Good Apposition Research Articles

V06-08 MODIFIED MARTIUS FLAP URETHROPLASTY

You have accessJournal of UrologyCME1 May 2022V06-08 MODIFIED MARTIUS FLAP URETHROPLASTY Jacob Rust, and Christian Twiss Jacob RustJacob Rust More articles by this author , and Christian TwissChristian Twiss More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002586.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Female urethral strictures are rare, and there is no consensus on proper surgical treatment. The literature is primarily limited to case reports and small case series. Surgical treatment has frequently been extrapolated from male urethroplasty techniques. However, female urethroplasty differs significantly from male urethroplasty because it is performed directly across the urinary sphincter. We describe our rationale and technique for female ventral urethroplasty utilizing a modified Martius flap. METHODS: A 50-year-old female with a chronic proximal to mid-urethral stricture requiring daily intermittent catheterization to maintain urethral patency underwent a ventral Modified Martius Flap Urethroplasty. Following guidewire and open-ended ureteral stent placement across the stricture, an inverted U-flap incision was made from the distal urethra to the bladder neck. A full thickness incision into the urethral lumen was made, extending past the bladder neck, and sounded with a 30 French urethral sound. A 5x2 cm portion of non-hair bearing inner labia tissue was harvested and mobilized on the anterior pedicle of a Martius flap. This was then tunneled under the vaginal wall and rotated over the area of the urethral defect. The flap was sutured in place with two 4-0 vicryl running suture lines, covering the entire gap in the urethra with good mucosal apposition. The remaining fatty tissue of the Martius flap was rotated over the suture lines, adding an extra layer to the repair. The inverted U flap incision was closed over the repair with 2-0 vicryl suture. The skin edges of the Martius flap harvest site were then closed in two layers with a deep 2-0 vicryl layer and a superficial 4-0 monocryl subcuticular suture, resulting in a cosmetic closure. RESULTS: Postoperative VCUG revealed an open bladder neck and no recurrent stricture. Uroflow peak flow was 20cc/s. The patient had no complaints of stress incontinence (SUI) and a negative cough leak test at 1 month follow-up. At 6 months follow-up, the patient continued to deny any SUI and had no obstructive voiding complaints with PVR=2cc. She had mild postoperative dyspareunia which had resolved by the 6-month follow-up appointment. CONCLUSIONS: Our technique using a ventral approach to female urethroplasty with a modified Martius flap is feasible and effective in the management of female urethral stricture disease. This approach offers potentially less damage to the sphincter, avoids possible clitoral nerve injury, allows for better maintenance of urethral support, and is an approach familiar to most FPMRS surgeons. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e567 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacob Rust More articles by this author Christian Twiss More articles by this author Expand All Advertisement PDF DownloadLoading ...

Coronary artery perforation after bioresorbable scaffold implantation treated with a new generation covered stent\u2014OCT insights

BackgroundCoronary artery perforation is a rare but potentially lethal complication of percutaneous coronary intervention (PCI) with an associated mortality of 7–17%. We report the case of coronary artery perforation complicating Absorb bioresorbable vascular scaffold (BVS) implantation and the associated technical challenges with managing this life-threatening complication.Case reportA 46-year-old male was referred to our institution and underwent PCI with an Absorb bioabsorbable vascular scaffold (BVS) to a proximal LAD long segment bifurcation lesion. Following pre-dilation and deployment of the 3.5 × 28 mm Absorb BVS, high pressure post-dilation of the distal scaffold was complicated by a large, Ellis type III coronary perforation with no flow to the distal LAD beyond the rupture, and associated with a large pericardial effusion confirmed on bedside transthoracic echocardiogram (TTE). The insult was temporised with prolonged balloon inflation within the Absorb BVS immediately proximal to the site of perforation, permitting urgent insertion of a pericardial drain. After deflation of the balloon, a 3.0 × 21 mm BeGraft covered stent was deployed across the perforation, restoring normal LAD flow and abolishing the perforation. Cardio-pulmonary resuscitation was not required and the patient remained conscious throughout the procedure. TTE demonstrated normal left ventricular function and the patient was discharged 3 days later. Repeat angiography at 3 months showed patent stents with TIMI III flow, and optical coherence tomography (OCT) showed good expansion and apposition of the proximal Absorb BVS and BeGraft. The patient has remained well 4 years after PCI with no major cardiovascular events.ConclusionThe utility of bioresorbable scaffold technology remains controversial although meticulous implantation techniques are associated with improved clinical outcomes. Adoption of the Pre-dilatation, Sizing and Post-dilatation (‘PSP’) method of BVS implantation with routine aggressive vessel preparation and scaffold optimization however may contribute to a higher risk of vessel perforation. The case emphasises the importance of accurate sizing of the vessel with intracoronary imaging and demonstrates the value of newer generation covered stents with single-layer design and slimmer crossing profile producing improved deliverability and procedural success.

