Hybrid Operating Research Articles

Small pulmonary nodule localization techniques in the era of lung cancer screening: a narrative review.

The widespread adoption of high-resolution computed tomography (CT) screening has led to increased detection of small pulmonary nodules, necessitating accurate localization techniques for surgical resection. This review examines the evolution, efficacy, and safety of various localization methods for small pulmonary nodules. Studies focusing on localization techniques for pulmonary nodules ≤30 mm in diameter were included, with emphasis on technical success rates and complication profiles. Preoperative CT-guided techniques, including hook-wire (success rate 94-98%) and anchored needle localization (success rate >99%, dislodgement rate 0%) demonstrate high technical success rates, though with varying complication profiles. Microcoil localization (97-98% success) shows comparable efficacy with lower complication rates. Dye-based methods offer simplicity but can be limited by rapid diffusion. Newer techniques like medical adhesive localization (success rate up to 100%) and electromagnetic navigation bronchoscopy (97.2% success) show promise in reducing complications and improving accuracy. Intraoperative methods such as ultrasound and hybrid operating room approaches provide real-time guidance but may be limited by nodule characteristics and available expertise. This review presents a radar chart analysis comparing techniques across key parameters and introduces an innovative decision-making algorithm that considers nodule characteristics, patient factors, and institutional resources, providing practical guidance and serving as a reference for clinicians. While no single method is universally superior, the trend towards minimally invasive, precise, and flexible approaches is evident. Future research should focus on large-scale comparative studies and the integration of artificial intelligence for optimized technique selection and improved patient outcomes.

NATO and Russia's actions in the Arctic as an example of symmetry in international security

ABSTRACT After Russia's full-scale invasion of Ukraine in February 2022, NATO was still present and exercising in the Arctic, a decision motivated by a decade of Russian militarisation in the region. This article integrates contemporary Arctic security with the dynamics of Russia and NATO. Moreover, it examines NATO’s actions in the Arctic during the war in Ukraine and analyses the development of strategic and operational assumptions tested mainly against the European part of the High North. The time-horizon adopted in the analysis of Moscow's activities is the last decade since the launch of hybrid operations in Lugansk and Donbas in 2014. To make the analysis comprehensive, it is theoretically backed by Gilpin and Wohlforth's assumptions of political realism. The analysis of NATO’s and Russia in the perspective of the conflict in Ukraine allows us to test the hypothesis on whether the Arctic exemplifies NATO's and Russia's strategic symmetry in international security.

Video-based propagation of tacit knowledge during coil embolization of intracranial aneurysms.

Neuroendovascular treatment of cerebral aneurysms is considered a basic procedure for neurosurgeons and interventional neuroradiologists; however, its critical technical nuances, termed "tacit knowledge," are challenging to impart. This study aimed to evaluate the efficacy of our novel video recording and editing method in enhancing trainees' experience. A wearable camera (wearable recording) and multiple media sources in a hybrid operating room (hybrid recording) were used to capture procedural details such as audio and conversation, thus enabling a re-experience. Trainees condensed both recordings into summary videos and a supervisor subsequently evaluated them. Six trainees watched the following three videos: Video 1, only hybrid recording; Video 2, only wearable recording; and Video 3, both wearable and hybrid recordings synchronized, and then provided semi-quantitative evaluations ranging from 0 (not useful at all) to 5 (extremely useful). We examined 64 unruptured cerebral aneurysm coil embolizations using hybrid wearable recording methods. Video 3 received the highest rating among all participants (5±0 [mean ± standard deviation]), while Videos 1 and 2 received relatively lower ratings (Video 1:3.8±0.7; Video 2:4.2±0.4). The educational impact of video editing across all videos was rated highly (4.4±0.8). The respondents showed diverse opinions on editing time, with some perceiving it as less time-consuming than other surgery video edits (3.4±1.1). Our hybrid and wearable recording and editing methods facilitated the propagation of tacit knowledge of coil embolization and enhanced surgical education by enabling more efficient learning of technical tips.

