High-pressure Balloon Dilatation Research Articles

Late In-Stent Restenosis of a Saphenous Vein Graft Treated with High-Pressure Balloon Dilatation and Drug Eluting Balloon Dilatation: Case Report

In the modern interventional treatment of degenerated saphenous vein grafts, the use of both bare metal and drug eluting stents have been described so far. Drug eluting balloons have been increasingly used in cases of in-stent restenosis and to some extent de novo stenosis of native coronary vessels. Based on pure logic approach, the use of drug eluting balloons in in-stent restenosis of the saphenous vein graft may be of great interest. Still, few high-quality data on this subject exist and no general recommendations can be made. This paper illustrates a typical case of a symptomatic late in-stent restenosis of a saphenous vein graft occurred 15 months after a percutaneous coronary intervention with implantation of two drug eluting stents. Intravascular ultrasound revealed a mixture of stent underexpansion and severe neointima. This was treated safely with a prolonged high pressure balloon dilatation followed by dilatation with a drug eluting balloon. The primary result was very good. During the intervention the patient remained asymptomatic and was discharged the next day on dual anti-platelet therapy. During the 10-month follow-up the patient remained asymptomatic. This case demonstrates the usefulness and clinical safety of drug eluting balloons in treating in-stent restenosis in the saphenous vein grafts.

Experimental study of the bilateral asymmetric single-rivet occluder device for transcatheter patent foramen ovale closure with reserved interatrial septal puncture area.

To evaluate a noval bilateral asymmetric single-rivet occluder with reserved interatrial septal puncture area for treating patent foramen ovale (PFO). The study established a pig model of patent foramen ovale (PFO) by puncturing the oval fossa and then performing high-pressure balloon dilation. A specially designed bilateral asymmetric occluder for the reserved interatrial septal puncture area was then. used to close the PFO through catheter-based intervention. The pigs were kept for 3 months before undergoing a second catheter-based intervention, involving interatrial septal puncture using a newly developed occluder in the reserved interatrial septal puncture area. During 6 months, the experimental pigs underwent assessment using digital subtraction angiography (DSA), echocardiography, and histological evaluation. A patent foramen ovale (PFO) model was successfully established in 6 pigs using the puncture atrial septum high-pressure balloon dilation method. The diameter of the unclosed PFO was measured (3.56 ± 0.25 mm). Using the newly developed occluder device, all 6 pigs with unclosed PFO underwent successful catheter-based closure surgeries, with intraoperative and postoperative transesophageal echocardiography showing excellent device positioning and complete closure without residual shunting. After 3 months of implantation, the catheter-based interatrial septal puncture was performed through the reserved interatrial septal puncture area, and all procedures were successful. Immediately following euthanasia, a histological examination revealed intact and undamaged occluder devices with visible puncture holes in the reserved interatrial septal puncture area. No fracture of the nitinol wire was observed, and the surface of the occluder device showed coverage of endothelial and connective tissues. Utilizing a bilateral asymmetric single-rivet occluder device implanted through the reserved interatrial septal puncture area has proven effective in closing PFO. After implantation, the occluder device allows subsequent interatrial septal puncture procedures through the reserved area. The novel occluder device demonstrated excellent closure performance, biocompatibility, and puncturability in the experiment. This indicates the feasibility of conducting further catheter-based interventions on the interatrial septum.

Results of primary obstructive megaureter treatment using high-pressure balloon dilatation of ureterovesical junction in children

Aim. To evaluate the age dependence of efficacy and safety in high-pressure balloon dilatation (HPBD) for primary obstructive megaureter (POM) in children under 2 years.
 Materials and methods. From 2020 to 2022, we performed a single-center, unblinded study, with a total of 200 children, treated with HPBD for POM: 117 boys and 83 girls. Study included patients from 1 month to 2 years. The follow-up period was 1 year.
 Results. In this series the overall treatment effectiveness was 92.5%. In 15 cases treatment was not effective and these children proceeded with ureteral reimplantation. We didn’t achieve positive treatment results in children older than 15 months and our statistical model was not significant for failed cases. Treatment failure we presumed to be due to hard to dilate severe stenosis and extreme length of the stenotic area.
 Conclusion. In our study we found HPBD of uretero-vesical junction to be safe and effective method for treatment of primary obstructive megaureter in young children. The overall success rate was 92.5%. We recommend considering HPBD as the first line treatment for POM in young children. In failure cases we suggest to perform ureteral reimplantation.

