Fluoroscopic Screening Research Articles

1814 EFFICIENCY OF FLEXIBLE URETERORENOSCOPY IN TREATMENT OF KIDNEY STONES IN PATIENTS WITH CHRONIC KIDNEY DISEASE

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopy or Percutaneous Stone Removal (III)1 Apr 20131814 EFFICIENCY OF FLEXIBLE URETERORENOSCOPY IN TREATMENT OF KIDNEY STONES IN PATIENTS WITH CHRONIC KIDNEY DISEASE Emrah Yuruk, Murat Binbay, Faruk Ozgor, Akif Erbin, Yalcin Berberoglu, and Ahmet Yaser Muslumanoglu Emrah YurukEmrah Yuruk Istanbul, Turkey More articles by this author , Murat BinbayMurat Binbay Istanbul, Turkey More articles by this author , Faruk OzgorFaruk Ozgor Istanbul, Turkey More articles by this author , Akif ErbinAkif Erbin Istanbul, Turkey More articles by this author , Yalcin BerberogluYalcin Berberoglu Istanbul, Turkey More articles by this author , and Ahmet Yaser MuslumanogluAhmet Yaser Muslumanoglu Istanbul, Turkey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2177AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the effects of kidney stone treatment with flexible ureterorenoscopy (f-URS) on patients with chronic kidney disease. METHODS Data of patients who underwent ureterorenoscopic kidney stone treatment were collected. Estimated glomerular filtration rate (eGFR) was calculated using chronic kidney disease epidemiology collaboration (CKD-EPI) formula for each patient. Patients were staged according to eGFR using National Kidney Foundation guidelines. Stage 3 and more was accepted as chronic kidney disease (CKD). Operative findings, postoperative complications and 3rd month success rates as well as overall eGFR change were documented. Success was evaluated with non-contrast enhanced computerized tomography in all cases. RESULTS Overall 339 patients were treated and 62 of them had stage 3 or more CKD. Male/female ratio was 24/38. Mean patient age was 56.79±11.45 (range: 14-80) years. Co-morbidities including hypertension, diabetes mellitus, chronic heart or lung disease were seen in 43 patients. Previous stone intervention including percutaneous nephrolithotomy and shock-wave lithotripsy was performed in 39 patients and 11 had solitary kidney. Mean stone size was 173.56±102.08 (range: 66-620) mm2. Stones were located in upper calyx in 7, middle calyx in 7, lower pole in 18, pelvis in 6, and multiple calyx in 24 patients. Operative time was 49.08±25.76 (range: 12-135) minutes. Fluoroscopic screening time was 2.90±2.05 (range: 0.5-15) minutes. Access sheath was used in 54 patients. Overall complications were seen in 12 patients. Mucosal tearing was seen in 8 patients and was the most common complication. Postoperative complications were also seen in 12 patients and colicky pain was the most common postoperative complication accounting in 9 patients. DJ catheter was used in 59 patients. Preoperative mean eGFR rate was 48.16±8.71 (range: 19-59) ml/min/1.73m2 and mean CKD stage was 3.01±0.12. Early postoperative mean eGFR and CKD stage was 49.0±11.71 (range: 17-72) ml/min/1.73m2 and 2.80±0.43, respectively while mean eGFR increased to 53.98±9.06 (range: 35-73) ml/min/1.73m2, and mean CKD stage decreased to 2.64±0.51 at 3rd month control. After the surgery, 40 patients were stone free while 14 had fragments less than 2mm in largest diameter. 8 patients had postoperative auxiliary treatment. Hospitalization time was 25.70±25.62 (range: 7-180) hours. At 3rd month control, 12 more patients were stone free and overall 83.8% SF rate was achieved with only one session fURS. CONCLUSIONS Flexible ureterorenoscopy, as in normal population, can be safely and effectively be used in chronically diseased kidneys. Although eGFR remains stable at the end of first week, the overall kidney function gets better at 3rd month control. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e746 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emrah Yuruk Istanbul, Turkey More articles by this author Murat Binbay Istanbul, Turkey More articles by this author Faruk Ozgor Istanbul, Turkey More articles by this author Akif Erbin Istanbul, Turkey More articles by this author Yalcin Berberoglu Istanbul, Turkey More articles by this author Ahmet Yaser Muslumanoglu Istanbul, Turkey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Circulation: Arrhythmia and Electrophysiology Editors’ Picks

