Longer Procedure Duration Research Articles

Characterization of the Mechanism and Substrate of Atrial Tachycardia Using Ultra-High-Density Mapping in Adults With Congenital Heart Disease: Impact on Clinical Outcomes.

BackgroundAtrial tachycardia (AT) is common in patients with adult congenital heart disease and is challenging to map and ablate. We used ultra‐high‐density mapping to characterize the AT mechanism and investigate whether substrate characteristics are related to ablation outcomes.Methods and ResultsA total of 50 ATs were mapped with ultra‐high‐density mapping in 23 procedures. Patients were followed up for up to 12 months. Procedures were classified to group A if there was 1 single AT induced (n=12) and group B if there were ≥2 ATs induced (n=11 procedures). AT mechanism per procedure was macro re‐entry (n=10) and localized re‐entry (n=2) in group A and multiple focal (n=6) or multiple macro re‐entry (n=5) in group B. Procedure duration, low voltage area (0.05–0.5 mV), and low voltage area indexed for volume were higher in group B (159 [147–180] versus 412 [352–420] minutes, P<0.001, 22.6 [12.2–29.8] versus 54.2 [51.1–61.6] cm2, P=0.014 and 0.17 [0.12–0.21] versus 0.26 [0.23–0.27] cm2/mL, P=0.024 accordingly). Dense scar (<0.05 mV) and atrial volume were similar between groups. Acute success and freedom from arrhythmia recurrence were worse in group B (100% versus 77% P=0.009 and 11.3, CI 9.8–12.7 versus 4.9, CI 2.2–7.6 months, log rank P=0.004). Indexed low voltage area ≥0.24 cm2/mL could predict recurrence with 100% sensitivity and 77% specificity (area under the curve 0.923, P=0.007).ConclusionsLarger low voltage area but not dense scar is associated with the induction of multiple focal or re‐entry ATs, which are subsequently associated with longer procedure duration and worse acute and midterm clinical outcomes.

Usefulness of Atherectomy in Chronic Total Occlusion Interventions (from the PROGRESS-CTO Registry)

There is limited data on the use of atherectomy during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We compared the clinical and procedural characteristics and outcomes of CTO PCIs performed with or without atherectomy in a contemporary multicenter CTO PCI registry. Between 2012 and 2018, 3,607 CTO PCIs were performed at 21 participating centers. Atherectomy was used in 117 (3.2%) cases: rotational atherectomy in 105 cases, orbital atherectomy in 8, and both in 4 cases. Patients in whom atherectomy was used, were older (68 ± 8 vs 64 ± 10 years, p <0.0001) and had higher Japan-chronic total occlusion score (3.0 ± 1.2 vs 2.4 ± 1.3, p <0.0001). CTO PCI cases in which atherectomy was used had similar technical (91% vs 87%, p = 0.240) and procedural (90% vs 85%, p = 0.159) success and in-hospital major adverse cardiac event (4% vs 3%, p = 0.382) rates. However, atherectomy cases were associated with higher rates of donor vessel injury (4% vs 1%, p = 0.031), tamponade requiring pericardiocentesis (2.6% vs 0.4%, p = 0.012) and more often required use of a left ventricular assist device (9% vs 5%, p = 0.031). Atherectomy cases were associated with longer procedural duration (196 [141, 247] vs 119 [76, 180] minutes, p <0.0001), and higher patient air kerma radiation dose (3.6 [2.5, 5.6] vs 2.8 [1.6, 4.7] Gray, p = 0.001). In conclusion, atherectomy is currently performed in approximately 3% of CTO PCI cases and is associated with similar technical and procedural success and overall major adverse cardiac event rates, but higher risk for donor vessel injury and tamponade.