Endoscopic treatment of primary obstructive megaureter with high pressure balloon dilation in infants

Ureteral reimplantation of the dilated ureter in infants is challenging; however, some patients with primary obstructive megaureter (POM) in this age group require intervention due to clinical or radiological progression. We sought to determine if high pressure balloon dilation (HPBD) can serve as a definitive treatment for POM in children under one year of age, or as a temporizing measure until later reimplantation. All patients from a single institution who underwent HPBD between October 2009 and May 2022 were retrospectively reviewed. Patients were excluded if older than 12 months or diagnosed with neurogenic bladder, posterior urethral valves, or obstructed refluxing megaureter. Patients with prior surgical intervention at the ureterovesical junction were excluded. Indications for surgery included progressive hydroureteronephrosis or urinary tract infection (UTI). Balloon dilation was performed via cystoscopy with fluoroscopic guidance, followed by placement of two temporary ureteral stents. Primary outcomes were improvement or resolution of megaureter and rates of subsequent reimplantation. Secondary outcomes included total number of anesthetics and postoperative UTIs. Fifteen infants with median age of 7.6 months (IQR3.8-9.7) underwent HPBD. Twelve (80%) patients were detected prenatally and 3 (20%) aftera UTI. Indication for surgery was progressivehydroureteronephrosis in 10 patients (67%) and UTI in five (33%). All had SFU grade 3 or 4 hydronephrosis on preoperative ultrasound and median distal ureteral diameter was 13mm. Median follow up was 2.9 years. Twelve (80%) succeeded with endoscopic treatment: 7 patients had an undetectable distal ureter on ultrasound at last follow-up, 5 were improved with median distal ureteral diameter of 7mm. Three patients (20%) required ureteral reimplantation due to progressive dilation, all with grade 4 hydronephrosis and distal ureteral diameters were 11, 15, and 21mm. Six patients (40%) required two anesthetics to complete endoscopic treatment. Among those, 4 patients required initial stent placement for passive dilation followed by a second anesthetic for HPBD weeks later. Two patients underwent repeat HPBD following postoperative proximal migration of the ureteral stents. All 15 patients had an additional anesthetic for removal of stents. Five patients (33%) were treated for a symptomatic UTI (4 febrile, 1 afebrile) with the stents indwelling but there were no UTIs in the group following stent removal. Balloon dilation is a practical option for treatment of POM in infants, and in most cases (80%) avoids subsequent open surgery (over median 2.9 years of follow-up).

Percutaneous approach to residual pulmonary bifurcation stenosis in conotruncal diseases.

Residual stenosis after right ventricle outflow tract surgery represents a major issue to manage in the children and adult patient with conotruncal defects. Despite a detailed multimodality imaging, the anatomy of distal pulmonary trunk and pulmonary artery bifurcation may be challenging in these patients.The aim of this study was to analyse retrospectively the outcome of the percutaneous transcatheter treatment in children with post-surgical stenosis of pulmonary artery bifurcation.We enrolled 39 patients with a median age of 6.0 years. Standard high-pressure balloon dilation was attempted in 33 patients, effective in 5 of them. Pulmonary branch stenting was performed in 10 patients, effective in 6. A kissing balloon approach was chosen in 17 patients (6 after angioplasty or stenting failure), and this technique was effective in 16 cases. Finally, a bifurcation stenting was performed in 10 patients (second step in 9 cases), effective in all the cases. None of the patients approached by kissing balloon needed a bifurcation stenting.In conclusion, standard balloon angioplasty and standard stenting might be ineffective in post-surgical stenosis involving pulmonary artery bifurcation. In this population, kissing balloon or bifurcation stenting, followed by side branch de-jailing, may be more effective in relieving the gradient.

