, age (OR: 1.12, 95% CI:1.014 – 1.269), female gender (OR: 13.75, 95% CI: 1.983 – 161.2), history of peripheral arterial disease (OR: 43.38, 95% CI: 3.754 - 1042) and femoral site of vascular access (OR: 13.29, 95% CI: 2.233 – 128.5) were independent predictors of major bleeding after PCI.
 Conclusions: Patients who reported bleeding after PCI had a significantly higher age, prevalence of female sex, serum creatinine, and transfemoral intervention before and after intervention compared to patients who did not report bleeding, while haemoglobin and transradial intervention before and after intervention were significantly lower in the bleeding cases than in the non-bleeding cases.

Periosteum-derived skeletal stem cells encapsulated in platelet-rich plasma enhance the repair of bone defect

BackgroundSpontaneous restoration of large bone defects remains a challenge under infections, tumors, and crushing conditions. Current stem cell-based therapies for treating bone defects need improvement, because the used stem cells are isolated by a traditional protocol, which is based on their properties of in-vitro plastic adherence and fibroblastic colony formation. The stem cells isolated by the traditional protocol belong to a multicellular type mixture, individual cells vary in proliferative and osteogenic potential. Thus, developing a protocol capable of isolating stem cell subset with higher purity is required and urgent. AimThis study aimed to sort a subpopulation of stem cells from periosteum using flow cytometry (named as FC-PSCs), and evaluate the proliferative and osteogenic capacity of FC-PSCs in-vitro, and then establish a new stem cell-based therapies for treating bone defects by delivering the FC-PSCs within platelet-rich plasma (PRP). MethodsMouse periosteum was used to sort FC-PSCs using flow cytometry with CD45-TER119-TIE2-ITGAV+CD90 + 6C3-CD105- markers, or isolate periosteum-derived stem cells with the traditional protocol (TP-PSCs) as control. After evaluating the FC-PSCs proliferation and osteogenic differentiation in-vitro as well as the promotive efficacy of platelet-rich plasma (PRP) on FC-PSCs proliferation and osteogenic differentiation, the FC-PSCs were delivered into the femoral epiphysis bone defect site of a mouse model by platelet-rich plasma (PRP). At postoperative 14 or 28 days, these mice were euthanized for harvest the femur specimens for micro-CT, histological evaluation. ResultsIn-vitro results determined that the FC-PSCs showed more capacity for proliferation and osteogenic differentiation compared with the TP-PSCs. In addition, in-vitro results showed the promotive efficacy of PRP on FC-PSCs proliferation and osteogenic differentiation. In-vivo results showed that the FC-PSCs delivered by PRP was able to facilitate the repair of bone defects by stimulating new bone formation and remodeling. ConclusionFC-PSCs delivered by PRP enhance the repair of bone defects by stimulating new bone formation and remodeling.

Anatomical Tissue Engineering of the Anterior Cruciate Ligament Entheses.

The firm integration of anterior cruciate ligament (ACL) grafts into bones remains the most demanding challenge in ACL reconstruction, since graft loosening means graft failure. For a functional-tissue-engineered ACL substitute to be realized in future, robust bone attachment sites (entheses) have to be re-established. The latter comprise four tissue compartments (ligament, non-calcified and calcified fibrocartilage, separated by the tidemark, bone) forming a histological and biomechanical gradient at the attachment interface between the ACL and bone. The ACL enthesis is surrounded by the synovium and exposed to the intra-articular micromilieu. This review will picture and explain the peculiarities of these synovioentheseal complexes at the femoral and tibial attachment sites based on published data. Using this, emerging tissue engineering (TE) strategies addressing them will be discussed. Several material composites (e.g., polycaprolactone and silk fibroin) and manufacturing techniques (e.g., three-dimensional-/bio-printing, electrospinning, braiding and embroidering) have been applied to create zonal cell carriers (bi- or triphasic scaffolds) mimicking the ACL enthesis tissue gradients with appropriate topological parameters for zones. Functionalized or bioactive materials (e.g., collagen, tricalcium phosphate, hydroxyapatite and bioactive glass (BG)) or growth factors (e.g., bone morphogenetic proteins [BMP]-2) have been integrated to achieve the zone-dependent differentiation of precursor cells. However, the ACL entheses comprise individual (loading history) asymmetric and polar histoarchitectures. They result from the unique biomechanical microenvironment of overlapping tensile, compressive and shear forces involved in enthesis formation, maturation and maintenance. This review should provide a road map of key parameters to be considered in future in ACL interface TE approaches.