Association between the use of contact force-sensing catheters and cardiac tamponade in atrial fibrillation ablation

IntroductionCardiac tamponade is a rare but life-threatening complication during atrial fibrillation (AF) catheter ablation. Contact force (CF)–sensing catheters improve ablation effectiveness. However, the impact of the application of CF-sensing catheters on the occurrence of cardiac tamponade remains unclear. The aim of this study is to evaluate the “real-world” impact of CF-sensing catheters on cardiac tamponade during AF ablation in an experienced medical center.Methods and resultsThis was a retrospective study of consecutive de novo AF ablation procedures at Beijing Anzhen Hospital between 2013 and 2016. The ablation procedure was divided into a CF group and a non-CF group. Logistic regression analysis was used to evaluate the association between the use of CF-sensing catheters and the risk of cardiac tamponade. A total of 5313 patients with AF were involved in this study. The incidence of cardiac tamponade in the CF group was significantly higher than that in the non-CF group (1.07% vs. 0.44%, P = 0.009). Of the cardiac tamponade cases in the non-CF group, 45.45% were delayed compared with 10% in the CF group (P = 0.011). Multivariate logistic regression analysis showed that CF-sensing catheters increased the risk of cardiac tamponade (OR = 2.34, 95% CI = 1.17–4.26, P = 0.015). Stratified analysis revealed patients with a smaller left atrium dimension, lower ejection fraction, longer procedure duration, or longer ablation duration had a greater risk of cardiac tamponade during ablation with CF-sensing catheters.ConclusionsCF-sensing catheters increase the risk of cardiac tamponade during AF ablation.

Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women.

Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5mg IUD insertion. Adolescent and young adult women ages 14-22years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22years. The median procedure duration (seconds±interquartile range) was longer for adolescents than for young adults (555±428seconds vs 383±196seconds; P=.008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P=.3832). The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.

Characteristics and outcomes of patients requiring bailout use of glycoprotein IIb/IIIa inhibitors for thrombotic complications of percutaneous coronary intervention: An analysis from the CHAMPION PHOENIX trial

AimsTo describe the characteristics and outcomes of patients receiving bailout glycoprotein IIb/IIIa inhibitors (GPI) for thrombotic complications of percutaneous coronary intervention (PCI) in a large, contemporary trial. Methods and resultsIn the CHAMPION PHOENIX trial, the use of GPI was restricted to bailout for thrombotic complications. We describe the characteristics and outcomes of patients requiring bailout GPI compared to patients not receiving GPIs, with adjustment through propensity-score. A multivariable model was constructed to identify independent correlates associated with bailout GPI use.A total of 380 out of 10,942 patients received GPI (3.5%); GPI patients were younger, more frequently male, more likely to present with ST segment elevation myocardial infarction and less frequently treated with cangrelor. At 48 h, GPI patients experienced higher rates of the primary composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis (ST) (19.2% vs 4.8%; adjusted OR: 5.65(4.08, 7.82), p < 0.0001) and a higher rate of GUSTO severe or moderate bleeding (2.6% vs 0.4% adjusted OR: 4.90 (1.98, 12.18), p = 0.0006) compared with non GPI patients. Independent correlates of GPI use were STEMI, use of unfractionated heparin, drug-eluting stents and longer procedure duration. ConclusionsIn a large contemporary trial, patients receiving bailout GPI for thrombotic complications of PCI experienced very high risks of both ischemic and bleeding complications, suggesting that prevention of periprocedural complications rather than bailout GPI may be preferable.Clinical Trial Registration: http://www.clinicaltrials.gov identifier: NCT01156571.

Routine postprocedure ultrasound increases rate of detection of femoral arterial thrombosis in infants after cardiac catheterization.