MP70-09 HIGH PRESSURE BALLOON DILATION FOR OBSTRUCTIVE MEGAURETER PATHOLOGIES IN THE PEDIATRIC PATIENT: STENT MIGRATIONS AND OTHER LESSONS LEARNED

You have accessJournal of UrologyCME1 Apr 2023MP70-09 HIGH PRESSURE BALLOON DILATION FOR OBSTRUCTIVE MEGAURETER PATHOLOGIES IN THE PEDIATRIC PATIENT: STENT MIGRATIONS AND OTHER LESSONS LEARNED Timothy Boswell, Carol Davis-Dao, Kai-Wen Chuang, Heidi Stephany, Elias Wehbi, and Antoine Khoury Timothy BoswellTimothy Boswell More articles by this author , Carol Davis-DaoCarol Davis-Dao More articles by this author , Kai-Wen ChuangKai-Wen Chuang More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , Elias WehbiElias Wehbi More articles by this author , and Antoine KhouryAntoine Khoury More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: High pressure balloon dilation (HPBD) is a treatment option for obstructive pathologies at the ureterovesical junction (UVJ). While it is less invasive than open reimplant, little has been described regarding technical factors or stent migrations which may pose challenges to its successful completion. METHODS: All patients from a single institution who underwent HPBD between 2009 and May 2022 were retrospectively reviewed. Those with obstructive pathologies at the UVJ included primary obstructive megaureter, obstructed refluxing megaureter, and obstructive megaureter secondary to neurogenic bladder or posterior urethral valves. Patients with prior treatment at the UVJ including reimplantation or endoscopic injection were excluded. Following HPBD, each patient had two indwelling ureteral stents placed. Success rates, technical factors, and stent migrations were analyzed. RESULTS: A total of 42 patients and 43 ureters were treated for obstructive pathologies at the UVJ. Median age was 14 months (IQR 7 – 89). Thirty four patients (81%) had primary obstructive megaureter (one bilateral), 4 (9%) had obstructed refluxing megaureter, and 4 (9%) had obstructive megaureter with underlying neurogenic bladder or posterior urethral valves. With a median follow-up of 2.4 years (IQR 1.7 – 3.8), 34 (79%) ureters were successfully managed endoscopically and did not require subsequent open surgery. Eight (19%) required reimplant and 1 (2%) diverting ureterostomy. Operative notes did not describe procedural difficulty in 19 (44%) cases; the remainder referenced narrow stenosis making cannulation difficult, and/or difficulty passing wires and stents up tortuous ureters. Four (10%) patients had intraoperative proximal stent migration, which was recognized permitting immediate repositioning of the stents. Five (12%) patients experienced postoperative stent migrations (3 of both stents, 2 of one stent). Ten (24%) patients required an additional anesthetic to complete HPBD after passive dilation by a stent (n=7) or repeat dilation due to double stent migration (n=3). All 3 patients who experienced postoperative migration of both stents required open surgery due to progressive hydroureteronephrosis. CONCLUSIONS: Approximately 80% of obstructive pathologies at the UVJ can be managed endoscopically with HPBD. Surgeons should be prepared to address the tight stenosis and tortuous megaureter that can pose a challenge to the endoscopic approach and may predispose to ureteral stent migration. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1007 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy Boswell More articles by this author Carol Davis-Dao More articles by this author Kai-Wen Chuang More articles by this author Heidi Stephany More articles by this author Elias Wehbi More articles by this author Antoine Khoury More articles by this author Expand All Advertisement PDF downloadLoading ...