Intravascular lithotripsy for the treatment of severely calcified carotid lesion: An early single center experience

Although endovascular carotid treatment became more efficient and prevalent, severely calcified carotid lesions remain one of the most challenging lesions and a strong predictor of complications for both endovascular and surgical treatment. We sought to evaluate the effectiveness and safety of intravascular lithotripsy (IVL) using Shockwave balloon device to treat severely calcified carotid lesions. We enrolled five patients with symptomatic severely calcified carotid lesions who were selected for endovascular treatment using IVL. Final stent expansion and calcium load plaque were evaluated using angiographic, ultrasound and intravascular imaging. A total of 5 patients were included in our study. The mean age was 79.6 years, all patients had at least one cardiovascular risk factor. Two patients had bilateral carotid lesions and three had concomitant coronary lesions. All procedures were done through a femoral access and cerebral protection device was used in all cases. Balloon pre-dilatation was performed in all cases with a small coronary balloon before crossing the lesion with the 5 × 60 mm Shockwave balloon. Four cycles of 30 pulses were used in 4 patients and five cycles in one patient. Post dilatation was performed with good balloon expansion in all cases. Good stent expansion was obtained in all cases. Angiographic and vascular ultrasound results showed successful debulking and calcified plaque disrupt. Intravascular imaging (2/5 patients) confirmed calcium disrupt and good stent apposition. There were no procedural complications. Post-procedural cerebral CT showed no stroke for all patients. Our early experience showed that IVL for the treatment of heavily calcified carotid lesions is feasible and safe following a rigorous technique and a good patient selection.

698 Acute coronary syndrome in neoatherosclerosis with major stent malapposition and OCT-guided PCI

AimsDue to its bidimensional nature, angiography is not always sufficient to accurately define coronary lesions, in particular when they are ambiguous or indeterminate. Intracoronary imaging, such as intravascular ultrasound or optical coherence tomography (OCT), is often useful in these cases to better characterize the ambiguous angiographic images, to identify the culprit lesion during acute coronary syndrome (ACS) and to guide percutaneous coronary intervention (PCI).Methods and resultsWe report a case of a 61-year-old male with multiple cardiovascular risk factors and a previous ST-segment elevation myocardial infarction treated by PCI of the right coronary artery (RCA) about 7 years before, wo was admitted to our emergency department after acute onset chest pain. At the time of admission, his ECG was normal and cardiac troponin was below the upper reference limit of normality with positive molecular SARS-CoV-2 diagnostic test. Echocardiogram disclosed a mild left ventricular dysfunction with inferior wall hypokinesia. Coronary angiography showed a moderate in-stent restenosis at mid RCA and a hazy, undetermined image at the proximal edge of the previously implanted stent. Left coronary artery angiography showed only diffuse atherosclerotic disease without significant stenoses and a myocardial bridge at the mid tract of left anterior descending artery. OCT pullback of RCA to better characterize the undetermined lesions shown by angiography. OCT revealed significant neointima hyperplasia and a focal area of neoatherosclerosis with unstable features (fissure/microthrombi) at mid RCA. Severe stent strut malapposition embedded neointimal hyperplasia was observed at the proximal stent edge, resulting in ‘dual’ lumen appearance. The two lesions were treated with a single 3.5/48 mm everolimus-eluting stent (stent-in-stent), which was post-dilated with a 3.5/20 mm non-compliant balloon (18 atm) in the mid-to-distal segments, and 4.5/15 mm (16 atm) and 5.0/8 mm (14 atm) semi-compliant balloons in the proximal stent segment. Post-PCI OCT imaging confirmed good stent expansion and apposition. Our case demonstrates the utility of OCT in clarifying the aetiology of ambiguous angiographic lesions and as a guide for PCI. Indeed, the ‘hazy’ appearance on the angiograms corresponded to the major stent malapposition covered by neointima disclosed by OCT as a ‘dual-lumen’. Of note, OCT allowed to confirm the correct guidewire position in the ‘true’ lumen preventing a crush of the previously implanted stent. OCT was also useful as a diagnostic modality for the identification and characterization of the mechanism underlying the ACS (neoatherosclerosis instability).ConclusionsDue to its unprecedented spatial resolution, OCT enables an ‘optical biopsy’ of the coronary artery wall and intrastent tissue. Therefore, OCT imaging should be considered when lesions are ambiguous or indetermined by coronary angiography to guide the diagnosis and treatments of ACS patients. OCT imaging is also useful to guide stenting and to optimize PCI result, and its impact on clinical outcome is under investigation in large randomized clinical trials.