Stiffness and Instability After MPFL Reconstruction Using a Fluoroscopic Versus Open Technique to Localize the Femoral Attachment Site: A Systematic Review and Meta-analysis.

Open and fluoroscopic techniques have been described for localization of the femoral attachment site in medial patellofemoral ligament (MPFL) reconstruction. No study to date has evaluated if one technique is superior to another in terms of complications. To review the literature comparing clinical outcomes of MPFL reconstruction using the fluoroscopic versus open technique to localize the site of femoral graft placement. Systematic review; Level of evidence, 4. A systematic literature review was performed via PubMed, Embase, and CINAHL to identify articles published between the inception of these databases and March 1, 2022, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. This search yielded 4183 publications for initial review. Studies with at least a 2-year follow-up and complete reporting of patient-reported outcomes, range of motion, recurrent instability, and/or complications (ie, stiffness, infection, persistent pain) were included. We excluded studies of patients with collagen disorders; revision surgeries; surgeries with concomitant procedures; synthetic MPFL reconstruction; MPFL repairs; combined open and radiographic technique; and case series that included <10 patients. A proportional meta-analysis was performed by calculating the pooled estimate of incidence with 95% CIs using a fixed-effects model with double arcsine transformation (Freeman-Tukey) for each type of surgical technique (fluoroscopic or open). A total of 29 studies met our inclusion criteria, of which 15 studies (566 patients) used the open technique and 14 studies (620 patients) used fluoroscopy. There were no significant differences between the open and fluoroscopic techniques in the incidence of postoperative apprehension (P = .4826), postoperative subjective instability (P = .1095), postoperative objective instability (P = .5583), reoperations (P = .7981), recurrent dislocation (P = .6690), or arthrofibrosis (P = .8118). Both open and radiographic localization of the femoral graft position in MPFL reconstruction offer similar outcomes and rates of complications.

Changes in BMD T-score from pre-to post-treatment with biosimilar teriparatide: A single-arm, multi-center study

IntroductionTeriparatide is a recombinant analog of the parathyroid hormone and an anabolic treatment modality for osteoporosis. This study aimed to evaluate the effectiveness of biosimilar teriparatide (CinnoPar®, CinnaGen Co., Iran) in osteoporotic patients after at least one year of treatment. MethodsIn this multi-center, single-arm study, 239 eligible patients received subcutaneous injections of biosimilar teriparatide 20 μg once daily for at least one year. The main outcome measure was the change in bone mineral density (BMD) T-score from baseline (pre-treatment) to end of the study (post-treatment). In addition, the change in the fracture risk assessment tool (FRAX) score was calculated to estimate the 10-year probability of major and hip fractures pre-and post-treatment. ResultsA total of 239 patients (age, 63 ± 12.14 years; female, 88.28 %) were included, of which 27.62 % (66/239), 14.64 % (35/239), and 57.74 % (138/239) received biosimilar teriparatide for 12–16 months, 17–20 months, and 21–24 months, respectively. From baseline to end of the study, the T-score at the lumbar spine increased from −2.67 ± 1.04 to −2.26 ± 1.11 (mean percent change, 13.07 ± 62.89; p-value<0.001). Similarly, the T-score at femoral neck increased from −2.18 ± 0.87 to −2.09 ± 0.93 (mean percent change, 3.81 ± 31.52; p-value = 0.006). The proportions of patients with maintained or improved BMD T-score at the lumbar spine and femoral neck sites were 85.36 % (204/239) and 69.04 % (165/239), respectively. Similar results were obtained in subgroups of patients with rheumatoid arthritis and those with a history of a previous fracture or parental hip fracture. FRAX scores did not change significantly during the study (p-values of 0.551 and 0.973 at the lumbar spine and femoral neck, respectively). ConclusionWe observed considerable improvements in BMD following treatment with the biosimilar teriparatide for one year or more. The biosimilar teriparatide can be considered as an effective treatment option in female and male patients with osteoporosis.