High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review

ObjectiveWe aimed to evaluate the effectiveness and complication rates of endoscopic high-pressure balloon dilatation (HPBD) in treating primary obstructive megaureter (POM) in children based on current literature. Specifically, we wanted to clarify the evidence on the use of HPBD in children under one year of age.MethodsA systematic search of the literature was performed via several databases. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. The primary outcomes studied in this systematic review were the effectiveness of HBPD in relieving obstruction and reducing hydroureteronephrosis in children. The secondary outcome was to study the complication rate of endoscopic high-pressure balloon dilatation. Studies that reported one or both of these outcomes (n = 13) were considered eligible for inclusion in this review.ResultsHPBD significantly decreased both ureteral diameter (15.8 mm [range 2–30] to 8.0 mm [0–30], p = 0.00009) and anteroposterior diameter of renal pelvis (16.7 mm [0–46] to 9.7 mm [0–36], p = 0.00107). The success rate was 71% after one HPBD and 79% after two HPBD. The median follow-up time was 3.6 years (interquartile range 2.2–6.4 years). A complication rate of 33% was observed, but no Clavien–Dindo grade IV–V complications were reported. Postoperative infections and VUR were detected in 12% and 7.8% of cases, respectively. For children under one year of age, outcomes of HPBD seem to be similar to those in older children.ConclusionsThis study indicates that HPBD appears to be safe and can be used as the first-line treatment for symptomatic POM. Further comparative studies are needed addressing the effect of treatment in infants, and also long-term outcomes of the treatment. Due to the nature of POM, identifying those patients who will benefit from HPBD remains challenging.

ЭФФЕКТИВНОСТЬ БАЛЛОННОЙ ДИЛАТАЦИИ ВЫСОКОГО ДАВЛЕНИЯ ПРИ ПЕРВИЧНОМ ОБСТРУКТИВНОМ МЕГАУРЕТЕРЕ У ДЕТЕЙ РАННЕГО ВОЗРАСТА

The purpose of the research was to evaluate the efficacy of the high-pressure balloon dilatation (HPBD) of the vesicoureteral segment (VMS) as treatment of primary obstructive megaureter (POM) in pediatric patients aged 1 month to 2 years old and to identify the clear indications for its practical application. Materials and methods of the research: a single-center experimental uncontrolled open study was conducted in 2019 - 2022; 97 children with POM who underwent HPBP of the VMS: 47 boys and 50 girls. The study involved patients aged 1 month till 2 y/o. Patients underwent targeted retrograde pyelography and were assessed for the parameters of the zone of ureteral stenosis before and after the HPBP of the VMS: the length of the stenosis, its diameter and area. The follow-up period for the patients was 1 year. Results: the overall effectiveness of treatment was 92.8% as 7 ineffective cases were reported that required further reimplantation of the ureter. The most statistically significant predictors for the successful treatment were the length of the stenotic area of less than 1.7 mm, its diameter of more than 0.6 mm and the area of stenosis of less than 96.8%. Also, recovery was predicted if the difference in the diameter of the stenosis zone before and after the HPBP of the VMS was 2.4 mm, and the difference in the stenosis area before and after the HPBP of the VMS was above 49.8%. Conclusion: the HPBP of the VMS is an effective treatment for POM in infants. At the same time, the assessment of the obstruction zone during the HPBP is a necessary diagnostic procedure that serves as a reliable method for predicting the success of the treatment. Upon the receipt of parameters that cannot provide high probability of the positive result of treatment the authors suggest the ureter reimplantation.

Efficacy and safety of high-pressure balloon dilatation for primary obstructive megaureter in children: A systematic review

PurposeEndoscopic treatment with high-pressure balloon dilatation (HPBD) has been proposed as a feasible, safe and minimally invasive procedure for primary obstructive megaureter, but the level of evidence is still low. This systematic review aims to evaluate the efficacy and safety of HPBD and its long-term results in paediatric population.MethodsThe review was conducted following the PRISMA guidelines. Systematic research of available literature in the English language from 1995 until June 2022 was conducted through EMBASE, MEDLINE, Cochrane Library and NIH Registry of Clinical Trials. For each relevant study, information was gathered regarding the study design, the inclusion/exclusion criteria, the indications for treatment, the success rate and the complications.ResultsThe final set included 13 studies. Median age of the patients ranged from 4 months to 7 years (full range 15 days-15 years). The indications for HPBD varied in different studies, however most authors included patients with increasing dilation, obstructive patterns found at diuretic renogram scan, decreased renal function or symptoms. All the studies analysed reported a success rate ranging from 69 to 100% for the treatment of POM with HPBD. This approach may avoid surgery in up to 77% of cases and is thought to be a less invasive, definitive and safe treatment for this disorder. The complication rate ranged from 0 to 50% and it was mostly infectious or associated to the stent placement or both.ConclusionHPBD demonstrated to be safe for the treatment of POM in infants, with effective long-term results and can be a definitive treatment in a considerable subset of patients. Nevertheless, the overall level of evidence for HPBD is still low and further comparative studies or randomized clinical trials are needed.