To examine the effect of implementing postcatheterization ultrasound (US) on femoral arterial thrombosis detection rates and factors associated with thrombosis in infants. Although femoral arterial thrombosis is an uncommon complication of cardiac catheterization, it can cause limb threatening complications. Previous studies assessing the utility of postprocedure US to detect thrombosis in infants have utilized US as an adjunct to standard clinical detection methods, are small scale, or include small cohorts of infants within older populations. We reviewed institutional records of patients 0-12 months undergoing catheterization from 2007 to 2016. Demographics and procedural data were compared between the thrombosis and non-thrombosis group. Pre- and post-US groups were compared for detected thrombosis rate. Using univariate and multivariable analyses, we identified factors associated with thrombosis. In total, 270 patients underwent 509 catheterizations, with 40 (7.9%) documented thromboses. The rate of thrombus detection in patients younger than 6 months increased from 8.3% to 23.4% (P = 0.006) after implementing routine US. On multivariable analysis, lower weight (P < 0.001), larger arterial sheath size (P < 0.001), and longer procedure duration (P = 0.003) were independently associated with higher odds of thrombosis. Higher rates of femoral arterial thrombosis detection were observed since implementing an US screening program. Further studies are needed to evaluate age-related changes in hemostasis in this population and how advanced screening methods and anticoagulation protocols may help improve short-term and long-term sequelae of femoral arterial thrombosis.

Radiofrequency ablation in the treatment of atypical cartilaginous tumours in the long bones: lessons learned from our experience

BackgroundSurgery is the cornerstone of treatment of symptomatic cartilaginous neoplasms. We previously studied the application of radiofrequency ablation of atypical cartilaginous tumours in the long bones. The purpose of the present study was to investigate the additional effect of placing multiple needles and a longer procedure duration on the proportion of completely ablated tumours. Post-ablation MRI findings and the occurrence of complications were also assessed.MethodsWe prospectively included 24 patients with atypical cartilaginous tumours in the long bones. Patients underwent CT-guided radiofrequency ablation followed by curettage with adjuvant phenolisation 3 months later, retrieving material assessed for viable tumour. Before curettage, gadolinium-enhanced MRI was performed to check for residual tumour. The occurrence of complications was noted.ResultsComplete tumour ablation was achieved in 17 out of 24 patients (71%). Complete ablation was achieved in 5 of the 6 cases (83%) when multiple needles were used in tumours ≥30 mm. There was incomplete ablation in 8% of patients. Post-ablation gadolinium-enhanced MRI findings agreed with the histological results in 17 out of 23 cases and there was a negative predictive value of 83%. One patient suffered a fracture after radiofrequency ablation.ConclusionRadiofrequency ablation could be an alternative to curettage when treating atypical cartilaginous tumours in the long bones. It was shown that multiple needle placement in addition to longer duration of the ablation procedure is an effective measure in achieving complete ablation in tumours ≥30 mm. Gadolinium-enhanced MRI has a negative predictive value of 83% and could guide post-ablation follow-up.

In-hospital Outcomes of Attempting More Than One Chronic Total Coronary Occlusion Through Percutaneous Intervention During the Same Procedure

The frequency and outcomes of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of more than one CTO during the same procedure have received limited study. We compared the clinical and angiographic characteristics and procedural outcomes of patients who underwent treatment of single versus >1 CTOs during the same procedure in 20 centers from the United States, Europe, and Russia. A total of 2,955 patients were included: mean age was 65 ± 10years and 85% were men with high prevalence of previous myocardial infarction (46%), and previous coronary artery bypass graft surgery (33%). More than one CTO lesions were attempted during the same procedure in 58 patients (2.0%) and 70% of them were located in different major epicardial arteries. Compared with patients who underwent PCI of a single CTO, those who underwent PCI of >1 CTOs during the same procedure had similar J-CTO (2.4 ± 1.3 vs 2.5 ± 1.3, p = 0.579) and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (1.5 ± 1.2 vs 1.3 ± 1.0 p = 0.147) scores. The multi-CTO PCI group had similar technical success (86% vs 87%, p = 0.633), but higher risk of in-hospital major complications (10.3% vs 2.7%, p = 0.005), and consequently numerically lower procedural success (79% vs 85%, p = 0.197). The multi-CTO PCI group had higher in-hospital mortality (5.2% vs 0.5%, p = 0.005) and stroke (5.2%vs 0.2%, p <0.001), longer procedure duration (162 [117 to 242] vs 122 [80 to 186] minutes, p <0.001) and higher radiation dose (3.6 [2.1 to 6.4] vs 2.9 [1.7 to 4.7] Gray, p = 0.033). In conclusion, staged revascularization may be the preferred approach in patients with >1 CTO lesions requiring revascularization, as treatment during a single procedure was associated with higher risk for periprocedural complications.