<i>Circulation: Arrhythmia and Electrophysiology</i> Editors’ Picks

Nationwide Fluoroscopic Screening of Recalled Riata Defibrillator Leads in Denmark

The natural history of insulation defects with inside-out conductor externalization in recalled St Jude Medical Riata defibrillator leads is not well understood. To determine the prevalence of externalization in a nationwide screening. Secondary aims were to examine time dependence and location of externalization, association with electrical failure, and fluoroscopic diagnostic performance. All 299 patients with recalled Riata leads in Denmark were identified, and all except one underwent fluoroscopy and device interrogation. Externalizations were confirmed by multiple investigators. The prevalence of externalization was 32 of 298 (11%) at a mean dwell time of 5.1 years. The prevalence was 21 of 98 (21%) for 8-F leads and 11 of 200 (6%) for 7-F leads; however, 8-F leads had longer dwell times. The degree of externalization was correlated with dwell time (Spearman's ρ = .37; P = .03). Externalization more often included the lead segment below the tricuspid annulus in dual coil leads than in single coil leads (69% vs 16%; P = .004). No association was observed between externalization and electrical function. Fluoroscopic diagnostic performance was good with positive and negative predictive values of 88% and 99%, respectively. The prevalence of externalization in a nationwide screening is at the same level as reported in previous studies with similar lead dwell times. The degree of externalization is time dependent, and location seems to differ between single and dual coil leads. Long-term lead performance and association with electrical failure need further clarification. Fluoroscopy has a good diagnostic performance in clinical practice.

182: Routine face-profile fluoroscopic screening may be useful for earlier detection, monitoring and management of externalized conductors in patients implanted with Riata leads

Increased rates of structural abnormalities have been reported in the Riata family of implantable cardioverter-defibrillator (ICD) leads. The reliability of defibrillation leads with insulation damage, or abraded cables that are not immediate cause of failure is unknown. The incidence of these defects can be underestimated due to the absence of abnormal electrical parameters detected by regular ICD interrogation. Little is known about the time lag for emergence of functional abnormalities in such leads. Forty eight patients who received small-caliber leads of the Riata family (models 1570, 1572, 1580, 1582, 7000, 7002) in our institution between May 2002 and March 2008 were systematically called for an additional visit including face-profile thoracic fluoroscopy to ascertain integrity of the leads followed by routinely repeated fluoroscopies at every six-month visits. We assessed the prevalence of insulation defects with externalized cables and their relation with adverse events requiring lead revision. We tried to evaluate the time lag for emergence of their electrical dysfunction. Thirty five patients, mean age=64±10 years, with at least 7-month completed fluoroscopy follow-up were included in analysis. After 55-month mean follow-up, 57% of patients completed 2 or more spaced fluoroscopies. Externalized conductors were identified in 7 (20%) patients after a 48-months (12-114) mean delay and in 4 (11%) cases the images were classified as borderline. Three of 7 patients with insulation damage required lead replacement for the reason of clinical adverse events. In two other patients an increase of abrasion was observed on repeated fluoroscopy without changes in electrical parameters. Insulation damage with externalized conductors was identified in 20% of patients implanted with Riata leads. Routine fluoroscopic screening allowed earlier detection of these defects and may be useful for their closer monitoring and better management.