In vivo study of a reserved atrial septal puncture area patent foramen ovale occluder.

After patent foramen ovale interventional closure, puncture of the interatrial septum through the occluder is difficult but sometimes needed for further interventional treatment. This paper presents findings from an in vivo experimental study of a reserved atrial septal puncture area patent foramen ovale occluder. A patent foramen ovale model was established in canines using trans-septal puncture of the fossa ovale and high-pressure balloon dilation. Then, patent foramen ovale closure was performed with a reserved atrial septal puncture area and all canines were raised for 3 months. Then, the occluder was crossed and left atrial angiography was performed on the septal area with the occluder. Finally, DSA angiography, echocardiography, and histology were used to evaluate the performance and feasibility of the reserved atrial septal puncture area. A patent foramen ovale model was successfully established in 10 canines using the atrial septal puncture method. The average diameter of the patent foramen ovale was 3.77 ±0.19 mm, and the patent foramen ovale was successfully closed in all canines using a reserved atrial septal puncture area. As assessed using transoesophageal echocardiography, the new occluder exhibited an ideal position and was occluded entirely without a residual shunt intraoperatively and postoperatively. A 100% success rate of atrial septum puncture was achieved across the new occluder. The occluders were completely endothelialised 3 months post-implantation. The reserved atrial septal puncture area was effective in patent foramen ovale closure and exhibited positive sealing performance and biological compatibility. Trans-septal puncture was feasible and effective after reserved atrial septal puncture area patent foramen ovale closure.

MP44-15 HIGH PRESSURE ENDOSCOPIC BALLOON DILATATION FOR TREATMENT OF URETEROVESICAL JUNCTION OBSTRUCTION IN CHILDREN

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-15 HIGH PRESSURE ENDOSCOPIC BALLOON DILATATION FOR TREATMENT OF URETEROVESICAL JUNCTION OBSTRUCTION IN CHILDREN Sergei Zorkin, and Dmitry Shakhnovskiy Sergei ZorkinSergei Zorkin More articles by this author , and Dmitry ShakhnovskiyDmitry Shakhnovskiy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Currently open ureteral reimplantation is considered to be the gold standard treatment for ureterovesical junction (UVJ) obstruction. The aim of this study was to assess long term effectiveness of high pressure endoscopic balloon dilatation for treatment of UVJ obstruction in children. METHODS: From 2015 to 2018 a total of 32 children with a median age of 10 months were treated with high-pressure balloon dilatation. Initial results were evaluated using ultrasonography (US), voiding cystourethrogram and MAG-3 renogram 6 months following the procedure. Then all patients were followed up with US examination annually for 3 years. Positive outcome we considered to be a decrease in pelvic and distal ureteral diameter and an improvement of drainage according to renogram. RESULTS: We observed no intraoperative complications. US pelvic diameter was decreased after balloon dilatation (delta, mm: -10,4±7,1. p<0.0001). MAG-3 renogram showed nonobstructive curve in all patients at 6 months follow up. Washout percentage showed an increase (delta, %: 25,3±13,5. p<0.0001). We observed also an increase in differential renal function after balloon dilatation (delta, %.: 4,3±1,5. p<0.0001). During a follow up period we found results of balloon dilatation to be stable according ultrasound pelvic and distal ureter diameter. CONCLUSIONS: Results of this study confirm that balloon dilatation proved its effectiveness for cases of UVJ obstruction, but further studies with bigger patient sample are needed to confirm long term positive results. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e798-e798 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sergei Zorkin More articles by this author Dmitry Shakhnovskiy More articles by this author Expand All Advertisement Loading ...

