Longer Procedure Time Research Articles

Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization.

Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.

Comparing clinical success and procedural difficulty between treatment-naïve and treatment-refractory patients with esophageal motility disorders during peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) can successfully treat patients with achalasia. Prior therapy with Botox (Allergan, Madison, NJ, USA) injections, pneumatic dilation (PD), and/or laparoscopic Heller myotomy (LHM) is believed to increase the difficulty of POEM procedures. We aimed to determine if prior treatment methods were associated with longer procedure times or lower clinical success. In this single-center retrospective study, consecutive patients who underwent POEM for achalasia between February 2017 and September 2021 were studied. Collected data were patient demographics, prior treatment, pre- and postprocedure Eckardt score (ES), distensibility indices (DIs), and procedure times. Primary outcomes were clinical success and procedure difficulty. Of 95 patients (mean age, 55.6 years; 45% women), 25 patients underwent POEM for type I achalasia, 31 for type II achalasia, and 33 for spastic esophageal pathologies. Thirty-three patients (34.7%) were treated for achalasia before POEM with onabotulinumtoxinA injections (n= 18), PD (n= 17), and LHM (n= 3). There were no significant differences in post-treatment ESs or technical success between the 2 groups (P= .98 and P= .66, respectively). Multivariate analysis showed that prior treatment was associated with decreased case time and easier tunneling during POEM. Prior treatment did not impact the clinical success rate of POEM and led to decreased case times and easier tunneling difficulty, likely because of persistent lower esophageal sphincter changes and differences in diagnostic indications. POEM should be considered for patients with treatment-refractory symptoms as a safe and feasible option. Further large-scale studies are needed to validate our findings.

Two-Stage Operations in Patients with Acute Right-sided Colonic Obstruction: a 15-year Single Institution Experience

Objective The aim of the study was to review the characteristics, surgical outcomes, complications, and long-term outcomes of two-stage operations for acute right-sided colonic obstruction (RSCO) in a single institution. Summary background data Although patients with acute RSCO can be treated by resection of the tumor with a primary anastomosis, longer procedure times and bigger wounds can result in more mortality and complications. A two-stage operation by diverting loop ileostomy was another surgical option. However, the outcomes of two-stage operations are lacking. Methods The retrospective study reviewed the patients who underwent emergency surgery for acute RSCO in a tertiary center from 2004-2018. First-stage operations other than diverting loop ileostomy, incomplete obstructions that could be treated medically, or pathologies other than adenocarcinomas were excluded. Perioperative data such as first and second operations, operative times, lengths of stay, harvested lymph nodes, and any complications were included. We assessed overall survival (OS) and disease-free survival (DFS) for the oncologic outcomes. Results Sixty-nine patients were included. Seven patients had surgical complications related to ileostomy. Three of them died within 30 days of first admission. Thirty-one patients received a second-stage operation by right hemicolectomy. None had anastomosis leakage or 30-day mortality. Only 9.7% of patients had fewer than 12 harvested lymph nodes. One-year OS was 34% in the patients who received only ileostomy, and 89% in those who received two-stage operations (P < 0.001). Among 26 patients who underwent curative resection of tumor, 3-year DFS was 61.5%. Conclusions A two-stage operation is associated with low mortality and morbidity rates in an emergency setting. The subsequent right hemicolectomy can harvest more lymph nodes than emergency resection. Long-term survival benefits can be expected.

Safety and feasibility of same-day discharge after endoscopic submucosal dissection: a Western multicenter prospective cohort study.

Recent Western studies support the safety and efficacy of endoscopic submucosal dissection (ESD) for lesions throughout the GI tract. Although admission for observation after ESD is standard in Asia, a more selective approach may optimize resource utilization. We aimed to evaluate the safety and feasibility of same-day discharge (SDD) after ESD and factors associated with admission. This was a post hoc analysis of a multicenter, prospective cohort of patients undergoing ESD (2016-2021). The primary end points were safety of SDD and factors associated with post-ESD admission. Of 831 patients (median age, 67 years; 57% male) undergoing 831 ESDs (240 performed in the esophagus, 126 in the stomach, and 465 in the colorectum; median lesion size, 44mm), 588 (71%) were SDD versus 243 (29%) admissions. Delayed bleeding and perforation occurred in 12 (2%) and 4 (.7%) of SDD patients, respectively; only 1 (.2%) required surgery. Of the 243 admissions, 223 (92%) were discharged after≤24 hours of observation. Interestingly, larger lesion size (>44mm) was not associated with higher admission rate (odds ratio [OR], .5; 95% confidence interval [CI], .3-.8; P= .001). Lesions in the upper GI tract versus colon (OR, 1.7; 95% CI, 1.1-2.6; P= .01), invasive cancer (OR, 1.9; 95% CI, 1.2-3.1; P= .01), and adverse events (OR, 2.7; 95% CI, 1.5-4.8; P= .001) were independent factors for admission. Admissions were more likely performed by endoscopists with ESD volume<50 cases (OR, 2.1; 95% CI, 1.3-3.3; P= .001) with procedure time >75 minutes (OR, 13.5; 95% CI, 8.5-21.3; P< .0001). SDD after ESD can be safe and feasible. Patients with invasive cancer, lesions in the upper GI tract, longer procedure times, or procedures performed by low-volume ESD endoscopists are more likely to be admitted postprocedure. Risk stratification of patients for SDD after ESD should help optimize resource utilization and enhance ESD uptake in the West. (Clinical trial registration number: NCT02989818.).