736 Hazy spots: through the eye of optical coherence tomography

Abstract Aims Acute stent thrombosis after coronary artery stent placement is a rare but serious complication in percutaneous coronary intervention (PCI). Stenting culprit lesions in acute coronary syndrome (ACS) has higher risk of acute stent thrombosis than stable coronary artery disease, and many local and systemic factors may contribute to increase this risk. Tissue protrusion (TP), and in particular, plaque prolapse after PCI can play a role in acute stent thrombosis, and intra-vessel imaging is the principal instrument to identify such underlying lumen alteration after stent implantation, and guide intervention. Methods and results We report the case of a 54-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, obesity and no other relevant comorbidities in remote history, who underwent a coronary angiography for an unstable angina. A long, calcific sub-occlusion of the left anterior descending artery (LAD), which involved LAD-first diagonal branch (D1) bifurcation (Medina 1.1.1) and LAD-D2 bifurcation (Medina 1.1.0) was found. After deployment of two overlapping drug-eluting stents (DES), (ULTIMASTER TANSEI 3.0 × 38 mm and 3.0 × 21 mm) and struts apposition optimization with sequence of proximal optimization technique (POT) on D1 and D2, and a kissing balloon technique (KS) on LAD-D2 bifurcation, a ‘hazy’ in-stent image was detected right after the LAD-D2 bifurcation, suggesting an acute in-stent thrombosis, in absence of flow alteration (TIMI 3), symptoms or ECG modifications. Multiple thrombus-aspiration were made and resulted in abundant thrombus removal and improvement in the angiographic image, with persistent valid flow on every three vessels (TIMI 3). After 5 days of triple anticoagulant therapy with ticagrelor, cardioaspirin and UFH infusion, he underwent a new coronary angiography control. A similar ‘hazy’ image was detected right after LAD-D2 bifurcation within the LAD. An optical coherence tomography (OCT) pullback was made to assess the nature of the angiographic finding. OCT showed good struts apposition in almost every cross-sectional images, but an evident TP was detected right on the angiographic hazy spot. OCT allowed to evaluate the lipid-richness of the stented plaque and the nature of the TP, which was mixed with evident both white and red thrombus apposition (minimum luminal area measured 4.5 mm2). OCT guided a new PCI, with a stent-in-stent implantation on LAD. TP was absent on the post-PCI OCT run. Conclusions In this report, we showed the usefulness of OCT in revealing a potential high risk thrombogenic source. OCT not only characterized something that angiography alone couldn’t, but suggested the etiology of the amount of thrombus removed by the vessel during the first PCI. Indeed, despite an optimized cycle of anticoagulant therapy, OCT still revealed several mixed thrombus apposition on the TP, and this suggested its role in the acute stent thrombosis. OCT guided the choice to appose a new stent-in-stent to solve a potential thrombogenic source.

Comparison of 6-month vascular healing response after bioresorbable polymer versus durable polymer drug-eluting stent implantation in patients with acute coronary syndromes: A randomized serial optical coherence tomography study.