Prospective Assessment of Direct Measurements of Absorbed Radiation Exposure in Operators and Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair

To analyze the direct dose of absorbed radiation exposure of the primary operator and the patient during fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Patients treated by FB-EVAR for CAAAs and TAAAs were prospectively enrolled between March and December 2022. Measurements of direct dose of absorbed radiation exposure were obtained using nanodots sensors (Landauer Inc., Glenwood, IL) positioned in standard location within unprotected skin area of the primary operator and patient face and periorbital area. The primary operator was positioned in the right femoral access site. Measurements of direct dose of absorbed radiation exposure (mGy) were compared with recorded metrics of the imaging unit including total radiation dose (mGy), dose area product (DAP) (mGy·cm2) and fluoroscopy time (minutes). There were 48 patients (75% male; mean age, 73 ± 9 years) enrolled in the study and treated by FB-EVAR for TAAAs in 38 patients (79%), CAAAs in 8 (17%), and arch aneurysms in 2 (4%). As shown in the Figure, measurements of DDRAE was three-fold higher for the patient compared to the primary operator (0.34 ± 0.27 vs 0.09 ± 0.06 mGy; P < .001). The left side of the primary operator face and periorbital artery was exposed to five-fold higher DDRAE compared to the right side (0.16 ± 0.12 vs 0.03 ± 0.004 mGy; P < .001). For the patient, the left side was exposed to significantly higher DDRAE as compared to the right side (0.42 ± 0.34 vs 0.32 ± 0.33 mGy; P < .001). All three recorded metrics (total radiation dose, DAP, and fluoroscopy time) had significant linear correlation with DDRAE measurements for the primary operator (P < .001). However, for the patient a linear correlation with DDRAE measurements was observed only for fluoroscopy time (P = .002) and not for total radiation dose (P = .28) or DAP (P = .49). Patients treated by FB-EVAR have on average five-fold higher dose of absorbed radiation in the unprotected face and periorbital areas as compared to their primary operators, with significantly higher doses in their left side as compared to the right side. For the primary operator, the left side of the face and periorbital area are exposed to three-fold more absorbed radiation that the right side. When compared to metrics provided by the imaging unit, measurements of DDRAE had linear correlation with fluoroscopy time, total radiation exposure and DAP for the primary operator, but only fluoroscopy time for the patient.

Total Transfemoral Approach Is Associated With Lower Rates of Cerebrovascular Events and Improved Outcomes Compared With Upper Extremity Approach During Fenestrated-Branch Endovascular Aortic Repair