T4-non-small cell lung cancer invading the thoracic aorta: the role of the hybrid operating room

T4-non-small cell lung cancer invading the thoracic aorta: the role of the hybrid operating room

A bi-objective Genetic Algorithm for flexible flow shop scheduling: A real-world application in the electrical industry

The electrical sector forces manufacturing companies of electrical solutions to continually innovate and implement new processes for greater efficiency. The growing demand for electrical energy, as well as the need to adapt to hybrid operations that combine multi-project operation models with continuous production models, requires efficient workflow management. Accordingly, this article proposes a Genetic Algorithm (GA) approach for solving the scheduling problem in a Flexible Hybrid Flow Shop (FHFS) environment considering a transfer batch approach to minimize makespan and total tardiness. The approach is inspired by a real-world application in the electrical industry and also accounts for unrelated parallel machines, precedence, release times, and due dates for jobs at each production center as key constraints. Three real-data scenarios were generated and evaluated. In the first scenario, a 7 % improvement in makespan was observed compared to real execution times. In Scenario 2, the makespan improved significantly by 33 %, and only 17.4 % of jobs were delayed, compared to 96 % in the real data. Likewise, GA showed a lightly better performance over Tabu Search (TS) in 3.01 % for makespan while the delayed jobs found by GA were 25 % below those obtained by TS. These results highlight the potential of the proposed method to improve overall production efficiency, not only in the electrical sector but also in similar industries.

SOCIAL COHESION IN HYBRID CONFLICTS. CASES OF MIGRATION CRISIS AT THE POLISH-BELARUSSIAN BORDER AND MIGRATION FLOWS FROM UKRAINE

Hybrid threats, which combine disinformation, cyber-attacks, economic pressure, and the use of irregular armed groups and regular forces (NATO), target society as a whole, specific groups and/or individuals in order to destabilize their functioning and undermine their sense of security. The European Union and individual countries recognize societal cohesion as one of the desirable tools to counter complex and interrelated threats, regardless of the category they belong to – hybrid interference, hybrid operations or hybrid warfare (EU). The migration crisis on the eastern border of the EU is analyzed with reference to the NATO framework of 5 elements (core values, common perception of the risk, trust in institutions and their policies and applied law) that can destabilize the coherent society. The conclusions draw attention to the progressive fracturing of society which can be slowed down by building social awareness with national and international law and policies including educational policies.

Intraoperative patient radiation dose from cone-beam computed tomography in thoracic surgery

BackgroundSeveral methods can be used to intraoperatively identify pulmonary lesion using radiation technology. However, little is known about patient radiation exposure during chest surgery. We aimed to measure patients’ radiation exposure from cone-beam computed tomography (CBCT) used in a hybrid operating room.MethodsThis retrospective study included patients who underwent surgical treatment in a hybrid operating room between April 2019 and December 2023 at the Teikyo University Hospital. All data was obtained prospectively, but the study was approved by the IRB as a retrospective study because of repeated extensions of study period in order to collect more cases. Skin radiation exposure was measured using five wearable dosimeters per patient. The measurements were compared to cumulative Air Kerma. Furthermore, the radiation exposure dose on the surgical side, which cannot be measured, was estimated by computer simulation.ResultsAmong 182 patients who underwent surgery in a hybrid operating room, radiation exposure measurements were conducted on 67 patients. The patients’ mean age was 60.7 years. The average number of CBCT scans was 2.1 (1–5) and the intraoperative identification rate was 100%, with no marking-related complications. Average patient’s skin radiation dose was 3.69 ± 5.48 mGy per dosimeter, and cumulative Air Kerma was 25.4 ± 19.3 mGy. The highest radiation exposure was recorded in the 5th intercostal space whereas the lowest was measured in the supraclavicular or 11th intercostal spaces. Referring to phantom and computer simulation data, the 5th and 8th intercostal spaces were significantly more exposed to radiation at not only measurement side but also the surgical field, particularly when the number of CT scans was four.ConclusionWe found that the patient’s 5th to 8th intercostal space was the most radiation exposed area by intraoperative CBCT imaging because the CBCT movement was restricted by the patient’s arm, anesthesia machine, and operating table during chest surgery. In future, it is strongly required to research for radiation protection in this area. Furthermore, performing no more than three scans intraoperatively may be preferable in order to protect patients from radiation exposure during CBCT guided thoracic surgery.