ObjectivesThis study was conducted to use optical coherence tomography (OCT) to compare vascular healing between bioresorbable polymer (BP) and durable polymer (DP) everolimus‐eluting stents (EES) in patients with acute coronary syndromes (ACS).BackgroundWhether BP‐EES induce better vascular healing compared to contemporary DP‐EES remains controversial, especially for ACS.MethodsIn this prospective, randomized, non‐inferiority trial, we used OCT to compare 6‐month vascular healing in patients with ACS randomized to BP versus DP‐EES: percent strut coverage (primary endpoint, non‐inferiority margin of 2.0%) and neointimal thickness and percent neointimal hyperplasia (NIH) volume. As an exploratory analysis, morphological factors related to the endpoints and the effect of underlying lipidic plaque on stent healing were evaluated.ResultsA total of 104 patients with ACS were randomly assigned to BP‐EES (n = 52) versus DP‐EES (n = 52). Of these, 86 patients (40 BP‐EES and 46 DP‐EES) were included in the final OCT analyses. Six‐month percent strut coverage of BP‐EES (83.6 ± 11.4%) was not non‐inferior compared to those of DP‐EES (81.6 ± 13.9%), difference 2.0% (lower 95% confidence interval‐2.6%), p non‐inferiority = 0.07. There were no differences in neointimal thickness 70.0 ± 33.9 μm versus 67.2 ± 33.9 μm, p = 0.71; and percent NIH volume 7.5 ± 4.7% versus 7.3 ± 5.3%, p = 0.85. By multivariable linear regression analysis, stent type was not associated with percent strut coverage or percent NIH volume; however, percent baseline embedded struts or stent expansion was positively associated with percent NIH volume. Greater NIH volume was observed in lipidic compared with non‐lipidic segments (8.7 ± 5.6% vs. 6.1 ± 5.2%, p = 0.005).ConclusionsSix‐month strut coverage of BP‐EES was not non‐inferior compared to those of DP‐EES in ACS patients. Good stent apposition and expansion were independently associated with better vascular healing.

Transient Neurovascular Interface for Minimally Invasive Neural Recording and Stimulation

AbstractNeural interfaces are used to mitigate the burden of traumatic injuries, neurodegenerative diseases, and mental disorders. However, the transient or permanent placement of an interface in close contact with the neural tissue requires invasive surgery, potentially entailing both short‐ and long‐term complications. To tackle this problem, a transient neurovascular interface for neural recording and stimulation is developed. This endovascular array has been fabricated with facile molding techniques using solely polymeric materials. In vitro experiments have shown promising electrochemical performance for both recording and stimulation, together with a lack of cytotoxicity in cultured cells. The device is compatible with standard endovascular catheters and, once deployed, provide good apposition to a cylindrical structure mimicking a blood vessel. The advantage of this device is twofold. On the one hand, the exploitation of the cerebrovascular system as an access route to the neural tissue avoids invasive surgeries. On the other hand, a transient device may reduce the inflammatory reaction and avoid additional surgeries for removal or replacement. This neurovascular interface combines the benefits of both transient bioelectronics and stent technology in a single device to broaden the range of applications of neural interfaces from neurological diseases and mental disorders to bioelectronics medicine.

The formation mechanism of acute dissection of blood blister-like aneurysm and its implication of endovascular treatment

BackgroundAcute mural dissection of the anterior wall of the internal carotid artery which may contribute to the development of blood blister-like aneurysms (BBLAs) was postulated, and stenting or flow diversion treatment across the soi-disant aneurysm was reported in this study.MethodsFrom December 2016 to December 2018, 8 patients presenting with subarachnoid hemorrhage (SAH) due to BBLA were subjected to endovascular treatment with stent-assisted coiling. Clinical outcomes were evaluated using a clinical outcome score scale.ResultsBased on angiograms, pathologic change involving the supraclinoid segments of the internal carotid artery (ICA) adjacent to BBLA was found in all patients. This pathologic change meant a focal dissection of the supraclinoid segment of the ICA which constituted the pathogenesis of BBLAs. Closed-cell, open-cell, and braided stents were used in 1, 1, and 6 patients, respectively. Complete obliteration was achieved following endovascular treatment among all 8 patients harboring BBLA. One re-bleeding successive to a closed-cell stent across the aneurysmal neck was observed. Follow-up angiograms revealed stable complete exclusion of all BBLAs from the parent vessel at 3 to 8 months. All patients had a favorable clinical outcome score of 0–1.ConclusionsAcute dissection of a focal point of the intracranial vessels underlies the development of BBLAs. Open-cell and braided-cell stent-assisted coiling may constitute appropriate treatment due to good apposition against the vascular walls. Adjunctive coils may facilitate immediate complete occlusion of BBLAs.

Clinical evaluation of minimally invasive plate osteosynthesis in tibial and metatarsal fracture repair in goats

In this study Minimally Invasive Plate Osteosynthesis (MIPO) technique using Locking Compression Plates (LCP) was employed in the stabilization of 2 tibial and 4 metatarsal fractures in goats. Immediate postoperative radiographs revealed good alignment and apposition of the fracture fragments in all the goats. All the goats showed partial weight bearing from the 1st post-operative day. Full weight bearing was observed between 7th to 30th post-operative days with a mean of 13.6 ±4.11 days. Postoperative radiographs on 60thday revealed complete radiological union in five out of six goats. The MIPO techniue using LCPs in tibial and metatarsal fracture repair, showed remarkable improvement with normal limb function and maintaining good implant stability throughout the treatment period without any complications.

