Lower Technical Success Rates Research Articles

Impact of Postprocedural Graft Flow on Outcomes Following Chronic Total Occlusion Intervention in Postcoronary Artery Bypass Graft Patients: A Detailed Angiographic Analysis

Chronic total occlusions (CTOs) are frequent in patients with previous coronary artery bypass graft (CABG) surgery. Percutaneous coronary intervention (PCI) is the usual revascularization strategy. Whether or not the presence of a graft on a CTO vessel and post-PCI graft patency impacts outcomes after CTO-PCI is unknown. We sought to evaluate the impact of post-PCI graft patency on the durability of CTO-PCI. In total, 259 patients with previous CABG who underwent CTO-PCI in 12 international centers in 2019 to 2023 were categorized into "grafted" and "ungrafted" groups based on the presence of graft on a CTO vessel. The grafted group was subdivided into "graft-occluded" and "graft-patent" groups, depending on graft patency. The primary end points were (1) technical success rate, (2) target vessel failure, and (3) CTO failure rates at 1 year. CTO failure was defined as target vessel revascularization and/or significant in-stent restenosis. A total of 199 patients (77%) were in the grafted group. Grafted CTOs showed higher complexity and lower technical success rates (70% vs 80%, p = 0.004) than nongrafted CTOs. Of the grafted CTOs, 140 (70%) were in the grafted-occluded group and 59 (30%) were in the grafted-patent group. The technical success was lower in the former group (65% vs 81%, p = 0.022). An occluded graft was an independent predictor of technical failure (odds ratio 2.04, 95% confidence interval 1.03 to 4.76, p = 0.049) and persistent post-PCI graft patency was a strong independent predictor of CTO failure at 1 year (hazard ratio 5.6, 95% confidence interval 1.2 to 27.5, log-rank p = 0.033). In conclusion, in patients with previous CABG who underwent CTO-PCI, post-PCI graft patency was a significant predictor of CTO failure.

Comparison between Endoscopic Ultrasound-Guided Antegrade and Transluminal Stent Implantation in Distal Malignant Biliary Obstruction after Failed ERCP.

Distal malignant biliary obstruction (DMBO) can result in obstructive jaundice. Endoscopic ultrasound- (EUS-) guided biliary drainage (EUS-BD) has been an alternative for DMBO after failed ERCP. To compare the efficacy and safety between antegrade and transluminal approaches in patients with unresectable DMBO when ERCP failed. Patients with DMBO leading to obstructive jaundice after failed ERCP were enrolled in this study. We retrospectively evaluated the safety and efficacy between EUS-guided transluminal stenting (TLS group) and antegrade stenting (AGS group). 82 patients were enrolled, of which 45 patients were in TLS group and 37 in AGS group. There were no statistical differences in the malignancy type, baseline common bile duct diameter, total bilirubin level, reason for EUS-BD, and history of biliary drainage between TLS and AGS groups. The technical success rate was statistically higher in TLS group than in AGS group (97.8 vs. 81.1%, P = 0.031). There were no statistical differences in clinical success rate, procedure-related adverse events, stent migration rate, stent dysfunction rate, reintervention rate, and overall patient survival time between TLS and AGS groups. The median time to stent dysfunction or patient death in TLS and AGS groups was 53 and 81 days, respectively (P = 0.017). Although AGS had a lower technical success rate than TLS, it was superior to TLS in stent patency in patients with DMBO.

Lumen-apposing metal stents versus traditional self-expanding metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis.