A prospective study of the method of intraoperative luminescent spectroscopy in the application of isolated profundoplasty in hybrid surgery of critical ischemia of the lower limb

Introduction. Currently, it is relevant to develop new diagnostic criteria for assessing the condition of the deep femoral artery (DFA), in order to determine the possibilities of its use in various hybrid reconstructions for critical lower limb ischemia.Aim: To determine the indications for isolated profundoplasty as the final stage of proximal hybrid reconstruction using the method of intraoperative luminescence spectroscopy.Material and Methods. The prospective open-label non-randomized pilot study included 64 people operated at City Clinical Hospital No. 29 with a clinical diagnosis of “Obliterating atherosclerosis of the arteries of the lower extremities. Stenosis of the external iliac artery. Steno-occlusive lesion of the common femoral/superficial femoral artery. Stenosis of the deep femoral artery of the thigh. Chronic arterial ischemia of the III st.”, in the volume of proximal hybrid reconstruction, including isolated profundoplasty. The first group (n = 28) consisted of patients who had stenosis or occlusion of the mouth of the deep femoral artery, the second group (n = 20) – had diffuse lesion of the deep femoral artery, the third group (n = 16) – had a distal type of lesion of this artery. The first stage of the hybrid operation was stenting of the external iliac artery. The choice of further intraoperative tactics occurred as a result of an assessment of the anatomy and severity of the lesion of the deep femoral artery, by measuring the ankle-shoulder and hip-popliteal indices. All patients underwent intravascular luminescent spectroscopy intraoperatively using our technique to determine the luminescent compensation coefficient (CI). The follow-up period was 3 months. The end point of the study was thrombosis of the reconstruction zone. The SPSS 17.0 software was used for statistical data processing when comparing study groups.Results. When comparing the obtained CI, a direct strong correlation was noted with a preoperatively determined hip-popliteal index (r = 0.76; at p < 0.005). When assessing the interval of the hip-popliteal index from 0.3 to 0.4; 4 patients with thrombotic complications in the early postoperative period and 3 patients with no thrombotic complications were evaluated. When correlating CI in these categories of respondents, the statistically significant differences in indicators were established: CI (without complications) = 0.46 (0.43; 0.50); CI (complicated) = 0.59 (0.58; 0.60); with p < 0.05. When studying preoperative deep femoropopliteal index in representatives of study groups 1 and 2 who had GPI in the range from 0.4 to 0.5, but differed in the outcomes of the late postoperative period, the statistical significance of differences in indicators was noted: Cl (without complications) = 0.44 (0.43; 0.46); Cl (complicated) = 0.61 (0.60; 0.62); at p < 0.05.Conclusion. Intravascular luminescence spectroscopy is an important method of clarifying the intraoperative feasibility of performing isolated profundoplasty in addition to preoperative assessment of the degree of the hip-popliteal index.

Optimal power management of a stand-alone hybrid energy management system: Hydro-photovoltaic-fuel cell

The field of electrical engineering with renewable energy systems has witnessed a remarkable improvement due to an increase in the world's growing population as available resources become limited. This study proposes an optimal and efficient hybrid energy management system that combines photovoltaic, hydro, and fuel cell renewable energy resources that can solve the drawbacks of current energy setups and offer a dependable power source for stand-alone purposes. This novel AC-linked hybrid energy system features a comprehensive power management strategy with actual weather data and a realistic load demand profile. The HOMER Pro technique is employed for calculating the emission of toxic gases, system economic benefits, sensitivity analysis and cost minimization of the system while providing sustainability. The numerical outcomes show optimal results as compared to the existing systems in the literature. The system consists of 55 kW of PV modules, a 30 kW FC generator, and 40 kW of hydropower, suggesting optimal and excellent economic and environmental sustainability. This system appeared to be an especially cost-effective solution, with a net present cost (NPC) of $248,773 and a cost of energy (COE) of $0.0546/kWh. The results show that the system can meet energy needs while utilising the available resources efficiently in different weather conditions. The proposed system has the potential to increase the sustainability and dependability of power generation in a variety of applications and aid in the design and implementation of alternative energy systems, particularly in off-grid or remote areas. The proposed system can be extended to other such locations that will provide a scalable and flexible solution for electricity generation, making it suitable for a variety of applications, from small rural power plants to large industrial power supplies. Overall, the proposed study provides an important resource for development in hybrid energy system design and operation, with far-reaching implications for the transition to a sustainable and low-carbon future.