High-pressure balloon dilatation for the treatment of primary obstructive megaureter: is it the first line of treatment in children and infants?

To evaluate the efficacy of high-pressure balloon dilatation (HPBD) as treatment of primary obstructive megaureter (POM) in paediatric patients, we analysed the data of our institute from June 2018 to September 2019. 14 patients, aged 5 months to 5 years, with POM were treated with HPBD. All patients had a distal ureter dilatation greater than 7 mm associated with obstructive features on a mercaptoacetyl triglycine-3 diuretic renogram scan, and a voiding cystourethrogram without vesicoureteral reflux. HPBD was performed in 12 patients, whereas 2 patients (14%), aged 5 and 6 months, required open surgical treatment because of failure to pass the balloon catheter through the vesicoureteral junction. The procedure was performed with a 5 Fr balloon catheter for two cycles of 5 minutes each at 17 atm. A double-J stent and a urinary catheter were inserted at the end of procedure in all patients. No operative complications or symptoms or recurrence were recorded in our series. The patients were generally discharged 24 hours after surgery. All the patients showed an improvement on ultrasonography at the postoperative follow-up, with no evidence of obstruction. During the procedure a clear stenotic ring was identified in 10 of the 12 patients, which disappeared in all 10 cases after the HPBD technique. Based on our experience, HPBD may be considered the first-line surgical approach in the treatment of POM in children, avoiding bladder surgery in most cases.

Successful double-layer metal stents rotational ablation under 2-dimensional and 3-dimensional optical coherence tomography guidance: a case report

BackgroundStent ablation with rotational atherectomy has been considered a bail-out strategy for the treatment of severe stent underexpansion. Only a few reports have yet shown rotational ablation for double-layer metal struts.Case presentationWe present a case of 80-year-old female patient presented to our hospital because of worsening effort angina. Coronary angiography revealed severe in-stent restenosis in the proximal left anterior descending artery. Optical coherence tomography (OCT) examinations found that severe stenosis occurred at the overlap region with 2-layer underexpanded stents and circumferential calcification beneath them. Under the guidance of 2-dimensional (2D) and 3-dimensional (3D) OCT, we successfully performed percutaneous coronary intervention (PCI) of this lesion after adequate stent ablation, high-pressure balloon dilatation, and subsequent everolimus-eluting stent implantation. The patient recovered well uneventfully and discharged from hospital 7 days later. No restenosis occurred after 12 months.ConclusionsWe report a very rare case of in-stent restenosis due to double-layer underexpanded stents. The entire percutaneous coronary intervention procedure was performed step by step under the guidance of high-resolution OCT. Our findings highlight the specific value of 2D and 3D OCT guidance in double-layer stents rotational ablation.

High-pressure balloon dilatation in children: our results in 30 patients with POM and the implications of the cystoscopic evaluation.

Primary Obstructive Megaureter (POM) is a common cause of hydronephrosis in children with spontaneous resolution in most cases. High-Pressure Balloon Dilatation (HPBD) has been proposed as a minimally invasive procedure for POM correction in selected patients. The aim of the paper is to review our experience with HPBD in patients with POM. We performed a retrospective study in a single Centre collecting data on patients' demographics, diagnostic modalities, surgical details, results and follow-up. In particular, the endoscopic aspect of the orifice permitted the identification of 3 patterns: adynamic ureteral segment, stenotic ureteric ring and pseudoureterocelic orifice. We performed HPBD in 30 patients over 6 years. We had 23 patients with adynamic distal ureteral segment (type 1), 4 with stenotic ring (type 2) and 3 with ureterocelic orifice (type 3). In 3 patients (10%) the guidewire did not easily pass into the ureter requiring ureteral stenting or papillotomy. Post-operative course was uneventful. Five patients (3 pseudoureterocelic) required open surgery during follow-up. HPBD for the treatment of POM is a safe and feasible procedure and it can be a definitive treatment of POM. Complications are mainly due to double J stent and none of our patients had symptoms related to vescico-ureteral reflux. The aspect of the orifice, identified during cystoscopy, seems to correlate with the efficacy of the dilatation: type 1 and 2 are associated with good and excellent results respectively; type 3 do not permit dilatation in almost all cases requiring papillotomy. HPBD can be performed in selected patients of all paediatric ages as first therapeutic line. The presence of a pseudoureterocelic orifice or long stenosis might interfere with the ureteral stenting and seems associated with worse outcomes.