Functional and technical outcomes in acute ischemic stroke patients with hyperdense middle cerebral artery sign treated with endovascular thrombectomy.

The hyperdense middle cerebral artery sign (HMCAS) is observed in a proportion of patients with acute ischemic stroke (AIS). This sign reflects the presence of an intravascular thrombus rich in red blood cells. Several studies have demonstrated that HMCAS increases the risk of poor outcomes in AIS patients treated with IV thrombolysis or no reperfusion therapy; however, whether HMCAS predicts a poor outcome in patients treated with endovascular thrombectomy (EVT) is less clear. We aimed to evaluate the functional outcome by the modified Rankin scale (mRS) at 90 days and technical challenges in patients with HMCAS undergoing EVT. We studied 143 consecutive AIS patients with middle cerebral artery M1 segment or internal carotid artery + M1 occlusions who underwent EVT. There were 73 patients (51%) with HMCAS. Patients with HMCAS had a higher frequency of cardioembolic stroke (p = 0.038); otherwise, no other baseline difference was observed. No differences in functional outcomes (mRS) at 90 days (p = 0.698), unfavorable outcomes (mRS > 2) (p = 0.929), frequency of symptomatic intracranial hemorrhage (p = 0.924), and mortality (mRS-6) (p = 0.736) were observed between patients with and without HMCAS. In patients with HMCAS, EVT procedures were 9 min longer, requiring a higher number of passes (p = 0.073); however, optimal recanalization scores (modified thrombolysis in cerebral infarction: 2b-3) were equally achieved by both groups. Patients with HMCAS treated with EVT do not have a worse outcome at 3 months compared with no-HMCAS patients. Patients with HMCAS required a greater number of thrombus passes and longer procedure times.

A single-center single-shot devices experience for pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) is the gold standard for treatment of atrial fibrillation (AF). Single-shot devices have been introduced to provide a faster and more simplified approach to achieve PVI. We sought to evaluate our single-center experience with different single-shot devices for the treatment of AF. Methods Evaluation included 25 propensity score matched patients (age, gender, AF-type, CHADSVAsc score) for each single-shot device (i) Arctic Front 4th generation cryoballon (CB G4), (ii) PolarX cryoballoon, (iii) X3 laserballoon, (iv) single-access pulsed field ablation (PFA) as part of our prospective observational AF registry who underwent first-time ablation for symptomatic AF. The first 20 cases (learning curve) with each technology and those with pre/post mapping were rejected from the analysis. Procedures were performed by the institute´s standard operational procedures. Procedural characteristics and safety data were compared. Results A total of 100 symptomatic AF patients (66±8 years, 57% paroxysmal AF, 42% female, CHADSVasc Score 1.2±1) underwent first-time PVI with a single-shot device. Acute PVI rates were 96-100%. Treatment with either cryoballoon systems revealed similar procedure characteristics between vendors. Balloon-based procedures were associated with longer procedure times between 54-57 min. Using a single-access PFA approach, procedure (26 [25-30] min) and fluoroscopy times (5 [IQR 5;7] min) were significantly reduced (p&amp;lt;0.001). Significantly smaller amounts of contrast medium were needed in laser and PFA procedures in comparison to both cryoballoons (p&amp;lt;0.001). Adverse event rates did not differ between technologies. Details are given in Table 1-3 and Figure 1. Conclusion In our prospective ablation registry, first-time AF ablation using single-access PFA outperformed other common single-shot devices. Procedure and fluoroscopy times were significantly reduced by approximately 50% in comparison to balloon-based technologies (p&amp;lt;0.001). A comparable safety profile was found between PFA, cryo- and laser energy.