Intraoperative Transbronchial Metallic Coil Marking for Small Peripheral Pulmonary Lesions in a Hybrid Operation Room.

Background/Objectives: Computed tomography (CT)-guided transbronchial metallic coil marking is useful for identifying the locations of small peripheral pulmonary lesions. Even deeply located lesions may be accurately identified and resected with adequate margins. This method is also applicable to multiple lesions. The present study examined the efficacy of our marking method using cone-beam CT (CBCT) under general anesthesia in a hybrid operation room. Methods: In the hybrid operation room, an ultrathin bronchoscope was inserted into the objective bronchus under virtual bronchoscopic navigation, and a metallic coil was installed under CBCT guidance. The lesion was then resected with wedge resection by single- or 3-port video-assisted thoracoscopic surgery under fluorescence guidance. Eighty-seven patients with 90 lesions were treated between October 2016 and December 2022. The median lesion size was 11 mm and the median distance from the pleural surface was 8.7 mm. Lesions comprised 19 pure ground-glass nodule (GGN), 35 partly solid, and 36 solid types. Results: All lesions were visualized by CBCT, and metallic coils were installed into the objective bronchi. The median distance from lesions to coils was 3.6 mm, and the median marking time was 23.5 min. All lesions were resected with sufficient margins. In total, 57 lesions were diagnosed as primary lung cancer, 26 as metastatic lung tumors, 3 as nodular lymphoid hyperplasia, and 4 as others. There were no complications associated with the marking procedure. Conclusions: CBCT represents an alternative modality for identifying peripheral lung lesions due to its ability to visualize even small GGNs. It is a minimally invasive technique because the treatment sequence is completed under general anesthesia with the same quality as previous methods performed in a CT-equipped interventional radiology suite.

Optimal operation guidelines for direct recovery of high-purity precursor from spent lithium-ion batteries: hybrid operation model of population balance equation and data-driven classifier

The direct resynthesis of precursor from spent lithium-ion batteries (LIBs) via co-precipitation is a crucial step in closed-loop cathode recycling systems. However, design and operation strategies for producing high-purity precursors have not been comprehensively explored or optimized. Herein, we propose the optimization of co-precipitation during the recovery of spent LIBs to achieve impurity-free precursor resynthesis. By incorporating the thermodynamic equilibrium model of the leaching solution of spent LIBs into a population balance equation (PBE) model, we identified the operating ranges that prevented the formation of impurities. Bayesian optimization was employed within the screened operating ranges to determine the optimal operating conditions for minimizing both operation time and maximum particle size. This optimization was performed for both unseeded batch and semi-batch systems. The results demonstrate that the selection of an optimal semi-batch operation can reduce the operation time by 23.33% and increase the particle size by 54.75%, owing to the high nucleation and particle growth rate during the initial time step. By employing an optimization approach based on the PBE model, this study provides detailed operational guidelines for batch and semi-batch co-precipitation, enabling the production of high-purity precursor materials from spent LIBs, while minimizing both operating time and maximum particle size.