Increasing lead burden correlates with externalized cables during systematic fluoroscopic screening of Riata leads

Riata and Riata ST defibrillator leads (St. Jude Medical, Sylmar, CA, USA) have been recalled due to increased risk of insulation failure leading to externalized cables. As this mechanical failure does not necessarily correlate with electrical failure, it can be difficult to diagnose. Fluoroscopic screening can identify insulation failure. Studies have suggested that insulation failure is predominantly seen in 8-Fr, single-coil models. Our patients have exclusively dual-coil leads and a high proportion of 7-Fr leads. Fluoroscopic screening was performed in 48 patients with recalled Riata leads. Twenty-three patients had 8-Fr Riata leads and 25 patients had 7-Fr Riata ST leads. Images were recorded in at least three projections and studies were reviewed by seven attending electrophysiologists. Externalized cables were seen in ten patients (21%), and another five patients (10%) had abnormal cable spacing. All device interrogations showed normal parameters. Patients with abnormal leads had more leads in situ (2.5 ± 0.7 vs. 1.6 ± 0.8 leads; P = 0.002) and a higher rate of nonischemic cardiomyopathy (80 vs. 24%; P = 0.03). There were no differences between the groups with regards to patient age, body mass index, lead age, lead parameters, or vascular access site. There was no difference with regard to lead size (P = 0.76). The Riata family of leads has a high incidence of mechanical failure, as demonstrated on fluoroscopic screening. In this study, the 7-Fr models were just as likely to mechanically fail as the 8-Fr models. Increasing lead burden and a diagnosis of nonischemic cardiomyopathy correlated with insulation failure.

Prevalence and Presentation of Externalized Conductors and Electrical Abnormalities in Riata Defibrillator Leads After Fluoroscopic Screening

Background— The Riata family of implantable cardioverter-defibrillator (ICD) leads is prone to a specific insulation abrasion characterized by externalization of conductor cables. The objective of this study was to determine the prevalence of externalized conductors and electrical abnormalities in Riata ICD leads by fluoroscopic screening and standard ICD interrogation. Methods and Results— All ICD implantation centers were contacted by the Netherlands Heart Rhythm Association Device Advisory Committee to identify all patients with an active Riata ICD lead and to perform fluoroscopic screening of the lead. In addition, the electrical integrity of the lead was assessed. As of March 1, 2012, data for 1029 active Riata leads were available; 47% of these were 8-F Riata and 53% were 7-F Riata ST. Externalized conductors were observed in 147 leads (14.3%). Proportion of externalized conductors was higher in 8-F Riata compared with 7-F Riata ST (21.4% vs 8.0%; P &lt;0.001). Median time from implantation to detection of externalized conductors was 65.3 months. The estimated rates of externalized conductors were 6.9% and 36.6% at 5 and 8 years after implantation, respectively. Of the 147 leads with externalized conductors, 10.9% had abnormal electrical parameters vs 3.5% in nonexternalized leads ( P &lt;0.001). Conclusions— The prevalence of externalized conductors in Riata leads is significantly high (14.3%) using fluoroscopic screening. The majority of externalized conductors are not detectable with standard ICD interrogation. Screening with fluoroscopy is reasonable.

Micropercutaneous Nephrolithotomy in the Treatment of Moderate-Size Renal Calculi

We present our initial experience with microperc in patients with moderate-size renal calculi. A retrospective analysis of 30 patients (male 14, female 16) with moderate-size (1-3 cm) kidney stones who underwent microperc between August 2011 and July 2012 was performed. The demographic values, perioperative and postoperative measures including age, stone size and location, body mass index, operative and fluoroscopy time, hemoglobin decrease, success and complication rates were prospectively recorded into a patient entry system. The average stone size was 17.9±5.0 mm (10-30 mm). The mean age of the patients was 41.5±18.2 years (range 3-69 years). The duration of the operation was calculated as 63.5±36.8 minutes (range 20-200 min). Mean fluoroscopic screening time was 150.5±90.4 seconds (range 45-360 seconds). The patients were discharged after a mean hospitalization period of 35.5±18.6 hours (range 14-96 hours). An overall success rate of 93% (including 10% of insignificant residual fragment rate) was achieved. In the follow-up, residual stone fragments were detected in two (7%) patients. Conversion to miniperc was necessitated in three (10%) patients. The mean hemoglobin drop was found to be 1.1±0.8 mg/dL (range 0-2.8 mg/dL). Complications were observed in five (13.3%) patients. Our initial results provide that microperc is a feasible, safe, and efficacious treatment modality for moderate-size kidney stones as well as small ones with its minimally invasive nature. Technical refinements are needed to achieve better results and overcome the limitations of technique.