Endoscopic drainage has become the preferred treatment for pancreatic fluid collections (PFCs). There is still a lack of reliable evidence to prove which metal stent is the best choice for endoscopic ultrasound (EUS)-guided drainage of PFCs. In this study, we aimed to evaluate the efficacy and safety of lumen-apposing metal stents (LAMS) compared to traditional self-expanding metal stents (SEMS) in meta-analysis. We systematically searched PubMed, Embase, Web of Science, and Cochrane Library up to July 15, 2023. Relevant publications that compared LAMS with traditional SEMS for drainage of patients' PFCs under EUS-guidance were included. This meta-analysis assessed endpoints using Review Manager 5.3 and Stata 14.0 statistical software. Nine citations comprising 707 patients with PFCs were included. The clinical success rate of LAMS tended to be higher than that of SEMS (RR = 1.07, 95%CI [1.00, 1.15], P = 0.05). LAMS had a lower technical success rate (RR = 0.97, 95%CI [0.94, 0.99], P = 0.02) and faster procedure time (minutes) (MD = - 24.29, 95%CI [- 25.59, - 22.99], P < 0.00001) compared to SEMS. In addition, LAMS had fewer overall adverse events (RR = 0.64, 95%CI [0.48, 0.87], P = 0.004). For specific adverse events, LAMS had fewer migration (RR = 0.37, 95%CI [0.19, 0.72], P = 0.003), occlusion (RR = 0.43, 95%CI [0.22, 0.82], P = 0.01) and infection (RR = 0.38, 95%CI [0.20, 0.70], P = 0.002). There was no significant difference in bleeding and perforation between the two stents. For hospital stay (days), LAMS group was similar to SEMS group (MD = - 3.34, 95%CI [- 7.71, - 1.03], P = 0.13). Regarding recurrence, LAMS group was fewer than SEMS group (RR = 0.41, 95%CI [0.21, 0.78], P = 0.007). Compared to traditional SEMS, LAMS has a higher clinical success rate, faster procedure time, fewer adverse events, similar hospital stay and lower recurrence rate in EUS-guided drainage of PFCs. LAMS is a good choice with a high technical success rate over 95%, and using a shorter length or "one-step" operation can further improve it. Richer placement experience is required for LAMS placement under EUS-guidance.

The Effect of Age on Peri-Operative Outcomes after FEVAR.

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor. A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest. During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest. In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Thoracic Duct Embolization Using Transabdominal Antegrade and Transcervical Retrograde Accesses

PurposeTo evaluate the technical success and clinical outcomes of thoracic duct embolization (TDE) using transabdominal antegrade and transcervical retrograde accesses to treat patients with chyle leak. Materials and MethodsThis study was a retrospective, nonblinded, single-institution chart review of all patients aged 18 years or older over a 6-year time frame who underwent lymphangiography with attempted TDE for iatrogenic or spontaneous chyle leaks using transabdominal antegrade and/or transcervical retrograde accesses. ResultsNinety-nine patients underwent 113 procedures. Eighty-five patients underwent 1 procedure, and 14 patients required 2 procedures. The technical success rate of TDE was 68% (72/106) with transabdominal antegrade access and 44% (15/34) with transcervical retrograde access. The overall technical success rate of TDE, including both the access methods, was 77% (87/113). The most common reasons for transabdominal access failure were small caliber of the cisterna chyli and thoracic duct (TD) occlusion. Five patients were lost to follow-up. Overall clinical success, defined as resolution of the chyle leak, was achieved in 83% (78/94) of the patients. There were 6 Society of Interventional Radiology (SIR) level 1 adverse events (AEs), 5 SIR level 2 AEs, and 2 SIR level 3 AEs. Nontarget embolization occurred in 2 patients. ConclusionsAlthough transcervical retrograde TDE is a challenging procedure, with a lower technical success rate than transabdominal antegrade access, retrograde access improved the technical and clinical success rates of the treatment of chyle leaks in cases of thoracic duct occlusion, small cisterna chyli, and leaks located in the abdomen.

HOW WE DO IT: the Keystone flap for large skin defects: our experience with 30 consecutive cases

Background The keystone perforator-based fasciocutaneous island flap is a method of locoregional skin defect reconstruction, consisting of two conjoined V to Y advancement flaps. In this article, we report a series of 30 consecutive cases in various body parts with the aim to demonstrate the versatility of the keystone flap in the reconstruction of various skin defects after removal of a suspected malignant skin lesion and evaluate our clinical experience while maintaining oncological safety and good aesthetic results. Methods Patients who underwent keystone flap reconstruction between January 2016 and January 2021 were retrospectively reviewed. Their demographics, operative details, oncological data and postoperative details were obtained from the institution’s internal electronic patient records system. Results The majority of the skin defects were the result of an oncologic resection (97%, n = 29) and were located in the pretibial region (47%, n = 14). In five cases (17%) there was a need for a double keystone flap to cover the skin defect. One or more risk factors (hypertension, smoking, anticoagulation, …) were identified in 22 patients (73%). Minor complications (partial wound dehiscence, effusion or surgical site infection) occurred in ten cases (33%) which were resolved with conservative wound management or systemic antibiotics. There were no major postoperative flap-related complications such as flap failure or need for re-surgery. Conclusion In our experience, the keystone island flap is an effective and reliable technique to attain a single stage tension-free closure of large skin defects. Due to its low technical complexity and high success rate, we consider it a feasible alternative to other reconstructive flaps and grafts for direct closure of secondary defects.