Histopathology of Microvascular Anastomosis—Comparison of Patent and Nonpatent Anastomosis: An Experimental Study

Abstract Objective To compare the histopathology of patent and nonpatent microvascular anastomosis using rat femoral artery end-to-end anastomosis model. Materials and Methods In 15 Sprague–Dawley rats, end-to-end anastomosis was performed on the right femoral artery. The classical method was used in four cases and one-way up method in 11 cases. The animals were sacrificed after 2 weeks and the anastomosis was subjected to histopathology. The pathological changes in patent and nonpatent cases were compared. Results The immediate patency rate and delayed patency (after 2 weeks) rate was 86.7% and 66.7%, respectively. The mean follow-up was 3 months. At sacrifice, 5/15 anastomosis were not patent. Marked subintimal thickening was noted in ⅘ (80%) of the nonpatent group, which was absent in the patent group. Severe loss or fibrosis of tunica media and marked adventitial inflammation were noted in all nonpatent cases (5/5, 100%). As much as ⅘ of the nonpatent cases had poor or indeterminate apposition; in contrast, good apposition was seen in 6/10 (60%) of the patent group. The mean clamp time and mean suturing time were significantly longer in the nonpatent group (69.2 minutes and 53.8 minutes, respectively) as compared with the patent group (48.8 minutes and 31.8 minutes, respectively). A single case that was initially nonpatent was found to have recanalized at 6 months. Conclusion Minimal intimal injury and reaction, minimal thinning of tunica media, mild-to-moderate adventitial changes, good apposition, and equidistant sutures were associated with a successful microvascular anastomosis. Short duration of vessel clamping time and suturing comes with experience and dedicated practice in a skills laboratory.

Management of fracture both bones forearm with plating/medullary nailing: A comparative study

Introduction: Fracture of both bones forearm in adults occupy a large field of modern traumatology. Maintenance of radial bow, regaining length, good apposition and alignment without malrotation is essential to restore good range of motion of forearm. Aim: to compare functional and radiographic results of plate osteosynthesis to IM nailing in treatment of diaphyseal forearm fracture in adults.Method: A prospective study comprising of 32 patients. 16 patients treated with open reduction and internal fixation using 3.5 mm DCP and 16 patients by IM nailing using 316L SS Talwarkar square nailing by closed or mini open reduction.Result: Mean age of patients was 36.4 years (range 20 to 58 years), Maximum number of patients in this study are middle age group and mean age is 48 years most fractures were of type 22A3 as per AO/OTA classification. Average operative time was 83 minutes and 64 minutes in plating and nailing respectively. Out of 16 patients in each group in our present study we encountered complications like restriction of movements at elbow in 5 (31.25%) plating cases and 3 (18.75%) nailing cases; restriction of movements at wrist in 1(6.25%) plating case and 0 nailing cases and loss of supination or pronation or both were observed in 6 (37.5%) each in nailing and plating cases. Localised bursitis were observed in 2 (12.5) nailing cases alone & wound healing and superficial infections were observed in 2 (6.25%) plating cases alone. We had 1 (6.25%) Non-Union is case of Plating and all fractures united in cases operated with nailing. Out of the 32 sample cases, taking into the account of our functional grading we have observed that about 9 (56.25%) cases have been graded with excellent outcome in plating group and 10 (62.5%) in nailing group, similarly about 5 (31.25%) have been graded with good outcome in plating and 3 (18.75%) in nailing group respectively and satisfactory outcome in 1 (6.25%) in plating group and 3 (18.75%) in nailing group. This has been only 1 (6.25%) case which had a Poor outcome in plating group in our study.Conclusion: We conclude that open reduction and internal fixation with dynamic compression plating is gold standard for treating diaphyseal forearm fracture in adults as it provides rigid fixation, restores forearm stability earlier and has negligible complications.

A Simple and Safe Technique of Olecranon Osteotomy.