The Role of Microperc in the Treatment of Symptomatic Lower Pole Renal Calculi

The treatment of symptomatic lower pole (LP) calculi poses a challenge because of lower clearance rates. We present our experience with microperc in the treatment of LP renal calculi. We retrospectively evaluated the symptomatic patients with LP renal calculi who underwent microperc between August 2011 and June 2012 from two referral hospitals. Patients were included only in cases of failure after shockwave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS) and according to patient preference. The percutaneous renal access was performed using the 4.8F "all-seeing needle" with C-arm fluoroscopy or ultrasonographic guidance with the patient in the prone position. Stone disintegration was established using a 200 μm holmium:yttrium-aluminum-garnet laser fiber. A total of 21 patients (mean age 37.3 ± 20.1 years) with LP stone underwent microperc. The mean body mass index was 28.6 ± 6.0 kg/m(2), and the mean stone size was 17.8 ± 5.9 (9-29) mm. The duration of surgery and fluoroscopic screening was 62.8 ± 25.2 minutes and 150.5 ± 92.8 seconds, respectively. The patients were discharged after a mean 37.5 ± 14.4 hours of hospitalization time. The mean hemoglobin drop was 0.8 ± 0.6 (0.1-2.3) g/dL. Conversion to miniperc was necessitated in one patient with loss of vision. Stone-free status was achieved in 18 (85.7%) patients. Clinically insignificant residual fragments were observed in only one (4.8%). The procedure failed in two (9.5%) patients. A total of two minor complications (renal colic necessitating stent insertion and urinary tract infection) were observed postoperatively, none severe. Microperc is a feasible and efficient treatment modality for symptomatic LP calculi. Our results provide that microperc might take a part in case of SWL and RIRS failures or as an alternative to percutaneous nephrolithotomy or RIRS in the management of symptomatic LP calculi.

Fluoroscopic Screening of Asymptomatic Patients Implanted With the Recalled Riata Lead Family

The Food and Drug Administration recently issued a class I recall of the St. Jude Medical Riata implantable cardioverter-defibrillator lead presumably because of increased risk of electric failure and mechanical separation via inside-out abrasion. We sought to examine the incidence and time dependence of inside-out abrasion in asymptomatic patients implanted with the Riata lead. Asymptomatic patients implanted with the Riata lead at our institution were offered voluntary fluoroscopic screening in 3 views. Electric testing of the Riata lead with provocative isometric muscle contraction was performed at the time of fluoroscopic screening. Of the 245 patients undergoing fluoroscopic screening, 53 (21.6%) patients showed clear evidence of lead separation. Of these externalized leads, 0%, 13%, and 26% had a dwell time of <3 years, 3 to 5 years, and >5 years, respectively (P=0.037). Externalized leads had a significantly pronounced decrease in R-wave amplitude (-1.7±2.9 mV versus +0.35±2.5 mV; P<0.001), and more patients with externalized leads had ≥25% decrease in R-wave amplitude from baseline (28.0% versus 8.1%; P=0.018). One patient with externalization exhibited new noise on near-field electrogram. The Riata lead exhibits time-dependent high rates of cable externalization exceeding 20% at >5 years of dwell time. Externalized leads are associated with a more pronounced decrease in R-wave amplitude, which may be an early marker of future electric failure. The use of fluoroscopic and electric screening of asymptomatic patients with the Riata lead remains controversial in the management of patients affected by the recent Food and Drug Administration recall.