Percutaneous coronary intervention without P2Y12 inhibitor pretreatment: A real-life study

Recent studies have challenged systematic pretreatment with a P2Y 12 inhibitor before percutaneous coronary intervention (PCI) in elective and non-ST-segment elevation myocardial infarction (NSTEMI) patients. The aim of this study was to assess outcomes after performing PCI immediately after coronary angiography with an exclusive ‘on-the-table’ P2Y 12 inhibitor loading dose, by evaluating ischaemic and bleeding complications in unselected patients. Consecutive patients admitted for elective PCI or NSTEMI were included in this bicentric, prospective observational study, and received a P2Y 12 inhibitor after coronary angiography when PCI was decided. The primary composite endpoint was first occurrence of cardiovascular death, myocardial infarction, stroke, urgent revascularisation or use of bailout glycoprotein IIb/IIIa inhibitors at 30 days after PCI. Stent thrombosis and bleedings (Bleeding Academic Research Consortium [BARC]) criteria were evaluated. Among 299 included patients, 188 were admitted for elective PCI and 111 for NSTEMI. The incidence of the primary endpoint was 8.5% (95% CI 5.7 to 12.4). No definite stent thrombosis occurred. Three independent predictive factors were associated with the primary endpoint: NSTEMI setting (OR 5.61 (95% CI 1.75 to 17.98), thrombotic coronary lesion (OR 4.26 (95% CI 1.45 to 12.54) and longer procedure duration (OR 1.06 (95% CI 1.03 to 1.09). Clinically relevant bleedings (BARC type 2, 3 or 5) occurred in 5.4% of patients. In an unselected population admitted for elective PCI or NSTEMI in real-life practice, administration of a P2Y 12 inhibitor only after coronary angiography is associated with a low rate of ischaemic and bleeding events at 30 days.

Radiofrequency Catheter Ablation of Atrial Tachycardias in Congenital Heart Disease: Results With Special Reference to Complexity of Underlying Anatomy.

Radiofrequency catheter ablation has become the treatment strategy of choice for atrial tachyarrhythmias in patients with congenital heart disease (CHD). We analyzed results of radiofrequency catheter ablation in a large cohort of patients with CHD with special reference to complexity of underlying anatomy. One hundred and forty-four patients with CHD and atrial tachyarrhythmias undergoing radiofrequency catheter ablation were classified according to complexity of underlying CHD: simple CHD, n=18 (12%); moderate CHD, n=53 (37%); and complex CHD, n=73 (51%). Overall acute success was achieved in 81% of the patients. Acute success was lower for tachycardias involving the left atrium compared with right atrial tachycardias. Complexity of CHD was associated with longer procedure duration. Tachycardia recurrence was observed in 54% of the patients after a total follow-up of 7.4 years. 75% of all recurrences occurred within the first year. Recurrence of tachycardia was more likely in patients with complex surgical atrial anatomy (ie, Fontan palliation or atrial switch procedure). Major complications occurred in 4 patients and were related to vascular access. Acute procedural success of atrial tachycardia ablation in congenital heart patients was not influenced by complexity of CHD. Long-term outcome with regard to tachycardia recurrence was worse in patients with complex surgical atrial anatomy.

Patient comfort scores do not affect endoscopist behavior during colonoscopy, while trainee involvement has negative effects on patient comfort.

Introduction Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists. Patients and methods The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis. Results NAPCOMS consists of 3 domains – pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P = 0.01) and fentanyl ( P = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P = 0.037), decreased midazolam use ( P = 0.001), and more position changes ( P = 0.002) among gastroenterologists. Conclusions The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.