Pressurizing the Fuel Cell in a Direct Hybrid System for Airborne Applications

The push towards achieving emission-free aviation is intensifying. The number of demonstrator aircraft like the HY4 form H2FLY or the ATR72 from Universal Hydrogen taking flight and gaining experience in electric aviation is increasing. One existing approach for the realization of an all-electric aircraft is a direct hybrid system comprising a fuel cell and a battery. During high-power phases of a mission, such as takeoff and climb, both the battery and the fuel cell contribute power. However, during cruise, power is solely supplied by the fuel cell to leverage the high energy density of hydrogen. In a direct hybrid system, the power share of the fuel cell and the battery is determined by the size and the operating conditions of both.The low ambient pressures at high altitude negatively affect the performance of fuel cells. This is not only important in fuel cell only propulsion systems but also when operating a direct hybrid system. The impact of low pressures on the behavior of a direct hybrid system, linking a fuel cell and a battery without a DC/DC converter, is demonstrated. The effects of a non-pressurized PEM-fuel cell in a direct hybrid with a lithium-ion battery in a low-pressure environment was analyzed previously (see attached figure).However, since weight and volume are crucial factors in an aircraft, the fuel cell reactants can be pressurized to increase the power density of the system. Pressurization improves the fuel cells performance and therefore reduces weight and volume of the system, but the pressurization of the ambient air to the desired inlet pressure of the fuel cell cathode requires energy. The pressurization of a fuel cell also changes its voltage power behavior, which in turn affects the operation of the direct hybrid system.In order to examine and analyze the influence of pressurization on the overall system performance, an open-source two-phase model of a fuel cell is used and compared to experimental measurement data to gain fuel cell data at different pressure levels.The behavior of the direct hybrid system at different operating conditions will be presented, where the net power of the pressurized PEM-fuel cell system is combined with a battery to form a direct hybrid system. At lower state of charge (SOC) levels, the share of the fuel cell increases due to the lower voltage level of the battery over all power levels. In a pressure-driven fuel cell system, we take advantage of the fact that the pressure of the reactants can be controlled. By adjusting the pressure, the power share of the fuel cell and battery can be actively controlled. Lower operating pressure results in a higher battery share, due to the lower fuel cell voltage. By increasing the pressure, the voltage level provided by the fuel cell increases and therefore the power share of the fuel cell also increases.In addition, a realistic flight mission is analyzed with a constant compression ratio for the fuel cell air supply resulting in variable operating pressures of the fuel cell during flight, due to the different environmental pressures. The performance of the pressurized fuel cell direct hybrid under those varying ambient conditions will be presented. Figure 1

Hybrid Aortic Arch Replacement with Frozen Elephant Trunk (FET) Technique: Surgical Considerations, Pearls, and Pitfalls.

The involvement of the aortic arch in thoracic aortic aneurysms (TAA), or acute aortic dissections (AAD), represents a challenging clinical entity, mandating a meticulous surgical plan, tailored to each individual case. The advent of endovascular techniques and the introduction of modern arch protheses have led to the implementation of the frozen elephant trunk (FET) technique. This one-step hybrid operation consists of a total aortic arch replacement combined with an antegrade delivery of a stent-graft for the descending aorta, which acts as a proximal landing zone facilitating a potential distal endovascular reintervention. In this manner, this technique addresses acute and chronic arch disease with an acceptable morbidity and mortality. Several FET prosthetic devices are available on the global market and have exhibited favourable outcomes, although with some disadvantages in complex cases; similarly, the hybrid procedure described in this review has also been associated with complications, such as coagulopathy and neurological and graft-related events. The purpose of this review is to thus provide key insights into successful hybrid aortic arch replacements and to discuss useful tips and relevant considerations regarding its use.

Early outcomes of treatment selections for infrarenal abdominal aortic aneurysms: The first five year experience of a single center

Aim: We examined the criteria governing patient selection in contemporary practice in cases of infrarenal abdominal aortic aneurysm (AAA) treated electively or urgently in our Cardiovascular Surgery Clinic (CVSC). Material and Methods: From January 2019 to January 2024, we retrospectively evaluated infrarenal AAA patients treated either electively or urgently with Open Surgical Repair (OSR) or standard Endovascular Aortic Repair (EVAR) at our CVSC. The primary endpoints are distribution of AAA patients by treatment modality, early morbidity and mortality. The secondary endpoints were intensive care unit (ICU) duration and length of hospital stay (LOS). Results: A total of 332 patients received EVAR (Group 1), including 296 elective cases, while 90 patients underwent OSR (Group 2), with 66 being elective. Early mortality rates were significantly lower in the EVAR group (1.3% for elective and 27.8% for emergent) compared to the OSR group (6.1% for elective and 54.2% for ruptured cases, p=0.001). Major postoperative complications occurred in 12.5% of elective EVAR patients and 39.4% of elective OSR patients (p=0.001), while in ruptured cases, the rates were 11.1% and 58.3%, respectively (p=0.001). Comparisons of ICU duration and LOS also favored EVAR (p=0.001). Conclusion: EVAR offers a survival benefit in the early period compared to OSR. The choice of treatment should be tailored to the patient's comorbidities, preferences, and the vascular surgeon's expertise. Advanced aortic centers with hybrid operating rooms (HOR) and specialized CVSCs should aim for optimized patient outcomes and cost-effectiveness in our country.