PTU-126 MR assessment of Crohn's related strictures correlates well with endoscopic findings facilitating safe and effective fluoroscopic dilatation

IntroductionIntestinal strictures are a known complication of Crohn's disease (CD) and may be inflammatory (in part), fibrostenotic or post-operative (anastomotic). Treatment options include a combination of medical, endoscopic or surgical...

Impact of Percutaneous Renal Access Technique on Outcomes of Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is regarded as the gold standard for the treatment of patients with renal stones larger than 2 cm in diameter. Creating a percutaneous renal access is the initial and probably the most important step in performing a PCNL. Two primary methods of obtaining proper percutaneous renal access under fluoroscopic guidance are described: The "triangulation" and the "eye of the needle" techniques. In this article, we compare these two techniques in terms of success and complication rates. From October 2010 to May 2011, 80 patients with simple renal stones were prospectively randomized into two groups according to the percutaneous renal access technique used for PCNL. Patients in group 1 (n=40) were assigned to the eye of the needle technique, and patients in group 2 (n=40) were assigned to the triangulation method. Patients needing multiple access points were excluded from the study. The preoperative, operative, and postoperative follow-up findings were thereafter analyzed and compared. No significant difference between the two groups was detected in terms of patient demographics (mean patient age, body mass index, stone size, or stone location). The operation time, fluoroscopic screening time (FST), and duration of hospitalization were similar in both groups (P=0.52, P=0.32, P=0.26, respectively). Patients in group 1 had a larger drop in hematocrit postoperatively than patients in group 2 (7.6 ± 3.7 vs 4.8 ± 2.1, P=0.001). The blood transfusion rate (7.5%) was similar in both groups, however. Although the complication rate was higher in group 1 than group 2, no significant difference was detected (20% vs 15%, P=0.76). The present study demonstrates that PCNL can be performed safely using two different percutaneous access techniques. The two techniques studied in this trial had similar FSTs, operation and hospitalization times, success rates, and complication rates.

Closed reduction and percutaneous fixation of sacroiliac luxations in cats using 2.4 mm cannulated screws – a cadaveric study

To describe fluoroscopically assisted percutaneous placement of 2.4 mm cannulated screws for fixation of artificially induced sacroiliac luxations in cats, and to evaluate the success of this technique in restoration of normal pelvic anatomy. Fluoroscopically assisted closed reduction and percutaneous fixation of sacro-iliac luxations using 2.4 mm cannulated screws was performed in cadavers of 12 cats. Pre- and postoperative radiographs and postoperative computed tomographic scans were used to evaluate screw placement, screw purchase within the sacral body, reduction of the sacroiliac joint, pelvic canal diameter ratio, and hemipelvic canal width ratio. Mean total surgical time was 6 minutes and 10 seconds ± 53 seconds and mean total time of fluoroscopic screening for each procedure was 44 seconds ± 6 seconds. Mean percent of reduction was 98.33% and mean screw purchase within the sacral body was 73%. Eleven out of 12 screws were placed in a satisfactory location in the sacral body. Pelvic canal diameter ratio and hemipelvic canal width ratio indicated successful restoration of the pelvic anatomy. Our results confirm that fluoroscopically assisted percutaneous placement of 2.4 mm cannulated screws is a feasible technique for fixation of sacroiliac luxations in cats. Mechanical properties of this fixation technique need to be evaluated before the use in clinical patients.