Impact of 3-dimensional electroanatomic mapping systems on fluoroscopy reduction in catheter ablation of supraventricular tachycardia - then and now

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is an effective first-line treatment for symptomatic and recurrent supraventricular tachycardia (SVT). The advent of 3D electroanatomic mapping (EAM) has led to a reduction in fluoroscopy use and consequently lower radiation exposure for patients and staff during SVT ablation. Purpose The aims of this study are to demonstrate if the use of EAM during SVT ablation reduces fluoroscopy time (FT), and determine if further reductions in FT are observed longitudinally. We hypothesise that over time, with continued use and wider adoption of EAM, greater operator experience, and technological advancements in EAM, there will be further reductions in radiation exposure as estimated by FT. Methods All cases of atrioventricular nodal re-entry tachycardia (AVNRT), atrioventricular re-entry tachycardia (AVRT), and/or atrial tachycardia (AT) ablation between May 2011 to May 2022 at a tertiary centre were prospectively recruited. FT between the groups with and without EAM were compared. Within the EAM subset, the trend of FT across the years was also analysed. Results Over this 11-year period, there were 1758 cases of SVT ablation (565 without EAM; 1193 with EAM). Between the two groups, there were no significant differences (p &amp;gt; 0.05) in age, sex, history of structural heart disease and/or ischaemic heart disease, stereotaxis use, and diagnosis (AVNRT, AVRT, AT). Cases using EAM were more likely to have &amp;gt;1 SVT ablated during the procedure (0.04) and require intracardiac echocardiography (ICE) (p &amp;lt; 0.001). The use of EAM was associated with mean reductions in FT and dose area product (DAP) by 19.6 minutes and 18 581 mGy*cm2 respectively (both p &amp;lt; 0.001). EAM was also associated with a longer procedure time (mean +8.8 minutes, p &amp;lt; 0.001). There was no difference in radiofrequency application time between the two groups (p = 0.143). After controlling for potential confounding factors including age, sex, use of stereotaxis, use of ICE, type and number of SVT, history of prior ablation, and structural heart disease and/or ischaemic heart disease, we found over time (2011-2022), further reduction in FT was observed, with a mean reduction of 0.9 minutes year on year (p &amp;lt; 0.001). EAM was gradually adopted through the years with the number of cases per year plateauing after 2017. Between 2011-2017, there was a significant reduction in FT (mean of -1.1 minute year on year, p = 0.020), which was not observed from 2017 onwards (p = 0.088). The greatest reduction in FT was observed after the first year of adoption, with a mean reduction of 6.9 minutes between 2012-2013. Conclusion This demonstrates that use of EAM in SVT ablation reduces FT and fluoroscopy DAP. There was no incremental benefit observed after 6 years of EAM adoption likely related to operator experience. While there is increased interest in zero fluoroscopy SVT ablation, complementary use of fluoroscopy may still be necessary in select complex cases.

Procedural time of PPCI (wire crossing time) in acute STEMI via radial approach versus femoral approach

Objective: The study aimed to compare the procedural time (wire crossing time) of primary percutaneous coronary intervention (PPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) using the radial approach versus the femoral approach. Study Design: A single-center, observational, retrospective cohort study was conducted. Setting: The study was carried out in the Cardiology Department of Saidu Group of Teaching Hospital (SGTH) in the period from July, 2022 TO December, 2022. Methods: Medical records of patients with acute STEMI who underwent PPCI using either the radial or femoral approach were retrospectively reviewed. Demographic, clinical, and procedural data were collected, and the primary outcome was the procedural time (wire crossing time) for each approach. Results: A total of 276 patients were included in the study, with 137 in the radial approach group and 139 in the femoral approach group. The mean procedural time (wire crossing time) was significantly longer in the radial approach group (29.6 ± 7.3 minutes) compared to the femoral approach group (24.2 ± 6.5 minutes), p&lt;0.001. Conclusion: In patients with acute STEMI undergoing PPCI, the radial approach was associated with a longer procedural time (wire crossing time) compared to the femoral approach.