Single balloon dilation of symptomatic duodenal web: Long-term success

Abstract Duodenal webs in neonates and infants have been traditionally managed with open or laparoscopic surgery. Surgical management has been associated with high morbidity and mortality and prolonged length of stay. Other treatments include endoscopic resection of the web with cautery or laser energy. This modality carries a high risk of perforation. Endoscopic balloon dilatation has been recently reported with good clinical outcome. Most of the patients reported in the literature required serial balloon dilatations to achieve resolution of the symptoms. We report a 10-month-old infant with duodenal obstruction secondary to a congenital duodenal web. He was successfully managed with a single high-pressure balloon dilatation using an interventional radiology technique. He tolerated liquid diet on day 2 post procedure and was discharged home on day 3. He has remained asymptomatic after 4 years of follow-up.

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions

BackgroundCalcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure. PurposeThe study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT. Methods and resultsThirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ± 2.77 mm2) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis.When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ± 24°; Group B: 21 lesions, calcium arc 289 ± 53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ± 0.29 mm; group B: 1.31 ± 0.52 mm, p = 0.63). ConclusionsA standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.

In-stent restenosis and longitudinal stent deformation: a case report

BackgroundLongitudinal stent deformation (LSD) is an infrequent complication of percutaneous coronary intervention (PCI), and it may lead to catastrophic clinical outcomes. However, reports of cardiac adverse events associated with LSD are rare.Case presentationA 55-year-old man with chest pain was treated for a severe left anterior descending branch (LAD)-diagonal 1 (D1) bifurcation lesion by PCI with two stents in the proximal LAD. LSD occurred during the withdrawal of the trapped D1 wire. High-pressure balloon dilatation was performed in the deformed stent, and the end-angiographic appearance was acceptable, but no additional corrective measures were implemented. Ten months later, the patient represented with acute coronary syndrome. Severe in-stent restenosis (ISR) had suboccluded the proximal LAD, and optical coherence tomography (OCT) visualized multilayered stent struts protruding into the lumen at the compressed segment of the stent. Following complete apposition with balloon dilation, a drug-coated balloon (DCB) was used to avoid an additional permanent metallic layer. He remained angina free, and the angiographic result demonstrated no residual stenosis at the six-month follow-up. To our knowledge, this case demonstrates the first report of ISR triggered by LSD in patients treated with DCBs under the guidance of OCT.ConclusionsThe current report underscores the importance of awareness of LSD, and OCT seems to be the preferred modality to confirm complete apposition. If left without performing additional corrective measures, LSD may be associated with a risk of ISR. Complete apposition with balloon dilation followed by a DCB is a feasible treatment option.

Endoscopic balloon dilatation of primary obstructive megaureter: method standardization and predictive prognostic factors.

The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon dilatation (EHPBD) is indicated when symptoms, increasing dilatation and progressive renal damage are recorded, particularly in children younger than one year of age. We identified and described endoscopic prognostic factors predicting the success or failure of endoscopic dilatation. Thirty-eight patients (33 M;5 F) with POM from 2005-2018 were included. Diagnosis was based on US distal ureter dilatation (>7 mm), obstructive MAG-3 diuretic renogram and absence of vesicoureteral reflux (cystography). 24 patients were under 1 year of age. All patients underwent cystoscopy and high-pressure balloon dilatation with 3,5 Fr dilating balloon, after ascending pyelography. Median follow-up was of 6.5 years. We identified characteristics with poor prognosis: stenotic punctiform ureteral ostium and/or ostium located in a bladder diverticulum (9 pts) and stenotic tract longer than 1 cm (5 pts). The patients with a stenotic tract shorter than 1 cm (18 pts) were divided into two groups: <5 mm (5 pts) and between 5 and 10 mm (13 pts) showed a good response to dilatation. Endoscopic evaluation of ureteral ostium with pneumatic dilatation when possible is a useful diagnostic and therapeutic solution for POM treatment, especially under one year of age. EHPBD is effective in short stenotic tracts (<5 mm). It may also be repeated with good results in intermediate stenotic sections (5 mm-1 cm). According to our preliminary results, the procedure is more effective if performed earlier (3-7 months of life). Greater cohort and longer follow-up are needed to verify the stability of these results.