Upper extremity (UE) access has been widely used during fenestrated-branched endovascular aortic repair (FB-EVAR) but potentially increases the risk of cerebrovascular events. Steerable sheaths have allowed more liberal use of a total transfemoral (TF) approach (Fig), but this technique may increase technical difficulty, operative time, and lower extremity ischemia. The aim of this study was to compare procedural metrics and early outcomes of FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms using either the UE or TF approach for vessel incorporation. Patients enrolled in a prospective, nonrandomized study to investigate FB-EVAR were analyzed (2013-2022). End points included procedural metrics, technical success, 30-day mortality, major adverse events (MAEs), and rates of cerebrovascular events in patients who had a UE or TF approach for renal-mesenteric vessel incorporation. A total of 541 patients (70% male; mean age 74 ± 8 years) were treated by FB-EVAR using the UE approach in 366 (68%) patients and TF access in 177 (33%) patients. A total of 2107 renal-mesenteric arteries were incorporated with a mean of 3.9 ± 0.5 vessels per patient. The TF approach was used in 8% of patients between 2013 and 2018 and progressively increased to 31% between 2018 and 2020 and 96% between 2020 and 2022 (P < .05). Both groups had similar characteristics, except for significantly (P < .05) less ASA >3 (51% vs 75%), less complex abdominal aortic aneurysms (24% vs 37%), and more thoracoabdominal aortic aneurysms (76% vs 63%) among patients who had a UE approach as compared to a TF approach, respectively. The use of the TF approach was associated with lower fluoroscopy time (P = .001), lower operative time (P < .001), similar cumulative air kerma (P = .20), and similar technical success (P = .96) as compared with the UE approach (Table). Mortality was 1% for all patients, with no difference between the groups (P = .67). Patients treated by the UE approach had significantly higher rates of MAEs (18% vs 8%, P = .006) and more cerebrovascular events (3% vs 0%, P = .035). Access complications occurred in 2% of patients, mostly related to femoral access sites, with no difference between the groups (P > .99). The total TF approach has been increasingly used during FB-EVAR and was associated with lower rates of MAEs and cerebrovascular events. There was no difference in technical success between the two approaches, but the TF approach was associated with a shorter operative time.TableDifferences in procedural metrics and outcomes between patients treated by fenestrated-branched endovascular repair using an upper extremity (UE) or total femoral (TF) approachUE (n = 366)TF (n = 175)P valueFluoroscopy time, minutes83 ± 3272 ± 39<.001Total operating time, minutes249 ± 78194 ± 71<.001Total endovascular time, minutes166 ± 63147 ± 58<.001Cumulative air kerma, mGy2 039.4 ± 1 7591 635.2 ± 1 304.2030-day mortality5 (1.4)1 (0.6).6730-day MAE67 (18)16 (9).006Acute kidney injury35 (9.6)13 (7.6).45Any cerebrovascular event10 (2.7)0 (0).035Any access complication8 (2.2)3 (1.7)>.99Any femoral access complication7 (1.9)3 (1.7)>.99Any UE access complication1 (0.3)0 (0)>.99MAE, Major adverse event.Continuous variables are presented as mean ± standard deviation, and categorical variables as number (%).Boldface P values represent significance P < .05. Open table in a new tab

Factors for failure of ultrasound-guided compression repair for femoral pseudoaneurysms after neuroendovascular therapy.

Pseudoaneurysms are a serious complication of neuroendovascular therapy with femoral artery puncture, for which ultrasound-guided compression repair (UGCR) is often the first choice of radical therapy. We sought to retrospectively investigate the factors for failure of UGCR for pseudoaneurysm at the femoral artery puncture site. Among patients undergoing neuroendovascular therapy with femoral artery puncture at our hospital between January 2018 and April 2021, those who received a diagnosis of pseudoaneurysm and underwent UGCR were enrolled. They were classified into two groups according to whether UGCR was successful (UGCR group) or was converted to surgical repair (SR group). Patient and procedural characteristics were compared between the two groups. During the study period, 577 patients underwent neuroendovascular therapy with femoral artery puncture, 10 of whom (1.7%) received a diagnosis of pseudoaneurysm and underwent UGCR. There were seven patients in the UGCR group and three patients in the SR group. The sheath diameter tended to be larger in the SR group than in the UGCR group (p = 0.16). The modified Rankin scale score when a diagnosis of pseudoaneurysm was made was significantly lower in the SR group than in the UGCR group (1 [0-2] vs. 3 [2-5], p = 0.037). Physical activity may be associated with failure of UGCR. In patients with high physical activity, the use of sedatives and analgesics to keep them at rest during puncture site compression after UGCR may lead to successful UGCR.

Efficacy and Safety of Axiostat® Hemostatic Dressing in Aiding Manual Compression Closure of the Femoral Arterial Access Site in Patients Undergoing Endovascular Treatments: A Preliminary Clinical Experience in Two Centers.