Safety and Efficacy of Ultrasound-guided Percutaneous Nephrolithotomy for Treatment of Urinary Stone Disease in Children

To present the feasibility and efficacy of ultrasound-guided percutaneous nephrolithotomy for the treatment of urinary stone disease in children. The medical records and files of 17 patients with renal stones (17 renal units) who were aged ≤ 16 years who had undergone ultrasound-guided percutaneous nephrolithotomy from 2008 to 2010 were retrospectively reviewed and analyzed. Ultrasonography was used for guidance in all patients in every step of the procedure. Fluoroscopy was used to aid in tract dilation in the initial cases of the series and to evaluate for stone clearance in all cases. The operative and postoperative findings were assessed. The average age of the patients was 8.8 ± 2.86 years (range 5-15). The mean stone size was calculated as 337.4 ± 52.9 mm(2) (range 260-446). The mean operative time was 67.9 ± 14.58 minutes (range 45-95). Fever, urine leakage, and bleeding requiring blood transfusion were observed in 3, 1, and 1 patient, respectively. The fluoroscopic screening time was limited to 17.76 ± 15.5 seconds (range 1-54). Neighboring organ injuries were not observed. The overall success rate improved from 82.35% to 100% with additional treatment modalities (shock wave lithotripsy in 2 and ureteroscopy in 1). Percutaneous nephrolithotomy can be safely performed with ultrasound guidance in children, providing the advantages of less radiation exposure, no adjacent organ injury, and similar success and complication rates compared with fluoroscopic guidance.

A randomised comparison of Cartomerge vs. NavX fusion in the catheter ablation of atrial fibrillation: The CAVERN Trial

PurposeIntegration of a 3D reconstruction of the left atrium into cardiac mapping systems can aid catheter ablation of atrial fibrillation (AF). The two most widely used systems are NavX Fusion and Cartomerge. We aimed to compare the clinical efficacy of these systems in a randomised trial.MethodsPatients undergoing their first ablation were randomised to mapping using either NavX fusion or CartoMerge. Pulmonary vein isolation by wide area circumferential ablation was performed for paroxysmal AF with additional linear and fractionated potential ablation for persistent AF. Seven-day Holter monitoring was used for confirmation of sinus rhythm maintenance at 6 months.ResultsNinety-seven patients were randomised and underwent a procedure. There was no difference in the primary endpoint of freedom from arrhythmia at 6 months (51% in the Cartomerge group vs. 48% in the NavX Fusion group, p = 0.76). 3D image registration was faster with Cartomerge (24 vs. 33 min, p = 0.0001), used less fluoroscopic screening (11 vs. 15 min, p = 0.039) with a lower fluoroscopic dose (840 vs. 1,415 mGyCm2, p = 0.043). There was a strong trend to lower ablation times in the Cartomerge group, overall RF time (3,292 s vs. 4,041, p = 0.07). Distance from 3D lesion to 3D image shell was smaller in the Cartomerge group (2.7 ± 1.9 vs. 3.3 ± 3.7 mm, p < 0.001).ConclusionsCartomerge appears to be faster and uses less fluoroscopy to achieve registration than NavX Fusion, but overall procedural times and clinical outcomes are similar.Electronic supplementary materialThe online version of this article (doi:10.1007/s10840-011-9632-7) contains supplementary material, which is available to authorized users.

Diagnostic reference levels for X-ray investigations in pain management units in Belgium

X-rays are commonly used in pain treatment centres where infiltrative techniques are performed. Although X-rays are useful in increasing the precision of infiltrative techniques, their use puts patients and staff at risk of radiation exposure. As a result, medical staff now have to obtain a certificate of training on the use of X-rays before being allowed to use X-rays in practice. This analysis was based on 373 detailed registrations of procedure-related parameters in the six centres that participated in this study between January 2009 and July 2009. Examinations chosen for inclusion in this study were the most commonly performed fluoroscopic imaging-guided procedures in a pain management unit: epidurals (cervical/lumbar), facet joint nerve blocks (cervical/lumbar) and transforaminal (cervical/lumbar). The sample size, the dose-area product (DAP) range for whole population, the mean and the third quartile DAP corrected for patient size (DAP(corr)), the screening time range, the mean and the third quartile screening time are presented. The proposed DRLs for epidurals, facet joint nerve blocks and transforaminal are 0.5, 2.5 and 3 Gy cm&sup2; for DAP values and 12, 60 and 50 s for screening times, respectively. In the absence of national diagnostic reference levels (DRLs) for pain management fluoroscopic procedures, these DAP and screening time values provide a possible way of establishing provisional DRLs for local use. The values for each examination type could be used as a baseline against which to monitor the effectiveness of dose reduction strategies as part of the optimisation process that is the goal of any quality control and patient dose monitoring system.