Thoracic Endovascular Aortic Repair for Metachronous Thoracic Aortic Aneurysms Following Prior Infrarenal Abdominal Aortic Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) for metachronous thoracic aortic aneurysms (M-TAA) after prior abdominal aortic aneurysm repair has been shown to be associated with higher risk of spinal cord ischemia compared with primary TEVAR. However, data regarding the impact of the type of prior repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality after TEVAR for M-TAA compared with primary TEVAR for TAA. We identified all patients who underwent TEVAR for TAA of the descending thoracic aorta in the Vascular Quality Initiative from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR after infrarenal open (iOAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression models. We included 1493 patients who underwent primary TEVAR (n = 1213; 81%) or TEVAR after prior iOAR (n = 135; 9%) or prior EVAR (n = 145; 10%). Compared with primary TEVAR, patients undergoing TEVAR for metachronous aneurysms were older, more commonly male, White, and more frequently had a history of genetic disorders and other comorbidities. Patients with M-TAA were more often asymptomatic at repair, presented with larger diameters, and required higher contrast volume and longer procedural time, relative to patients undergoing primary TEVAR. After risk adjustment, compared with primary TEVAR, prior EVAR was associated with higher perioperative mortality (10% vs 3.9%; odds ratio [OR]: 4.5, 95% confidence interval [CI]: 2.0-9.9; P < .001) (Table) and 5-year mortality (40% vs 24%; hazard ratio: 1.9, 95% CI: 1.3-2; P = .001) (Fig), along with higher odds of acute kidney injury (10% vs 6.2%; OR: 2.0, 95% CI: 1.0-3.8; P = .04). However, other in-hospital complications including spinal cord ischemia were not notably different. On the other hand, TEVAR after prior iOAR was associated with similar perioperative mortality (4% vs 4%; OR: 0.8, 95% CI: 0.3-2.0; P = .75), 5-year mortality (28% vs 24%; hazard ratio: 1.2, 95% CI: 0.72-1.9; P = .54), and in-hospital complication and reintervention rates, relative to primary TEVAR. Type of prior repair has a significant impact on outcomes in patients undergoing intervention for M-TAA. Further efforts should aim to identify the reasons behind these differences in outcomes to help improve care of patients with M-TAA.TablePerioperative outcomes and 5-year mortality after primary TEVAR and TEVAR after prior iOAR or EVARPrimary TEVARPrior iOARPrior EVARPrimary TEVAR vs prior iOARPrimary TEVAR vs prior EVARUnadjusted event rates, %Odds ratio (95% CI)P valueOdds ratio (95% CI)P valuePerioperative mortality3.94.49.71.2 (0.32-3.7).754.5 (2.0-9.9)<.001Any complication1814230.92 (0.50-1.6).771.5 (0.89-2.3).13 AKI6.26.7101.3 (0.56-2.9).492.0 (1.0-3.8).04 Postoperative dialysis1.01.51.42.1 (0.24-1.2).461.4 (0.07-9.1).78 Spinal cord ischemia2.60.72.80.22 (0.01-1.2).161.3 (0.35-3.5).69 Leg ischemia1.90.72.11.2 (0.06-7.2).862.0 (0.42-7.0).33 Bowel ischemia0.501.4NANA3.0 (0.40-15).22 Stroke3.11.54.10.63 (0.10-2.3).541.3 (0.40-3.3).58 Pulmonary complication5.06.76.91.8 (0.72-4.0).181.9 (0.83-3.8).11 Cardiac complication2.53.02.81.7 (0.45-5.2).971.02 (0.23-3.2).97Reintervention4.93.76.21.2 (0.38-3.0).761.5 (0.64-3.3).30Unadjusted estimatesHazard ratio (95% CI)P valueHazard ratio (95% CI)P value5-year mortality2325401.2 (0.72-1.9).541.9 (1.3-2.8).001AKI, Acute kidney injury; CI, confidence interval; iOAR, infrarenal open aortic repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent significance P < .05.*Adjusted for age, gender, diameter, race, saccular, presentation, prior myocardial infarction, prior congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, smoking, renal dysfunction, prior medication use (aspirin, statin, and β-blocker), and genetic history. Open table in a new tab

Outcomes Following Fenestrated Endovascular Aortic Repair for Failed Infrarenal Endovascular Aortic Repair Compared With Primary Fenestrated Endovascular Aortic Repair