Chevron osteotomy of the olecranon during the posterior approach of the elbow joint has become universally common. We modified the technique to see if it is better than the standard technique to perform, reconstruct and finally evaluate the results. A prospective study was done in 17 cases of comminuted distal humeral intercondylar fractures. A modified osteotomy was done using a Gigli saw instead of a power saw. The indications remained the same. After fixing the distal humerus fracture, the olecranon fragment was stabilised with tension band wire technique. The post-operative management was similar to that of standard AO technique. There were no per-operative difficulties with the new technique. The osteotomy was easy to do with no risk of damage to the distal humeral cartilage, as the direction of the osteotomy was away from the joint. Gigli saw produced congruent antero-posterior chevron surfaces which helped the fragment to sit well in its trough with good bony apposition. Stable reduction of the olecranon facilitated easy fixation. In this series, all osteotomies united well. There were no osteotomy-related complications. Two cases had prominent wires which were removed after the union of the osteotomy. We feel that this osteotomy is easy to perform, safe and takes less time than the standard technique, though a comparative study in a large number of cases by different surgeons needs to confirm the benefits.

SAFETY OF ADEQUATE PREDILATATION IN CAROTID ANGIOPLASTY

Objective: In carotid angioplasty a lot of interventionists avoid predilatation or perform predilatation using smaller diameter balloons to avoid distal embolization. The objective of our study was to determine the procedural safety and complications of predilatation of carotid artery using adequate diameter balloon in patients undergoing angioplasty. Methodology: Symptomatic patients with greater than 50% common carotid artery (CCA) or internal carotid artery (ICA) stenosis, asymptomatic patients with 80% or more carotid stenosis, asymptomatic patients planned for Coronary Artery Bypass Graft Surgery (CABG) with bilateral severe carotid stenosis (70-99%) or a unilateral severe carotid stenosis with a contralateral occlusion undergoing CABG, were selected for carotid artery angioplasty. Cerebral angiogram was performed before and after carotid intervention. Results: A total of 25 patients were included in this study. Adequate diameter balloon used for predilatation before stenting in all cases. Post dilatation was required in 6 (24%) patients. Distal embolic protection device was used in all patients. No complication was seen after predilatation in any case. No mortality or neurological deficit was seen in the study. Conclusion: This study shows that proper predilatation with adequate diameter balloon, sized according to diameter of internal carotid artery, before carotid stent implantation is an effective and safe procedure. We believe that this leads to good stent expansion and full apposition with better long term outcomes. Moreover it is now important to adequately predilate carotid arteries, for proper sizing of carotid stents with close cell design, to avoid unnecessary longitudinal stent lengthening due to inadequately prepared carotid bed.

Bench-Top Comparison of Three Different Types of Stents Used for Treatment of Intracranial Atherosclerotic Stenosis.

PurposeFour key bench-top tests, including trackability, conformability, wall-apposition, and bending stiffness, were performed to understand the mechanical characteristics in 3 different types of stents applicable for treatment of intracranial atherosclerotic stenosis: Balloon-expandable D+Storm, Pro-Kinetic Energy, and self-expandable Wingspan stents.Materials and MethodsTrackability was assessed by measuring the tracking forces of each stent with its delivery systems. Conformability and wall apposition were quantified and analyzed using curved vessel models. A 3-point bending test was employed to evaluate bending stiffness.ResultsD+Storm showed the lowest tracking forces while the conformability of the Wingspan stent was superior to that of the tested stents. Pro-Kinetic Energy and D+Storm had better wall apposition in curved vessels than the Wingspan stent. Bending stiffness of the Wingspan stent was notably lower, whereas no significant differences were found between D+Storm and Energy. Pro-Kinetic Energy and D+Storm not only indicated lower gap ratios between the struts and the vessel wall but also maintained good wall apposition even in the curved model.ConclusionThese bench-top measurements may provide clinicians with useful information in regard to selecting suitable stents for treatment of intracranial atherosclerotic stenosis.

OUTCOME OF INTRAMEDULLARY NAILING OF PROXIMAL THIRD RADIUS FRACTURES IN ADULTS USING TALWALKAR SQUARE NAIL.