OPTIMIZATION OF SURGICAL TREATMENT OF PRIMARY OBSTRUCTIVE MEGAURETER IN YOUNG CHILDREN

Introduction. The primary obstructive megaureter in children of the first months and years of life does not require surgical treatment in most cases. But if the kidney function deteriorates and an obstructive pattern of urodynamics of the upper urinary tract is formed, then surgical intervention is required. Reimplantation is usually applied, if a patient is older than one year. In infants, minimally invasive endoscopic methods are more applicable. Nevertheless, results of treatment are ambiguous and not satisfactory in some cases. Purpose. To assess and to compare levels of efficiency of endoscopic stenting, high pressure balloon dilatation (HPBD) and reimplantation. To propose an algorithm for the selection and sequential application of the discussed surgical procedures depending on patient’s age and on the degree of renal function damage. Material and methods. 224 children were taken into the study. They were divided into three groups. Stenting, HPBD or reimplantation were used as a treatment modality in each group, respectively. Effectiveness criteria were: improvement of renal function by the nephroscintigraphy, reduction in size of the ureter and excretory system as well as the increase in parenchyma volume by ultrasound. Non-parametric statistics - Wilcoxon test, chi-square test, Spearman correlation. The level of significance is 0.05. Results. Stenting is effective in 48% of children of the first year of life, but in older patients its effectiveness significantly decreases (about 20%). A high level of HPBD efficiency (about 70%) was achieved in subgroups of patients of the first three years of life; however, it was significantly lower in patients of older age. Reimplantation is maximally effective (about 98%) in subgroups of patients older than one, but not effective (33%) in the subgroup of patients of the first year of life. Conclusion. Endoscopic stenting is indicated for patients of the first year of life with minimal disorders in their urodynamics and renal function, while it is not an option for older patients. HPBD is more effective in patients of the first two years of life with moderate urodynamic disorders. Reimplantation with the effectiveness level about 100% is a method of choice in patients older than one year and cannot be recommended in infancy.

High Pressure Balloon Dilatation of Primary Obstructive Megaureter in Children: A Multicenter Study.

Aim of the Study: We described the initial experience of four referral centers in the treatment of primary obstructive megaureter (POM) in children, by high-pressure balloon dilatation (HPBD) of the ureterovesical junction with double JJ stenting. We managed a retrospective multicenter study to assess its effectiveness in long-term.Methods: We reviewed the medical records of all children who underwent HPBD for POM that require surgical treatment from May 2012 to December 2017 in four different institutions. The primary outcome measured was ureterohydronephrosis (UHN) and its degree of improvement after the procedure. Secondary outcomes were postoperative complications and resolution of preoperative symptomatology.Main Results: Forty-two ureters underwent HPBD for POM in 33 children, with a median age of 14.7 months – (range: 3 months −15 years). Ureterohydronephrosis improves in 86% of ureters after one endoscopic treatment. Three cases required a second HPBD. Four patients required surgical treatment for worsening of UHN after endoscopic treatment. The post-operative complication rate was 50% (21 ureters). In 13 cases (61%), they were related to double J stent. The median follow-up was 24 months (2 months −5 years) and all patients were symptom-free.Conclusion: We reported the first multicenter study and the largest series of children treated with HPBD, with an overall success rate of 92%. Endoscopic treatment can be a definitive treatment of POM since it avoided reimplantation in 90% of cases. Complications are mainly due to double J stent.