Abstract 4120270: Risk Factors for Catastrophic Complications Requiring Emergent Extracorporeal Life Support in Patients Undergoing Transcatheter Aortic Valve Replacement

Background: Transcatheter Aortic Valve Replacement (TAVR) is often performed in the cardiology catheterization suite. Although rare, instances of annular rupture, cardiac arrest, and coronary occlusion may occur requiring institution of emergent extracorporeal life support (ECLS). This study aims to examine the risk factors for complications requiring ECLS during TAVR procedures to identify patients who may benefit from having procedures performed in hybrid operating rooms. Methods: Data from the Transcatheter Valve Therapy registry for our institution was obtained on patients (n=4908) who underwent TAVR between November 2012 and July 2023. Univariable logistic regression was performed to compare relevant covariates in those requiring intraoperative ECLS (n=23) to the rest of the patient cohort (n=4885). All-cause mortality during the follow-up period was compared to assess the impact of emergent intraoperative ECLS. Results: The patients requiring ECLS experienced significantly higher all-cause mortality (69.6% versus 28.8%, p<0.001) with median follow up of 2 years (Table 1) . Female sex (p=0.013) and smaller annulus size (p=0.007) were significant independent risk factors for complications requiring emergent intraoperative ECLS based on univariable logistic regression (Table 2). Patients requiring ECLS had significantly smaller annulus sizes (21.0-23.2 mm) compared to the uncomplicated cohort (22.0-25.8 mm). Of the patients requiring ECLS, 11 cases (47.8%) were due to annular/ventricular rupture while 4 cases (17.4%) resulted from valve embolization. Of note, valve type (self-expanding versus balloon expandable), annular calcification, and porcelain aorta were not found to be significant risk factors. Conclusions: In this large volume single-center retrospective cohort study, female sex and smaller aortic annular size significantly increased the risk of complications necessitating ECLS support during TAVR procedures. Our study represents the first to identify independent risk factors for catastrophic complications during TAVR procedures. Patients with these high-risk profiles should have their TAVR procedures performed in the hybrid operating room with cardiopulmonary bypass on immediate standby.

Station-based, free-float, or hybrid: An operating mode analysis of a bike-sharing system

The profit-oriented bike-sharing industry, such as Mobike in China and Limebike in the USA, has widely adopted the free-float mode, which allows users to rent and return bikes without any restrictions with regard to stations. Compared to the traditional station-based mode, this new mode improves convenience and satisfies a variety of travel demands, but it also results in higher operating costs and lower number of available bikes (the number of bikes can be found). So far, no theoretical study has been done comparing the performance levels of the two different operating modes. Some bike-sharing firms are now attempting to design a hybrid operating mode that combines the advantages of the two modes. We design a mixed-integer program to model these three operating modes under different operating conditions. The model captures some of the new features of free-float bike-sharing systems. These new features include discounts for returning bikes to designated stations, different numbers of available bikes at stations and free-float areas, differences in station-based return levels as well as in convenience levels in the three operating modes. This study also considers the interactions between the free-float and station-based modes in meeting the demand and in managing relocation processes. Extensive numerical experiments are conducted and the results reveal that in more than half of the total cases under different parameter settings, the profits of the hybrid mode outperform the profits of the other two modes. The station-based mode is suitable for settings with high convenience levels, low number of available free-float bikes, and limited budgets for bike acquisitions, whereas the free-float mode can ensure high profits with low convenience levels and a large number of bikes being available. Our models can serve as a decision-making tool for bike-sharing firms in their selection of an optimal operating mode.