Significant reduction in procedure duration in remote magnetic-guided catheter ablation of atrial fibrillation using the third-generation magnetic navigation system

The magnetic navigation system (MNS) has shown to be safe and effective for catheter ablation of atrial fibrillation (AF). However, longer procedure duration as compared to manual catheter ablation may limit its widespread use. This study aimed to assess the impact of the newest generation MNS using an optimized mapping and ablation protocol on the efficacy and safety of remote magnetic catheter (RMC)-guided pulmonary vein isolation (PVI). This observational study included 52 patients with symptomatic AF who underwent RMC-guided PVI using the second-generation MNS Niobe II (initial 28 patients, group I) or the third-generation MNS Niobe ES in combination with an optimized mapping and ablation protocol (24 patients, group II). Acute PVI was achieved in 26/28 (93%) patients in group I and 24/24 patients (100%) in group II. Mean procedure time was 263.9±81.9min in group I and significantly lower in group II (139.7±22.6min, p<0.01). Mean fluoroscopy time was 18.8±8.7min in group I and decreased to 7.9±2.6 in group II (p<0.01). After a median follow-up of 640.5days (Q1 460.75; Q3 766.5), 16/24 (67%) patients undergoing RMC-guided PVI in group II remained in stable SR. No periprocedural complications were noted for either group. Use of the third-generation MNS for RMC-guided PVI is safe, effective, and drastically reduced procedure times.

Evaluation of endothelial dysfunction with flow-mediated dilatation after transradial coronary angiography

Objective Transradial coronary angiography (TRCA) may lead to endothelial dysfunction. Therefore, this study investigated the TRCA-related endothelial dysfunction and its relation to operator experience, the number of punctures and procedure duration.Methods and results A total of 57 patients (42 males and 17 females) who underwent TRCA were included in this single-centre study. Nine months after the procedure, all patients underwent radial artery B-mode ultrasound imaging, and flow-mediated dilatation (FMD) and nitroglycerin-mediated dilatation (NMD) techniques were employed. The non-intervened right radial artery was accepted as control. The percentage change in diameter after FMD was significantly greater in the right radial artery compared to the left radial artery (right 13.6% vs left 10.1%, P = 0.041). The percentage change in diameter after NMD was similar in both right and left radial arteries (right 23.8% vs left 23.4%, P = 0.932). According to the puncture numbers, the percentage change was significantly lower in the intervened artery among patients with more than one puncture (13.3% vs 7.8%, P = 0.005). According to the operator experience, the percentage change in the intervened artery was significantly higher in patients in whom the procedure was performed by experienced operators (13.7% vs 7.6%, P = 0.002). The procedure duration also showed a negative correlation with the percentage change in the intervened artery (r = -0.349, P = 0.008).Conclusions TRCA may lead to endothelial dysfunction represented by FMD. Moreover, higher puncture numbers for sheath insertion, longer procedure durations and less experience in radial interventions may have adverse effects on the endothelial function.

Abstract WP34: Prevalence and Predictors of Endovascular Treatment-related Nephropathy in Acute Ischemic Stroke Patients: an Analysis of the Acute Stroke Due to Intracranial Atherosclerotic Occlusion and Neurointervention Korean Retrospective (ASIAN KR) Registry