Background : In the management of Proximal Third Radius Fractures in Adults it is very important to take care of posterior Interosseous nerve, regain the length of the bones, maintaining the radial bow, good apposition, intact fracture haematoma and alignment without any malrotation, early mobilization of wrist and elbow to get good results. Intra medullary nailing of these fractures can be considered as a good alternative method. The aim of the study was to evaluate results of intramedullary nailing using Talwalkar square nails in adult forearm fractures.
 Method: It’s a prospective multicentric study where we treated 92 adult patients with Proximal Third Radius Fractures, isolated or along with ulna fracture with over the period of four years may 2013 to may 2018 with a follow up for one years.
 Result: The average time to complete union was 12.1 (SD +3.2) weeks with cast support for a mean of 8.5 weeks. Union was achieved in 88 out of 92 patients. Using the Grace and Eversmann rating system, 57 patients were excellent, 24 were good, and 7 had an acceptable result. Four patients had non-unions, 2 for the radius and two for the ulna. There were three cases of superficial infection, two had olecranon bursitis. Complication rates associated with the use of square nails were lower compared to plate osteosynthesis and locked intramedullary nails. To control rotation postoperatively, there is a need for application of an above-elbow cast after nailing. There were no incidences of Posterior Interrosseous Nerve injury
 Conclusion: Use of Talwalkar’s design of the square nail has resulted in and continues to result in predictable and good results. Complication rates are lower as compared to plate osteosynthesis, although application of above-elbow cast after nailing is a downside of the procedure. The square nail still has a future in repair of forearm fractures considering its complications rates, cost and acceptable results.
 Keywords: Proximal Radius fractures, square nail, Talwalkar Nail, closed intramedullary nailing, radius-ulna nailing

Management of Post-DALK Recipient Posterior Stromal Scarring: A Novel Approach.

Management of recipient posterior stromal scarring following deep anterior lamellar keratoplasty (DALK) by a novel approach. A side port knife bent at the tip is used to make a linear incision in the host posterior stroma. Plane between host posterior stroma and DALK tissue is separated using a reverse sinskey hook and multiple radial incisions are made using microvitroretinal scissors. The recipient posterior stromal wedges are removed using 20G vitrector with a cut rate of 800 cuts/min. A Descemet stripping endothelial keratoplasty lenticule is inserted into the anterior chamber and apposed to the posterior surface of DALK tissue using air tamponade. This technique was used in 10 patients who showed clearing of the scarring after the surgery with good apposition of the donor graft to the previous DALK tissue. Conclusion: This is a sutureless, relatively simple, inexpensive, and effective novel surgical technique that avoids complications of open sky procedure and can be replicated in any ophthalmologic operation theatre setup.

Treatment of prolapsed gland and cartilage deformity of the nictitating membrane with pocket technique and chondrectomy alone, or combined with a wedge conjunctivectomy: 132 dogs (1998-2018).

To evaluate the results obtained using Morgan pocket technique and chondrectomy (MPTC) alone, or combined with a wedge conjunctivectomy (MPTC+WC) for the treatment of prolapsed gland associated with cartilage deformity of the nictitating membrane (PGCD) in dogs. Medical records of dogs diagnosed with PGCD that received a MPTC or MPTC+WC were reviewed between 1998 and 2018. Success rate was defined by lack of recurrence of the prolapsed gland with a minimum of 6months follow-up. Histological examination of the excised cartilage was performed in 13 eyes. A total of 132 dogs (181 eyes) met the inclusion criteria. Median follow-up time was 25months (range, 6-166months). MPTC was used in 131 eyes with 91.6% success rate. MPTC+WC was used in 50 eyes with 100% success rate. Postoperative complications occurred in 6.9% and 4%, respectively, for MPTC and MPTC+WC, including lacrimal cysts (8 eyes) or corneal erosion (3 eyes). Recurrence and complications rates were significantly lower using MPTC+WC compared with MPTC in the giant breed dogs (P=.019 and P=.002, respectively), but not in the overall study population (P=.328 and P=.290, respectively). Histological cartilage anomalies were noted in 2/13 specimens from chronic PGCD. MPTC+WC offers a good therapeutic option for giant breed dogs with PGCD. The combined technique provides a good apposition and mobility of the nictitating membrane onto the ocular surface and potentially reduces the risk of recurrence in these giant canine breeds.