Hybridization of wind farms with co-located PV and storage installations

This paper evaluates the concept of hybridizing an existing wind farm (WF) by co-locating a photovoltaic (PV) park, with or without embedded battery energy storage systems (BESS), leveraging the WF’s existing grid connection infrastructure on the grounds of resource complementarity. The feasibility and economic benefits of hybridization are established by comparing the levelized cost of energy of co-located and independently installed assets. A wide range of PV-to-wind capacity ratios and BESS power and energy capacities are investigated, modelling the operation of hybrid and independent configurations over their lifetime. To address the integration of BESS, a mixed-integer linear programming optimization algorithm is employed with an hourly timestep and over-diurnal horizon, adopting a price-taker approach against externally defined wholesale market price timeseries. The main finding is that hybridization noticeably improves the utilization of existing grid infrastructure, constituting an economically advantageous option for a range of PV-to-wind capacity ratios up to 82.5% in the case of plain PVs or up to 90-140% for BESS-equipped PVs, depending on the duration of integrated storage. When renewable curtailments due to system-level supply-demand equilibrium limitations are also considered, the analysis showcases that hybrid configurations remain competitive while, interestingly, the preferred range of PV capacities is further extended.

Intraoperative Position System guided with Augmented Reality Improves the Learning Curve of Endovascular Navigation in Endovascular Naïve Operators

ObjectiveThis study aimed to compare the completion of gate cannulation task performed by participants of varying experience using fluoroscopy, the Intra-Operative Positioning System (IOPS) – an FDA-cleared endovascular navigation system that has been developed to reduce dependence on fluoroscopy – or an investigational augmented reality electromagnetic navigation technology based on IOPS. MethodsThe task consisted in the cannulation of the gate of a GORE Excluder AAA endoprosthesis bifurcated aortic stent graft (W.L. GORE & Associates, Flagstaff, AZ USA) deployed into a 3D printed abdominal aortic aneurysm (AAA) model connected to a 7000 MDX flow pump (Sarns Inc/3M, Ann Arbor, MI USA) reproducing physiological conditions. The procedure was performed in a hybrid operating room (GE Allia IGS 7). Each participant performed the cannulation task with fluoroscopy, standard IOPS guidance with flat screen display (IOPS-FS), and the investigational IOPS with augmented reality headset (IOPS-AR), in a randomly assigned order. All participants used the same sensorized guidewire and steerable 6Fr catheter during their three cannulation tasks. A total of 26 participants were classified in three groups of experience: Group 1 (endovascular naïve; n = 13), Group 2 (surgeon in training; n = 12) and Group 3 (one expert surgeon). Primary endpoints included cannulation time and technical success, which was defined as the advancement of the catheter over the guidewire within the main body of the aortic stent graft within a maximum 15 minutes cutoff time for each trial. ResultsIn group 1, the mean cannulation time was shorter using IOPS-AR versus fluoroscopy (4.3 ±4.4 min vs 7.1±4.9 min; P=.04), but not statistically different when comparing IOPS-FS and fluoroscopy (6.3±4.5 min vs 7.1±4.9 min; P=.63). In group 1, technical success was 77% with fluoroscopy and 92% with both IOPS-FS and IOPS-AR (P=.59). In group 2, although there was no significant difference between cannulation time amongst the three different endovascular approaches, there was a trend towards shorter cannulation times with IOPS-FS or IOPS-AR as compared to fluoroscopy (mean time of 2.5±0.9, 4.4±4.0 and 5.2±4.5 min, respectively). In group 2, technical success was 92% with fluoroscopy and 100% with both IOPS-FS and IOPS-AR (P>.99). The expert vascular surgeon repeated the cannulation task four times for each endovascular approach, with 100% technical success and no difference in mean cannulation time between the imaging modalities (P=.89). ConclusionsAugmented reality allows for reducing the gate cannulation time as compared to fluoroscopy in participants with no previous exposure to any endovascular procedure. This suggests that augmented reality can be beneficial for individuals early in their career and can mitigate the learning curve. As individuals become experts, their ability to adapt to different endovascular modalities increases, eliminating the learning curve altogether.