Background and Purpose: As endovascular therapy (EVT) occupies a growing role in the management of acute ischemic stroke (AIS), contrast-induced nephropathy (CIN) associated with consecutive contrast media administration for vascular imaging and distal subtraction angiography is an emerging concern. We investigated the incidence, risk factors and clinical outcome of CIN in AIS patients who underwent EVT. Methods: Multicenter data from the ASIAN KR registry collected between January 2011 and Mar 2016, on consecutive patients who received EVT for AIS, were analyzed. Diagnostic criteria for CIN were: an absolute increase in serum creatinine (SCr) by ≥0.3 mg/dL from baseline within 48 hours after EVT; or a relative increase in SCr levels by ≥50% from baseline. Results: Of 721 patients, 616 patients (85%) were eligible for this study. CIN was diagnosed in 47 (7.6%), and was more associated with history of hypertension (p=0.011), history of diabetes mellitus (DM) (p=0.002), and higher initial NIHSS score (16.6 vs. 18.7 p=0.006). In multivariable analysis, independent risk factors of CIN were hypertension history (OR 2.465, 95% CI 1.027-5.919, p=0.043), DM history (1.978, 1.023-3.822, p=0.042), initial NIHSS score (1.071, 1.014-1.132, p=0.014), initial SCr level (1.603, 1.159-2.217, p=0.004) and duration from puncture to final angiography (1.006 per minute, 1.000-1.012, p=0.045). In multiple logistic regression, CIN was an independent risk factor of poor clinical outcome (modified Rankin Scale at 3 months 4-6; 3.782, 1.770-8.083, p=0.001) after adjusting age, sex, initial NIHSS, hypertension history, DM history, onset to puncture time and successful reperfusion. Conclusions: CIN is not uncommon and associated with poor clinical outcome after EVT in AIS. Clinicians should be aware that key factors associated with an increased likelihood of CIN are hypertension history, DM history, abnormal SCr level, higher NIHSS score and longer procedure duration.

Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions

Background and purposeThe benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in...

Efficacy and Safety of Duodenal Endoscopic Mucosal Resection: A Single-Center Experience

Introduction: Endoscopic mucosal resection (EMR) for duodenal lesions is an appealing alternative to surgical resection. However, the duodenum is considered a challenging and high-risk site for endoscopic interventions. Herein, we report a single-center 2-year experience of performing duodenal EMR to assess its therapeutic outcomes. Aim: Evaluate efficacy and safety of EMR for duodenal adenoma resection and assess risk factors associated with residual duodenal polyp at follow up. Methods: A retrospective review of all the patients undergoing EMR of non-ampullary and non-polyposis associated duodenal adenomas of size > 10 mm at a tertiary referral center between January 2014 and December 2015 was performed. Data collection included information about: patient demographics, lesion characteristic, procedure details and follow up details. (Table 1) Main outcomes included: admission, intraprocedural bleeding (IPB), delayed bleeding (DB) and residual/recurrent adenomas. Groups were compared using t-tests and chi-square. (Table 2)Table 1: Characteristics of the study subjectsTable 2: Association of different factors with procedure outcomesResults: Sixty patients were included with a mean age of 69.7 ± 10.7 years, 58.3% were males. Mean lesion size was 26.8 ± 15.9 ranging from 10 to 70 mm, 58% of them were tubular adenomas. Most of the lesions (71.7%) were resected in a piecemeal fashion. IPB was reported in 16 (26.7%) cases and 9 (15%) patients had prophylactic clips to close the mucosal defect. There were no reported immediate complications, while 6 patients had delayed complications and 4 of them were bleedings. Admission was significantly associated with lesion size, villous component, EMR duration, piecemeal resection and number of resected pieces. IPB was associated with piecemeal resection and number of resected pieces, however, neither EMR duration nor recent use of anti-platelet or anti-coagulant agents were associated with IPB. Delayed bleeding was only associated with EMR duration. Thirty (50%) patients underwent their first surveillance endoscopy, 10 (32.3%) of them had residual adenoma. All of these residual/recurrences were managed endoscopically. Presence of residual tissue was slightly associated, yet not significant, with the villous component and piecemeal resection (p = 0.068 & 0.083 respectively). Conclusion: Overall, EMR treatment for duodenal adenomas is an effective and safe procedure in referral center-settings. However, IPB and recurrence are major concerns. Longer procedure duration was strongly associated with delayed bleeding.