AMBULATORY PLEURODESIS: SUCCESSFUL USE OF TALC WITH INDWELLING PLEURAL CATHETER FOR MANAGEMENT OF BILATERAL MALIGNANT PLEURAL EFFUSIONS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Malignant pleural effusions affect more than 750,000 patients each year in Europe and the United States and account for greater than 125,000 hospitalizations and have an estimated cost of $5 billion per year1,2. Treatment for malignant pleural effusions with expandable lung would favor treatment with talc pleurodesis and often requires days of inpatient hospitalization for management and observation3. Placement of indwelling pleural catheters (IPCs) can be used as successful alternative for management of symptoms in an ambulatory setting3,4. Additionally, administration of talc through an IPC shows increased probability of pleurodesis4. We present a patient with bilateral malignant pleural effusions with successful bilateral pleurodesis using talc instilled through bilateral IPCs. CASE PRESENTATION: A 72-year-old man with a past medical history significant for metastatic melanoma presented to the ED with complaints of progressive dyspnea at rest. Imaging revealed large bilateral pleural effusions with symptomatic improvement with therapeutic thoracentesis. Initial studies were consistent with exudative effusion with negative cytology and patient was discharged with follow-up in Pulmonary Clinic. He underwent repeat large-volume thoracentesis with repeat cytology showing metastatic melanoma. Given rapidly re-accumulating fluid and symptoms, a left IPC was placed with significant improvement and a right IPC was placed 2 weeks later with continued improvement and decreased effusions on repeat U/S. At this time, further management with talc pleurodesis was discussed to ideally eliminate the need of IPCs and enhance the patient’s quality of life. Talc was instilled per IPC plus protocol4 with subsequent ultrasound monitoring with <25 cc of output daily. Given good apposition, the left IPC was removed and 2 weeks later, talc was administered to the right IPC with similar results on ultrasound with upcoming removal of right IPC given continued good apposition and decreased drainage. DISCUSSION: We demonstrate a validated alternative treatment strategy in a patient with bilateral malignant pleural effusions. This presents a plausible alternative to patients to decrease hospital days and expenses, while improving quality of life and allowing for pleurodesis in an outpatient setting. We show success using bilateral IPCs with sequential talc pleurodesis and removal of IPCs. No hospitalizations were made during this time period and the patient tolerated all procedures well. CONCLUSIONS: Given continued advancement in techniques, we continue to show patient-centered care in a challenging population with an outpatient centered treatment approach and use of U/S imaging for clinical management. Reference #1: 1. Marel M, Zrustova M, et al. The incidence of pleural effusion in a well-defined region: epidemiology study in Central Bohemia. Chest 1993; 104:1486-9. Reference #2: 2. Taghizadeh N, Fortin M, Tremblay A. US hospitalizations for malignant pleural effusions: data from the 2012 National Inpatient Sample. Chest 2017;151:845–854. Reference #3: 3. Feller-Kopman D, Reddy C, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guidelines. Am J Respir Crit Care Med. 2018 Oct 1; 198(7):839-849. 4. Bhatnagar R, Keenan E, et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med. 2018 Apr 5;378(14):1313-1322. DISCLOSURES: No relevant relationships by Michael Gonzales, source=Web Response No relevant relationships by Tyson Sjulin, source=Web Response No relevant relationships by John Untisz, source=Web Response

Trochanteric entry VS piriformis entry in case of antegrade nailing of femoral shaft fracture treatment: A prospective randomised comparative study

Background: Intramedullary nailing is the best modality for femoral shaft fractures as it is biological fixation with good apposition with minimal tissue damage and fxation is bio mechanically superior to plates and fixators with immediate rehabilitation and fewer complications. The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. Since the study by Ricci et al, there have been a number of randomized, controlled trials (RCTs) and cohort studies comparing the efficacy of the 2 entry points on various patient-and procedure-related outcomes. As per our knowledge, there has been very less systematic review of the literature on optimal entry point during antegrade nailing of femoral shaft fracture. Aims and ObjectivesAims: To compare the operative and fluoroscopic time required for IM nail fixation, time taken for taking entry, the amount of blood loss, and other complication in the form of iatrogenic neck femur fracture in surgery of femoral shaft fractures using the GT (greater trochanter) versus PF (Pyriformis fossa) entry point. A secondary objective was to determine whether there were any differences in complications (delayed and non union), fracture alignment and healing and functional outcomes in the form of thorensen score, and HHS (harris hip score) between the 2 entry points. Materials and Methods: The present pilot project was conducted in a time span of 2 year and 4 months. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 30 (n = 30).

Visualization of stent apposition after stent-assisted coiling of intracranial aneurysms using high resolution 3D fusion images acquired by C-arm CT

PurposeWe used an imaging technique based on 3-dimensional (3D) C-arm CT to assess the apposition of three types of stents after coiling of intracranial aneurysms.MethodsAll patients with intracranial aneurysms were...