The short- and long-term results of therapy of surgical diabetic foot patients

Introduction. The arterial limb threating is the leading cause of non-traumatic amputations in diabetic foot patients. The breakthrough in the treatment of this group of patients was the widespread introduction of transluminal balloon angioplasty (TLBA) of the arteries of the lower extremities.Aim. To evaluate the results of the surgical treatment of the patients with diabetic neuro ischemic foot syndrome according the data of Government Center of Limb Salvation in 2022–2023 years.Materials and methods. The study presents a retrospective analysis of medical documentations and the results of a survey one year after discharge from the hospital of 180 patients.Results. The arterial limb threating is observed in equal frequency in both men with diabetes and women at a relatively young age (66.0 ± 12.8 years). The glycemic control in most patients is above the target values. Various groups of sugar-lowering drugs are widely used. More than a third of patients with CKD suffer from CKD with GFR less than 60 ml/min, however inSGLT-2 are used in slightly more than 15% of cases. The damages of the lower extremities arteries below the knee are observed in the most of cases. Every third patient has the occlusion/hemodynamically significant stenosis of the femoral and tibia arteries. The method of choosing revascularization is TLBA the lower extremities arteries without stenting, hybrid operations are performed in up to 10% of cases in the hospital. During the first year of follow up the 21.2% of the patients have recurrences of the ischemic tissue lesions of the feet including revascularization. The recurrences of the ischemic tissue lesions of the feet after surgical approach are revealed in 9% cases only. There are TLBA in all other cases. The mortality rate is 9.6 cases per 100 patients per year.Conclusion. The patients after revascularization for the neuro-ischemic diabetic foot tissue loss and limb salvage remain at high risk of both mortality and recurrence of arterial limb threating in the early and delayed follow up.

Distinguishing factors in regional variations of TAVI in Japan: the unique role of administrative facility standards compared to other procedures in a high-cost medical care subsidy system

Abstract Background Transcatheter aortic valve implantation (TAVI) is less invasive than surgical aortic valve replacement and is becoming increasingly popular worldwide, particularly among patients with aortic valve stenosis (AS) due to aging. However, regional differences are expected to exist not only between countries but also within a single country. Reports from Western countries indicate the presence of regional differences in TAVI and the reasons for these differences, which include differences in medical infrastructure, economic resources, health insurance systems and policies, geographic factors, and availability of specialized medical personnel. TAVI is expensive, but in Japan, the economic aspect is relatively unimportant due to the high-cost medical assistance system. Furthermore, there is little socioeconomic disparity between regions. In such a society, we have reported that the number of specialists and resources for PCI can explain regional differences in ablation and endovascular treatment (EVT). However, unlike those other cardiovascular procedures, there are specific requirements for facilities to perform TAVI, such as the number of transesophageal echocardiographies, as well as cardiologists and cardiovascular surgeons, and the equipment itself, such as hybrid operating rooms. We examined how these facility requirements, which are thought to be controlled by the government, are related to regional differences in TAVI implementation. Methods and Results We used the Japanese Ministry of Health, Labour and Welfare national database to determine the rate of TAVI for patients with AS performed per 100,000 population aged ≥40 years in all 47 prefectures in 2022. A linear regression model was developed to assess factors contributing to the regional medical supply, including the rates of PCI per 100,000 population aged ≥40 years and the numbers of cardiologists, cardiovascular surgeons, cardiovascular intervention and therapy training facilities, cardiovascular surgery base facilities, and TAVI facilities. The numbers in the highest and lowest regions were 26.6 and 3.9 (a 6.8-fold difference) for TAVI number. The number of TAVI facilities contributed most significantly to the TAVI volumes (P = 0.0105), while the rates of PCI and other factors did not contribute significantly. The number of TAVI facilities was positively correlated with the number of transesophageal echocardiographies the most (r = 0.353). Conclusion This study revealed large regional variations in TAVI volumes in Japan, of which administrative facility standards were a major determinant.