Ultrasonography as a Diagnostic Tool in Assessing Deltoid Ligament Injury in Supination External Rotation Fractures of the Ankle

The medial deltoid ligament is the primary stabilizing structure in the ankle joint following lateral malleolar fracture. However, medial deltoid ligament ruptures are difficult to diagnose using current imaging modalities. We hypothesized that ultrasonography can be used to accurately allow early clinical assessment of ankle fracture stability, thereby negating the need to perform plain film stress views of the acutely injured ankle. This prospective study included 12 patients (age range, 18-72) with supination external rotation fractures requiring operative fixation. Following induction of anesthesia, ultrasonography examination was performed, followed by an arthrogram under fluoroscopic screening. Radiographs, ultrasonography, and arthrographic findings were compared. There was 100% correlation between ultrasonography and arthrogram findings. Ultrasonography accurately diagnosed medial deltoid rupture with a sensitivity of 100% and specificity of 100%. Plain film radiographs of the ankle had a sensitivity of 57.1% and a specificity of 60%. The difference between these was significant (χ(2)=.0091). This study demonstrates diagnostic ultrasonography to be an accurate diagnostic modality in assessing medial deltoid ligament integrity in patients with supination external rotation fractures. It offers the same sensitivity and specificity as arthrography without the need for additional invasive procedures. Its relative ease of use and lack of ionizing radiation make it a potentially useful tool, particularly in a busy trauma service.

Efficacy of the RADPAD Protective Drape During Real World Complex Percutaneous Coronary Intervention Procedures

The RADPAD is a lead-free surgical drape containing bismuth and barium that has been demonstrated to reduce scatter radiation exposure to primary operators during fluoroscopic procedures. It is not known to what degree the RADPAD reduces radiation exposure in operators who perform highly complex percutaneous coronary intervention (PCI) requiring prolonged fluoroscopic screening times. Sixty consecutive patients due to undergo elective complex PCI involving rotational atherectomy, multivessel PCI, or chronic total occlusions were randomized in a 1:1 pattern to have their procedures performed with and without the RADPAD drape in situ. Dosimetry was performed on the left arm of the primary operator. There were 40 cases of chronic total occlusion, including 28 with contralateral injections; 15 cases involving rotational atherectomy; and 5 cases of multivessel PCI. There was no significant difference in screening times or dose-area products between the 2 patient groups. Primary operator radiation dose relative to screening time (RADPAD: slope = 1.44, R² = 0.25; no RADPAD: slope = 4.60, R² = 0.26; analysis of covariance F = 4.81, p = 0.032) and dose-area product (RADPAD: slope = 0.003, R² = 0.26; no RADPAD: slope = 0.011, R² = 0.52; analysis of covariance F = 12.54, p = 0.008) was significantly smaller in the RADPAD cohort compared to the no-RADPAD group. In conclusion, the RADPAD significantly reduces radiation exposure to primary operators during prolonged, complex PCI cases.

A comparison of fluoroscopic airway screening with flexible bronchoscopy for diagnosing tracheomalacia