Hemostasis of the femoral arterial access site by manual compression or a vascular closure device is critical to the safe completion of any endovascular procedure. Previous investigations evaluated the hemostatic efficacy at the radial access site of some chitosan-based hemostatic pads. This study aims to assess the efficacy and safety of a new chitosan-based hemostatic dressing, namely Axiostat®, in aiding manual compression closure of the femoral arterial access site in patients undergoing endovascular treatments. Furthermore, the outcomes were compared with evidence on manual compression alone and vascular closure devices. This investigation is a two-center retrospective analysis of 120 consecutive patients who had undergone, from July 2022 to February 2023, manual compression closure of the femoral arterial access site aided by the Axiostat® hemostatic dressing. Endovascular procedures performed with introducer sheaths ranging from 4 Fr to 8 Fr were evaluated. Primary technical success was achieved in 110 (91.7%) patients, with adequate hemostasis obtained in all cases of prolonged manual compression requirements. The mean time-to-hemostasis and time-to-ambulation were 8.9 (±3.9) and 462 (±199) minutes, respectively. Clinical success was achieved in 113 (94.2%) patients, with bleeding-related complications noted in 7 (5.8%) patients. Manual compression aided by the Axiostat® hemostatic dressing is effective and safe in achieving hemostasis of the femoral arterial access site in patients undergoing endovascular treatment with a 4-8 Fr introducer sheath.

Difficult-to-treat resistant gram-negative blood stream infections – the beginning of a superbug era – a prospective observational study

IntroductionCarbapenem resistant gram-negative bacterial infections are a growing concern worldwide. However, India is already in the era of a shortage of effective antibiotics for the management of these infections. Moreover, Difficult-to-Treat Resistance (DTR) gram-negative infections, which are not much studied, further complicate the scenario. This study emphasized the incidence and outcomes of DTR infections. MethodologyThis is a single-center prospective observational study. The study included hospitalised patients aged ≥18 years with gram-negative bacterial bloodstream infections (GNBSI). Blood cultures with the growth of contaminants and/or single positive culture taken from the femoral site were excluded. Incidences of DTR infections and outcomes in the form of 30-day mortality were analysed. ResultsTwo hundred forty patients with GNBSI episodes were recorded. The Incidence of DTR GNBSI was 37.9% (91/240). Multivariate analysis found that Hospital-acquired infections, ICU admission and mechanical ventilation were independent risk factors for DTR GNBSI. The most common DTR GNB isolates were Klebsiella pneumoniae (31/49, 63.3%) and Acinetobacter baumannii (26/52, 50%). The adjusted relative risk of mortality was remarkably high in DTR GNBSI (aRR 3.9; 95% CI 1.9–7.9) as compared to CR+/DTR- GNBSI (aRR 0.3; 95% CI 0.1–1.0) and ESCR/CS GNBSI (aRR 1.1; 95% CI 0.5–2.4). ConclusionDTR GNB infections are growing concern in India and this need to be evaluated in multicentric studies. Moreover, DTR GNBSI was associated with significantly higher mortality and there is need of further empowerment of antibiotic stewardship practices.

Splenic Artery Embolism in Liver Transplant Patients: A Single-Center Experience.

Hypersplenism, portal hypertension, and ascites have been seen after liver transplants. Patients are usually treated medically with refractory patients potentially undergoing splenectomy. Splenic artery embolism (SAE) is an alternative that can be performed to limit the surgical intervention that may have the benefit of improving portal hypertension. Few studies have studied the effect on main portal vein (MPV) velocities and hepatic artery resistive indices (HARIs) which may be beneficial as markers of portal hypertension. This study aims to evaluate the efficacy and safety of interventional radiology (IR)-guided SAE for the management of portal hypertension in patients who have had liver transplants. A retrospective analysis was conducted on liver transplant patients who had undergone IR-guided SAE post-transplant at a single tertiary transplant center from 2012 to 2022. The primary outcome of intervention efficacy was quantified by peak HARIs and MPV velocities. Ultrasound with Doppler obtained before and after the intervention was reviewed for these parameters. Secondary outcomes included adverseeventsat the time of the procedure and within one year of the procedure, the need for splenectomy, and spleen size. Twenty-eight patients met the criteria for inclusion. The mean age of patients was 52.5 years (21-71 years) and the time after transplant was 149.5 days (2-1588 days). About 96.4% of SAEs were technically successful (n=27). Twenty-one patients had MPV velocities available, and 24 had peak HARIs available. In these patients, HARIs decreased by an average of 0.063 (95% CI 0.014-0.112) after SAE. MPV velocity decreased by an average of 47.2 cm/s (95% CI 27.3-67.1) after SAE. About 10.4% of patients (n=3) developed a procedure-related complication, all of which were femoral access site aneurysms. No (0) patients suffered from bleeding, infections, or abscesses after the procedure. About 10.7% of patients (n=3) required splenectomy after SAE: one splenectomy was due to technical failure and two were due to refractory symptoms. We performed one of the first analyses on MPV and RI and showed that our patients saw an improvement post-embolization with a theoretical improvement in portal hypertension. The complication rate and risk of infection seem to be acceptable risks, making SAE a feasible option for management.