Fenestrated endovascular aortic repair (FEVAR) is a potential treatment option in patients with failed EVAR due to proximal disease progression. However, studies evaluating the outcomes after FEVAR in patients with prior EVAR are limited to data from single-center and high-volume institutions. Therefore, we compared the outcomes after FEVAR in patients with prior EVAR vs without any prior aortic surgery (primary FEVAR). We identified patients undergoing elective FEVAR for complex abdominal aortic aneurysm in the Vascular Quality Initiative between 2014 and 2022 and included those who underwent no prior aortic surgery (n = 2362) or prior EVAR (n = 117). Perioperative outcomes and 5-year mortality were analyzed using logistic regression and Cox regression models. Sac changes were assessed based on differences in aneurysm sac diameter between the 1-year computed tomography scan and preoperative imaging and were categorized as regression (>5 mm decrease), stability (<5 mm change in size), and expansion (>5 mm increase) for analysis. We included 2362 primary FEVAR patients and 117 patients who underwent FEVAR after EVAR. The FEVAR after EVAR patients were older (76 [72-82] years vs 74 [68-79] years; P < .001), less frequently female (12% vs 23%; P = .004), had larger aneurysm diameters (68 [60-80] mm vs 58 [55-63] mm; P < .001), and more preoperative comorbidities. After EVAR patients, FEVAR patients were more likely to undergo repairs at high-volume centers performed by high-volume surgeons (P < .001). Furthermore, FEVAR after EVAR involved more proximal aortic zones with a higher number of branches and longer procedural time and radiation (all P < .05). Despite these differences, FEVAR after EVAR showed comparable perioperative outcomes relative to primary FEVAR (Table I). However, in the FEVAR, after EVAR group, 1-year sac regression rates were lower (24% vs 51%; P = .005), whereas sac expansion was more likely (39% vs 7.3%; P < .001) compared with the primary FEVAR group (Table II). At 2-year follow-up, FEVAR after EVAR was associated with similar mortality (26% vs 19%; hazard ratio: 1.4, 95% confidence interval: 0.84-2.2; P = .20) and reinterventions (14% vs 13%; hazard ratio: 1.04, 95% confidence interval: 0.36-3.0; P = .91) compared with primary FEVAR. FEVAR after EVAR has a similar risk of perioperative and 2-year mortality compared with primary FEVAR. However, the higher rate of sac expansion at 1 year in these patients raises significant concerns about the durability of these repairs. Therefore, patients undergoing FEVAR after EVAR may benefit from closer surveillance or even consideration for open conversion. Future studies should evaluate open conversion as an alternative to endovascular treatment for proximal failure of EVAR.Table IPerioperative outcomes after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 2373)FEVAR after EVAR (n = 130)P valueFEAVR after EVAR vs primary FEVARP valueUnadjusted rates, %Adjusteda OR [95% CI]Perioperative death2.82.3.800.62 [0.13-2.2].50Any complication9.611.770.65 [0.29-1.4].30 Stroke0.60.66NANA AKI1214.700.75 [0.38-1.4].4 Postoperative dialysis1.72.3.740.73 [0.10-3.28].71 Bowel ischemia1.91.51.01.4 [0.18-6.2].71 Spinal cord ischemia1.53.1.270.85 [0.11-4.0].85 Leg ischemia1.92.3.740.68 [0.10-3.0].65 Pulmonary complications3.64.6.620.70 [0.21-2.0].52 Cardiac complications3.53.81.00.53 [0.14-1.6].30 Completion type 1A endoleak3.40.8.120.32 [0.02-1.73].29Reintervention during index hospitalization4.26.2.380.73 [0.48-1.1].12Unadjusted rates, %P valueAdjusteda HR [95% CI]P value2-year reintervention1314.201.04 [0.36-3.0].912-year mortality1926.701.4 [0.84-2.2].20AKI, Acute kidney injury; CI, confidence interval; EVAR, endovascular aortic repair; FEVAR, fenestrated EVAR; HR, hazard ratio; OR, odds ratio.aAdjusted for age, gender, diameter (>65 mm), hypertension, diabetes, prior myocardial infarction, prior chronic obstructive pulmonary disease, obesity, prior chronic kidney disease, anemia, proximal sealing zone, center volume, and physician volume. Open table in a new tab Table IISac dynamics at 1 year after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 853), %FEVAR after EVAR (n = 33), %P valueSac regression, >5 mm5124.005Stable sac, <5 mm4232.67Sac expansion, >5 mm7.339<.001EVAR, Endovascular aortic repair; FEVAR, fenestrated EVAR.Boldface P value represents significance P < .05. Open table in a new tab

Mortality and Survival Following Early TEVAR for Complicated and Uncomplicated Type B Dissection