Flexible bronchoscopy (FB) is the gold standard method of diagnosing tracheomalacia but it is not always feasible in settings with limited resources. Fluoroscopy is sometimes performed as an alternative diagnostic tool but there are no prospective studies that have evaluated the diagnostic accuracy of airway fluoroscopy for tracheomalacia using a-priori definitions. We determined the sensitivity, specificity, and likelihood predictive ratio of airway fluoroscopy compared with FB in children suspected of having an airway abnormality. Airway fluoroscopic examination was undertaken within 2-weeks of a FB in children aged <18-years and reported by a pediatric radiologist blinded to FB data. Fluoroscopic and FB methods and diagnostic criteria were standardized and defined a-priori. Tracheomalacia diagnosed by FB were independently scored (mild, moderate, severe) by 2 pulmonologists in a blinded manner. In 22 children (median age 33 months, range 1-187) evaluated for airway abnormality, tracheomalacia was found in 21 children at bronchoscopy. Of these, fluoroscopy detected tracheomalacia in five children. Airway fluoroscopy was poorly sensitive (23.8%) but highly specific (100%), positive likelihood ratio was 8.6. However, in moderate-severe tracheomalacia, the sensitivity improved to 57.1% but the specificity reduced (93.3%). The agreement between bronchoscopists for tracheomalacia severity was excellent, weighted kappa 0.74 (95% CI 0.77, 0.98). Airway fluoroscopy cannot replace FB which remains the tool for definitively diagnosing airway malacia. However, in absence of other modalities for diagnosis fluoroscopy should be considered in the setting of persistent respiratory symptoms compatible with the clinical picture of tracheomalacia.

The radiation burden from increasingly complex endovascular aortic aneurysm repair

ObjectivesWith increasing experience, endovascular aortic aneurysm repair (EVAR) has been extended to patients with less suitable aorto-iliac anatomy in an attempt to reduce peri-operative mortality. However, more complex EVAR procedures may take longer and can result in higher rates of complications, additional interventional procedures and more frequent radiological imaging, which may offset some of the benefit. This study determined the radiation burden for standard EVAR, as determined by the EVAR-1 trial criteria, and more complex EVAR.MethodsA total of 123 elective patients aged >60, with aneurysms >5.5 cm who received a bifurcated stent-graft were allocated into a group based on whether or not they fulfilled strict EVAR-1 trial criteria. The mean radiation dose was calculated for each group, together with the additional radiation burden from routine pre- and post-EVAR CT examinations and pre-EVAR iliac artery embolisation.ResultsPatients not meeting the EVAR-1 trial criteria had significantly longer fluoroscopic screening times and higher radiation doses. The radiation burden in all patients was higher following exposure from routine CT examinations and following pre-EVAR iliac artery embolisation.ConclusionWhilst the radiation from standard EVAR is acceptable, more complicated and challenging EVARs, accompanied with additional radiological investigations and procedures, can significantly increase the radiation burden.

The Locator: Novel Percutaneous Nephrolithotomy Apparatus to Aid Collecting System Puncture—A Preliminary Report

Precise needle puncture of the renal collecting system is an essential step for successful percutaneous nephrolithotomy (PCNL). Puncture is technically challenging and has many pitfalls for the urologic surgeon. We describe the development of a novel navigation system, the Locator, to assist accurate percutaneous needle placement and compare this with conventional manual techniques. The essence of the device is that it stabilizes the needle for PCNL puncture. It relies on an adjustable lockable multidirectional head that is securely fixed to the operating table. The radiolucent head holds a 10F metal guide that allows renal collecting system puncture. The system uses the traditional fluoroscopic "bull's-eye sign" to achieve precise and fixed alignment. Objective assessment was obtained by in vitro testing using simulated PCNL puncture with and without using the Locator. Time to successful puncture and fluoroscopy screening time (FST) was assessed. Six urologic trainees were recruited to test the Locator. Simulated PCNL puncture was quicker and with reduced fluoroscopy when the apparatus was used. The mean FST for traditional hand vs Locator puncture was 46 vs. 16 seconds (P = 0.03), and the mean time to puncture was 225 vs. 118 seconds (P = 0.26). The Locator is a simple, cheap, and novel assistant to achieving successful PCNL puncture. It achieves this by stabilizing the needle during puncture. Preliminary in vitro testing suggests that the device may reduce fluoroscopy exposure and be quicker. The device warrants further evaluation in the clinical setting.