A new score for improving cardiovascular risk prediction and prevention

Background and aimsThe ultrasonographic detection of subclinical atherosclerosis (scATS) at carotid and femoral vascular sites using the atherosclerosis burden score (ABS) improves the risk stratification for atherosclerotic cardiovascular disease beyond traditional cardiovascular (CV) risk factors. However, its predictive value should be further enhanced. We hypothesize that combining the ABS and the Framingham risk score (FHRS) to create a new score called the FHRABS will improve CV risk prediction and prevention. We aim to investigate if incorporating the ABS into the FHRS improved CV risk prediction in a primary prevention setting. Methods and results1024 patients were included in this prospective observational cohort study. Carotid and femoral plaques were ultra-sonographic detected. Major incident cardiovascular events (MACEs) were collected. The receiver operating characteristic curve (ROC-AUC) and Youden's index (Ysi) were used to compare the incremental contributions of each marker to predict MACEs.After a median follow-up of 6.0 ± 3.3 years, 60 primary MACEs (5.8%) occurred. The ROC-AUC for MACEs prediction was significantly higher for the FHRABS (0.74, p < 0.024) and for the ABS (0.71, p < 0.013) compared to the FHRS alone (0.71, p < 0.46). Ysi or the FHRABS (42%, p < 0.001) and ABS (37%, p < 0.001) than for the FHRS (31%). Cox proportional-hazard models showed that the CV predictive performance of FHRS was significantly enhanced by the ABS (10.8 vs. 5.5, p < 0.001) and FHRABS (HR 23.30 vs. 5.50, p < 0.001). ConclusionsFHRABS is a useful score for improving CV risk stratification and detecting patients at high risk of future MACEs. FHRABS offers a simple-to-use, and radiation-free score with which to detect scATS in order to promote personalized CV prevention.

Obesity and vascular complication in percutaneous transfemoral transcatheter aortic valve insertion.

Obesity has been associated with an increased risk of vascular complication during percutaneous coronary intervention, but there are no data on the risk of vascular complication during percutaneous transfemoral transcatheter aortic valve insertion (TAVI). We hypothesized there would be a similar increased risk associated with TAVI. We reviewed the records of 1176 patients who received percutaneous transfemoral transcatheter aortic valve insertion from September 2015 to September 2020. All patients received 1) preoperative computed tomoraphy angiography assessment of the abdomen and pelvis to delineate iliofemoral artery anatomy, 2) ultrasound-guided percutaneous femoral arterial access, and 3) pre-closure of the delivery sheath femoral access site. Vascular complication was recorded based on definitions set forth by Valve Academic Research Consortium 3. The median age of patients was 81 years, and 60% were men. The median body mass index (BMI) was 29 kg/m2 (range, 11-67), and 91 (8%) patients had a value ≥40 kg/m2 (i.e., morbid obesity). Delivery sheath size was 14-French in 859 (73%) patients, 16-French in 311 (26%), and 18-French in 6 (1%). Vascular complication occurred in 53 (5%) patients, including 39 (7%) among the first half of procedures and 14 (2%) among the second half (p < 0.001). When stratified by obesity status (BMI < or ≥30 kg/m2 , p < 0.001), the complication rate was 4% in nonobese patients and 5% in obese patients. Multivariable analysis showed no overall association between risk of vascular complication and BMI categories (p = 0.583)BMI continuous values (p = 0.529), or sheath size (p = 0.217). Obesity is not associated with a vascular complication during percutaneous transfemoral transcatheter aortic valve insertion. The operation should not be denied in obese patients.