The use of thoracic endovascular aortic repair (TEVAR) to treat patients with both uncomplicated and complicated acute type B aortic dissections (tB-Ad) continues to rise, yet there exists limited national data evaluating outcomes and predictors of adverse events. Therefore, we compared the presentation and clinical features of early TEVAR for complicated and uncomplicated aortic dissections as well as outcomes and survival following repair. We queried the Vascular Quality Improvement registry (2011-2022) for TEVAR cases for acute (<2 weeks) and subacute (2-12 weeks) tB-Ad, dichotomizing patients into uncomplicated vs complicated dissections. Complicated dissection was defined as presentation with visceral malperfusion, rupture, or rapidly increasing aortic size, with uncomplicated dissection including all other presentations. Outcomes included postoperative morbidity and mortality, thoracoabdominal life-altering events (TALE defined as a composite of stroke, death, dialysis, or paraplegia), and 3-year survival. Risk adjusted analyses were performed using logistic regression clustering by center and Cox proportional hazard regression. Among 1749 patients treated for acute and subacute tB-Ad, 775 (44%) presented with complicated dissections. Patients with complicated dissection were more likely to be male (70% vs 61%; P < .01) and older (61.3 vs 59.7 years; P < .02), with longer procedural time (150 minutes vs 115 minutes; P < .01). Complicated dissections had higher unadjusted rates of 30-day mortality (16% vs 4.4%; P < .01), spinal cord ischemia (11% vs 4.6%; P < .01), stroke/transient ischemic attack (8.9% vs 4.7%; P < .01), new dialysis (5.8% vs 1.2%; P < .01), TALE (31% vs 12%; P < .01), and higher reintervention during index hospitalization (21% vs 9.0%; P < .01). Furthermore, complicated dissections had lower 3-year survival (82% vs 72%; P < .01) (Figure). After adjustment, complicated dissection was independently associated with higher odds of 30-day mortality (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.4; P < .01) and postoperative complications (OR, 1.9; 95% CI, 1.5-2.4; P < .01). Factors associated with increased three-year mortality included emergency repair (hazard ratio [HR], 2.3; 95% CI, 1.5-3.4]; P < .01), preoperative dialysis (HR, 2.8; 95% CI, 1.7-4.7; P < .01), and coronary artery disease (HR, 1.7; 95% CI, 1.2-2.4; P < .01). These data present contemporary results of TEVAR for tB-Ad, showing excellent mortality and morbidity for both uncomplicated and complicated presentations as compared to prior reports of medical and operative therapy. In light of these findings, and the risk of late aortic-related mortality shown in the literature, early aggressive intervention with TEVAR remains a necessity for complicated presentation and should be strongly considered in patients with acute uncomplicated tB-Ad. Further analyses regarding optimal timing for TEVAR in patients with tB-Ad are warranted.

Association of Procedure Time With Clinical and Procedural Outcome in Patients With Basilar Occlusion Undergoing Embolectomy.

Previous studies have demonstrated the association between the procedure time (PT) and outcomes for patients with proximal large vessel occlusion; however, whether the relationship remains for patients with acute basilar artery occlusion (ABAO) was not clear. We aimed to characterize the association between PT and other procedure-related variables on clinical outcomes among patients with ABAO who underwent endovascular treatment (EVT). Patients with ABAO who underwent EVT with a documented PT in the EVT for Acute Basilar Artery Occlusion (BASILAR) study from January 2014 to May 2019 among 47 comprehensive centers in China were included. Multivariable analysis was performed to reveal the association between PT and 90-day modified Rankin Scale score, mortality, complications, and all-cause death at 1 year. Of the 829 patients from the BASILAR registry, 633 eligible patients were included. Longer PT were associated with a lower rate of favorable outcome (by 30 minutes, adjusted OR 0.82 [95% CI 0.72-0.93], p = 0.01). In addition, a PT ≤ 75 minutes was associated with a favorable outcome (adjusted OR 2.03 [95% CI 1.26-3.28]). The risk of complications and mortality increased by 0.5% and 1.5% with every 10 minutes increase in PT, respectively (R2 = 0.64 and R2 = 0.68, p < 0.01). The cumulative rates of favorable outcomes and successful recanalization plateaued after 120 minutes (2 attempts). Restricted cubic spline regression analysis for the probability of favorable outcomes had an L-shape association (p nonlinearity = 0.01) with PT with significant benefit loss before 120 minutes and then appeared relatively flat. For patients with ABAO, procedures that exceeded 75 minutes were associated with an increased risk of mortality and lower odds of a favorable outcome. A careful assessment of futility and the risks of continuing the procedure should be made after 120 minutes.

Recent advances in endoscopic management of gastric neoplasms

The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.