Effect of Previous Failure on Subsequent Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention (from a Contemporary Multicenter Registry)

We sought to examine the impact of previous failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCIs from 2012 to 2015 at 12 US centers. Mean age was 65 ± 10years, and 84.8% of patients were men. A previously failed attempt had been performed in 215 patients (17.5%). As compared with patients without previous CTO PCI failure, patients with previous failure had higher Multicenter CTO Registry in Japan CTO score (2.40 ± 1.13 vs 3.28 ± 1.29, p<0.0001) and were more likely to have in-stent restenosis (10.5% vs 28.4%, p <0.0001) and to undergo recanalization attempts using the retrograde approach (41% vs 50%, p= 0.011). Technical (90% vs 88%, p= 0.390) and procedural (89% vs 86%, p= 0.184) success were similar in the 2 study groups; however, median procedure time (125 vs 142minutes, p=0.026) and fluoroscopy time (45 vs 55minutes, p= 0.015) were longer in the previous failure group. In conclusion, a previously failed CTO PCI attempt is associated with higher angiographic complexity, longer procedural duration, and fluoroscopy time, but not with the success and complication rates of subsequent CTO PCI attempts.

The role of contrast-enhanced ultrasonography in image-guided liver ablations.

We read with great interest the paper by Kim et al. [1] entitled “Local ablation therapy with contrast enhanced ultrasonography for hepatocellular carcinoma: a practical review,” recently published in Ultrasonography. We think that contrast-enhanced ultrasonography (CEUS), together with the development of reliable navigation systems, is likely to represent one of the most important advances in image-guided ablations in recent years. Thus, we offer some considerations on the topic. Percutaneous ablations, performed with different technologies, are increasingly used to treat a variety of conditions, including liver, kidney, and even neck tumors [2,3]. Whatever the technology, most procedures are performed under sonographic guidance, which provide a reliable, real-time, and cheap guidance method even in extremely complex conditions. However, in some cases, lesions may be not clearly detectable on ultrasonography, due to low conspicuity or when visibility is impaired by bones or aerated organs (i.e., the lungs and bowel). In these cases, the use of more complex guidance modalities, such as computed tomography (CT), magnetic resonance imaging (MRI), or even positron-emitting tomography (PET), have been reported [3]. However, all these methods imply an increased level of technical difficulty, longer procedure duration, and higher costs. Kim et al. [1] highlighted how the use of CEUS may help in performing liver ablations in cases of lesions not clearly visible on standard ultrasonography. We consider the intra-procedural use of CEUS of paramount importance for image-guided ablations. In our experience, CEUS has allowed for the immediate retreatment of patients with incomplete ablations. This implied a dramatic decrease in rate of repeat visit and repeat ablation, thus also remarkably reducing the overall costs per patient [4]. Unlike Kim et al. [1], we generally perform post-ablation CEUS after 5-7 minutes, as soon as the gas that developed during the procedure has disappeared. At 20-40 minutes, a peripheral hyperemic halo may be present, potentially mimicking the presence of a residual peripheral tumor. However, even CEUS may not be sufficient to fully depict the lesion with full conspicuity in certain patients. Under these conditions, fusion imaging between ultrasonography and pre-acquired CT, MRI, or PET images, together with virtual navigation, may represent a valuable option [5]. In our experience, we were able to achieve correct targeting of lesions not thoroughly detectable at ultrasonography or CEUS in more than 90% of cases, thanks to the availability of a fusion system [5]. In conclusion, we think that CEUS, virtual navigation, and fusion systems may enable the application of minimally-invasive image-guided procedures to a larger population, potentially avoiding major surgery in a selected subset of patients.

The impact of chronic opioid use on colonoscopy outcomes.

Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation. We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects. This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times. Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002). Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.

Stagnation of treatment times over a decade: results of a pooled analysis from the MERCI registry, MERCI, TREVO, and TREVO 2 trials

BackgroundThere has been a growing interest in improving systems of care for the endovascular treatment of acute ischemic stroke. We analyzed data from previous registries and studies to determine if...