Surgical treatment for ipsilateral femoral neck and shaft fracture

To retrospectively analyze efficacy of single structure internal fixation and double structure internal fixation in the treatment of ipsilateral femoral shaft and neck fracture, and analyze their indications. From June 2015 to December 2020, 21 patients with ipsilateral femoral shaft and femoral neck fracture were treated, including 14 males and 7 females, aged 23 to 69 years old with an average of(38.1±12.9) years old. According to different femoral shaft fracture sites, some patients were fixed with cephalomedullary implant for both femoral neck and the femoral shaft(single structure, InterTan or PFNA Ⅱ), some patients were fixed with cannulated screws for the femoral neck and a retrograde locking nail for the femoral shaft (dual structure), and postoperative function and complications were recorded during follow-up. In 10 cases of single-structure fixation, the femoral necks were all basicervical fractures, and the femoral shaft fractures were located in the proximal isthmus;11 cases were double-structure fixation, 9 cases in 11 were basal type of femoral neck, 2 cases in 11 were neck type, and the femoral shaft fractures were located in the isthmus and the distal isthmus. All patients were followed up for 12 to 27 months. No femoral head necrosis, deformity, delay or nonunion occurred in the patients with single-structure fixation, and no delayed union or nonunion occurred in femoral shaft fractures;At the final follow-up, Harris score of patients with single-structure fixation was 91.8±4.1, with 8 cases were excellent and 2 cases were good. The fractures of patients with dual-structure fixation achieved good union without femoral head necrosis, except 1 case of femoral shaft fracture had delayed union;At the final follow-up, Harris score of patients with dual-structure fixation was 92.4±5.9, 7 cases were excellent, 3 cases were good, and 1 case was fair. Good reduction and fixation is the key to the treatment of such fractures. Both the single-structure fixation and the dual-structure fixation are good methods, and it should be selected according to the locations of femoral shaft and femoral neck fractures. Single-structure fixation is a good choice for femoral shaft fractures located at the proximal isthmus and basal femoral neck fractures. For isthmus and distal femoral shaft fractures combined with ipsilateral femoral neck fractures, dual-structure fixation is recommended.

Extracorporeal membrane oxygenation in COVID-19: Results of the Croatian Extracorporeal Membrane Oxygenation Referral Center

At the beginning of the COVID-19 pandemic, the role of extracorporeal membrane oxygenation (ECMO) was uncertain and the outcomes of ECMO-treated patients were unfavorable. During the pandemic, medical community realized that carefully selected patients may benefit from ECMO support. The goal of the study was to present the outcomes of ECMO-treated patients with severe COVID-19 ARDS referred to the respiratory ECMO hub in Croatia and to determine variables that influenced the outcome. Our study included all adult patients with confirmed COVID-19 ARDS that required ECMO treatment, in the period between February 2020 and April 2022. All ECMO circuits were veno-venous with femoro-jugular configuration, with drainage at the femoral site. A total of 112 adult patients with COVID-19 induced ARDS were included in the study. All patients had veno-venous ECMO treatment and 34 survived. Surviving patients were discharged home either from the hospital or from a designated rehabilitation facility. The mortality was associated with the incidence of nosocomial bacteremia, occurrence of heparin induced thrombocytopenia and acute renal failure. In order to reduce the mortality in COVID-19 ECMO patients, the treatment should be started as soon as criteria for ECMO are met. Furthermore, complications of the procedure should be detected as soon as possible. However, despite even the optimal approach, the mortality in COVID-19 ECMO patients will surpass that of non-COVID-19 ARDS ECMO patients, mostly due to poor resolving and long lasting ARDS with longer ECMO runs and ensuing infectious complications.