Outcomes of Catheter-Based Interventions for the Treatment of Intermediate to High-Risk Pulmonary Embolism in Patients With High Bleeding Risk: A Single-Centre Experience

Background Catheter-based reperfusion therapy is considered an alternative treatment for intermediate to high-risk pulmonary embolism (PE). These therapies can be divided into catheter-directed thrombolysis and catheter-based thrombectomy. High bleeding risk (HBR) were generally excluded from previous studies. Outcomes of these two treatment modalities in patients with high-risk PE are limited. Method This is a single centre retrospective cohort study of patients who were admitted for intermediate to high-risk PE and who were treated with catheter-based interventions due to contraindications for systemic thrombolysis. Baseline demographics, procedural details, clinical outcomes including 30 days PE-related mortality, and bleeding complications including blood transfusion and incidence of ICH were reported. Result 28 patients with acute PE (mean age 58 years) and contraindications for systemic thrombolysis were included in this study, of which 8 (28%) were high-risk. 14 patients (42.9% high and 57.1% intermediate-risk) were treated by aspiration thrombectomy (AT) and 14 (14.3% high and 85.7% intermediate-risk) by ultrasound-assisted catheter-directed thrombolysis (USCDT). There were 3 (10.7%) PE related mortality within 30 days. All of them were high-risk PE and in the USCDT arm. Overall incidence of moderate to severe bleeding was 41.7% (50% in AT and 21.4% in USCDT arm) and most of these patients required blood transfusion. The procedural time were 107.6 minutes for AT and 57.1 minutes for USCDT. Conclusion Catheter-based interventions with either aspiration thrombectomy or ultrasound assisted catheter-directed thrombolysis are viable treatment option for intermediate to high-risk pulmonary embolism in patients with high bleeding risk. Aspiration thrombectomy was associated with lower mortality rate in high-risk patients but higher incidence of blood transfusion and longer procedural time.

Weekday vs. weekend oocyte retrievals: is there a difference?

The purpose of this study was to evaluate whether there is a difference in procedure duration and time spent in the post anaesthesia care unit (PACU) between weekday (WD) and weekend (WE) oocyte retrievals (ORs). This was a retrospective cohort study of patients compared and stratified based on number of oocytes retrieved (1–10, 11–20, and >20). Student’s t-test and linear regression models were used to assess the relationship between AMH, BMI, and a number of oocytes retrieved with the duration of procedure and total time spent in the PACU. 664 patients underwent OR of which 578 met inclusion criteria and were analyzed. There were 501 WD OR cases (86%) and 77 (13%) WE ORs. When stratified by number of oocytes retrieved, there was no difference in procedure duration or PACU time between WD vs. WE OR. Longer procedure times were associated with higher BMI (p = 0.04), AMH (p = 0.01) and oocytes retrieved (p < 0.01). Increased PACU times positively correlated with the number of oocytes retrieved (p = 0.04), but not AMH or BMI. While BMI, AMH, and number of oocytes retrieved are associated with longer intra-operative and post-operative recovery times, there is no difference in procedure or recovery time when comparing WD vs. WE procedures.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review.

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Radiation dose and factors related to exceeding the diagnostic reference level in 496 transnasal ileus tube placement procedures from the REX-GI study.

We aimed to examine the factors contributing to radiation exposure exceeding the DRL of the transnasal ileus tube placement in this post hoc analysis from the cohort of the REX-GI study. Patients with transnasal ileus tubes were enrolled in the rex-gi study from may 2019 to december 2020. We investigated the endoscope insertion time (min), procedure time (min), tube insertion length (cm), fluoroscopy time (FT: min), air kerma at the patient entrance reference point (Ka.r: mGy), and air kerma-area product (PKA: Gycm2). The third quartile value of the PKA value was calculated as the diagnostic reference level (DRL) value. We explored the factors associated with radiation exposure exceeding the DRL. In the REX-GI study, 496 patients who underwent transnasal ileus tube placement were enrolled. The median age of the patients was 71 years. The median endoscopy insertion time, procedure time, and tube insertion length were 6 min, 20 min, and 170 cm, respectively. The third quartile/median FT, Ka.r, and PKA were 18/11.9 min, 99.2/54.4 mGy, and 46.9/28 Gycm2, respectively. The third quartile value of PKA (47 Gycm2) was set as the DRL value. There were differences in distribution by the hospital. Compared with procedures under the DRL, the FT (19 vs 10 min), procedure time (25 vs 18 min), and tube insertion length (185 vs 165 cm) were significantly longer for procedures above the DRL. We report the DRL for transnasal ileus tube placement in Japan. A longer procedure time and tube insertion length may be associated with DRL exceedance. Transnasal ileus tube placement under fluoroscopy guidance is a standard clinical procedure for bowel obstruction. However, the appropriate radiation dose level has not yet been established.We report the (DRL) for transnasal ileus tube placement in Japan. A longer procedure time and tube insertion length may be associated with DRL exceedance.

A prospective assessment of the medic autologous blood transfusion skills for field transfusion preparation.

Data demonstrate the benefit of blood product administration near point-of-injury (POI). Fresh whole blood transfusion from a pre-screened donor provides a source of blood at the POI when resources are constrained. We captured transfusion skills data for medics performing autologous blood transfusion training. We conducted a prospective, observational study of medics with varying levels of experience. Inexperienced medics were those with minimal or no reported experience learning the autologous transfusion procedures, versus reported experience among special operations medics. When available, medics were debriefed after the procedure for qualitative feedback. We followed them for up to 7 days for adverse events. The median number of attempts for inexperienced and experienced medics was 1 versus 1 (interquartile range 1-1 for both, p = .260). The inexperienced medics had a slower median time to needle venipuncture access for the donation of 7.3 versus 1.5 min, needle removal after clamping time of 0.3 versus 0.2 min, time to bag preparation of 1.9 versus 1.0 min, time to IV access for reinfusion of 6.0 versus 3.0 min, time to transfusion completion of 17.3 versus 11.0 min, and time to IV removal of 0.9 versus 0.3 min (all p < .05). We noted one administrative safety event in which an allogeneic transfusion occurred. No major adverse events occurred. Qualitative data saturated around the need for quarterly training. Inexperienced medics have longer procedure times when training autologous whole blood transfusion skills. This data will help establish training measures of performance for skills optimization when learning this procedure.

Risk factors for postoperative anastomotic leakage after repair of esophageal atresia: a retrospective nationwide database study.

Postoperative anastomotic leakage is the most frequent short-term complication of esophageal atresia repair in neonates. We conducted this study using a nationwide surgical database in Japan to identify the risk factors for anastomotic leakage in neonates undergoing esophageal atresia repair. Neonates diagnosed with esophageal atresia between 2015 and 2019 were identified in the National Clinical Database. Postoperative anastomotic leakage was compared among patients to identify the potential risk factors, using univariate analysis. Multivariable logistic regression analysis included sex, gestational age, thoracoscopic repair, staged repair, and procedure time as independent variables. We identified 667 patients, with an overall leakage incidence of 7.8% (n = 52). Anastomotic leakage was more likely in patients who underwent staged repairs than in those who did not (21.2% vs. 5.2%, respectively) and in patients with a procedure time > 3.5h than in those with a procedure time < 3.5h (12.6% vs. 3.0%, respectively; p < 0.001). Multivariable logistic regression analysis identified staged repair (odds ratio [OR] 4.89, 95% confidence interval [CI] 2.22-10.16, p < 0.001) and a longer procedure time (OR 4.65, 95% CI 2.38-9.95, p < 0.001) as risk factors associated with postoperative leakage. Staged procedures and long operative times are associated with postoperative anastomotic leakage, suggesting that leakage is more likely after complex esophageal atresia repair and that such patients require refined treatment strategies.

476 Technical and Clinical Outcomes in Concurrent Multivessel Occlusions Treated With Mechanical Thrombectomy: Insights from the STAR Collaboration

INTRODUCTION: Endovascular thrombectomy(EVT) has become the mainstay treatment of large vessel occlusion, however its role in the treatment of patients with simultaneous multi-territory occlusions(MVOs) has not been established. METHODS: We reviewed the STAR registry and included patient data from 35 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions from 2017-2020. RESULTS: We included a total of 7723 patients who underwent EVT for acute ischemic stroke. 54 patients (0.7%) underwent EVT for MVOs (mean age 69 ± 12.5; Female 50%). 28% had bilateral and 72% had concurrent anterior and posterior circulations occlusions. We used propensity score matching to match patients with MVOs to another group with single vessels occlusions by age, gender, race, admission NIHSS, baseline mRS score, onset to groin, use of IV-tPA. The rate of recanalization (TICI2B/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the 2 groups. Multivariate analysis confirmed that MVOs was not a predictor of poor functional outcome, increased symptomatic hemorrhage, or longer procedure time. CONCLUSIONS: Compared to single vessel occlusions, EVT in appropriately selected MVOs has similar efficacy and safety profile.