Effect of Ice Bag Application to Femoral Region on Pain and Vital signs in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Randomized Controlled Trial

Background: Patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) experience a great deal of pain and discomfort in the femoral region induced by femoral catheter removal, which can stimulate the sympathetic system and affect some vital signs. Objective: The aim of this study was to determine the effect of ice bag application to femoral region on pain and vital signs in patients with acute MI undergoing PCI. Methods: This is a double-blind randomized controlled trial study. The sample of this study consisted of 60 patients with acute MI undergoing PCI, including 30 patients per group, selected by convenience sampling method and assigned to intervention and control groups by block randomization method. The intervention included the use of an ice bag in the femoral catheter insertion site. Data collection tools included demographic information form, Numerical Rating Scale (NRS), and vital signs form. Femoral site pain and vital signs were measured in both groups before, during, and after femoral catheter removal. The data were entered into SPSS ver. 22. Using descriptive statistics, Chi-square and Mann Whitney test, data were analyzed. Results: Two groups were matched in terms of all demographic and disease-related variables (p&gt;0.05). Pain score was lower in intervention group than in control group during and after the intervention (p&lt;0.0001). Also, systolic, diastolic blood pressure, and temperature scores of the patients in the intervention group were significantly lower than the control group during and after catheter removal (p&lt;0.05). Respiratory rate of the intervention group was significantly lower than the control group (p = 0.005). No significant difference between the two groups in the mean of heart rate in all three time periods (p&gt;0.05). Conclusion: Application of the ice bag on the femoral region is effective in stabilizing the vital signs and decreasing the pain caused by femoral catheter removal in MI patients undergoing PCI. Therefore, considering its low cost and complications, topical application of an ice bag, as a nursing intervention to control the pain and keep stable vital signs, is recommended. Clinical Trial Registration No: IRCT201511070249191N7.

Transplantation of Ultra-Long Cross-Donor Conjoined Perforator Flaps with Multiple Blood Supply Sources for Wound Repair.

There are reports about the surgical method and clinical efficacy of using ultra-long cross-donor perforator skin flap transplantation with multiple blood supply sources to repair wounds. Between January 2013 and March 2019, 29 wounds were repaired using ultra-long skin flaps from the donor site of the chest, abdomen and anterolateral thigh. All patients were followed up on a regular basis with a view to the following: appearance of skin flap, function of recipient area and healing of donor area. After the operation, all 28 skin flaps were fine. On the fifth day after the operation, one case of a 47-cm anterolateral thigh flap had dark skin color in the distal-most area measuring about 5 cm×4 cm, and the incision showed slow bleeding. In 11 cases, linear scars with soft edges and no obvious contractures were left in the donor area of the chest and abdomen. Eighteen cases with lateral femoral donor sites healed successfully, with linear scars forming without contracture. Three cases with lateral femoral donor sites had wide linear scars that were slightly above skin level and exhibited no contracture. Transplantation of ultra-long conjoined cross-donor perforator flaps with multiple blood supply is beneficial to wound repair and worthy of clinical promotion.

An alarm device for mechanical compression device displacement at femoral artery puncture sites

Objective To develop an alarm device for the mechanical compression device displacement (MCD), and further evaluate its effectiveness in clinical use. Material and methods The alarm device is mainly composed of buzzer, indicator light, magnetic sheet. This is a prospective randomized and controlled study. Four hundred patients who met the inclusion/exclusion criteria were included and randomly assigned to two groups (MCD group vs alarm + MCD group). The primary outcome measures were the sensitivity and specificity of the alarm device to detect MCD displacement, time to hemostasis (TTH), time to ambulation (TTA), time to hospital discharge (TTHD), hospital costs (HC), complication rates, and patient satisfaction. Results The sensitivity and specificity of the alarm device in detecting MCD displacement were 94.44% and 88.46%, respectively. The study group achieved shorter TTH (p = .034), shorter TTA (p = .021), lower complication rates (p = .025), and better patients’ satisfaction (p < .001) compared to the control group. However, no significant difference was observed in TTHD (p = .361) and HC (p = .583). Conclusion The alarm device is highly sensitive in detecting MCD displacement, while achieving better clinical outcomes compared with artificial monitoring.