Surgical therapy for chronic internal carotid artery occlusion: a systematic review and meta-analysis.

Chronic internal carotid artery occlusion (CICAO) significantly increases the risk of recurrent stroke. Given unfavorable outcomes, revascularization procedures are not generally recommended for CICAO. In the last several years, loads of studies reported successful surgical revascularization for CICAO with promising success rate and favorable short-term outcomes. Meanwhile, due to the lack of high-quality evidence, the safety and efficacy of revascularization procedures remain debatable. This systematic review aims to scrutinize current evidence for the applicability of revascularization for CICAO. We also investigated potential predictors of postoperative prognosis. We searched clinical studies on surgical treatment of CICAO on the Medline, Cochrane library, and Embase databases, published from Jan 1990 to Jan 2021. Surgical operation was restricted to bypass surgery, endarterectomy, endovascular therapy, and hybrid surgery. Controlled clinical studies were included for clinical outcomes. Large-sample single-arm studies were supplemented to assess complications and success rate. Co-primary endpoints were technical success rate and neurological function; secondary endpoints were recurrent stroke/cerebrovascular events, complications, and deaths within follow-up. This systematic review has been registered in PROSPERO (CRD42020181250). One RCT and 5 cohort studies with a total of 465 patients were included in this review. Seven single-arm studies were supplemented for assessing success rate and complications. Bypass surgery presented the highest graft patency of 96% and a low incidence of complications, but no benefits on neurological function, recurrent stroke, or deaths. Endovascular therapy (carotid stenting) was characterized by a relatively lower technical success rate, significant neurological function recovery, and nonsignificant reduction of cerebrovascular events and deaths. Hybrid surgery was considered as a potential treatment for CICAO because of a high technical success rate and significant neurological improvement. Endarterectomy is only suitable for short-segment occlusion. Prospective clinical trials should focus on carotid stenting and hybrid surgery for their significant capacity of improving neurologic function and potential capacity of reducing deaths and cerebrovascular events.

Effect of Complete Revascularization vs. Staged PCI of Secondary Lesion on LV Systolic Function in Patient with STEMI

After a myocardial infarction, early restoration of normal coronary perfusion reduces infract size, preserves left ventricular function, and lowers mortality. Reperfusion therapy's major goal is to not only restore the culprit epicardial vessel's patency, but also to reperfuse tissue to preserve myocyte viability and hence LV function. The pathophysiology of myocardial infarction, on the other hand, is not limited to the culprit vessel. The treatment of non-culprit lesions in STEMI is a contentious issue. Previously published guidelines (the 2011 PCI and 2013 STEMI guidelines) recommended treating the culprit lesion only if the patient was in cardiogenic shock. These guidelines are based on expert opinions rather than randomized controlled trials, which take into account safety concerns such as complications from repeated intervention, a low technical success rate, a high incidence of coronary restenosis, and renal insufficiency after contrast agent use. The aim of this work is to Long-term outcomes Lt ventricular ejection fraction (6 months) between complete revascularization and culprit-only revascularization (followed by staged percutaneous coronary intervention of secondary lesions) in STEMI patients with multi vessel coronary disease undergoing primary angioplasty. This prospective analysis included 50 patients with acute ST elevation myocardial infarction who were amenable to primary coronary intervention and were admitted to the critical care unit. And was blindly randomized alternatively into 2 groups: Group A: Complete coronary revascularisation during primary percutaneous intervention. Group B: Culprit-only revascularization during primary PCI. This study enrolled 50 patients, 35 males (70%) and 15 females (30%); in G I, there were 18 males (72%) and 7 females (18%) while in G II there were 17 males (68%) and 8 females (32%). The age ranged from 34 yrs. to 82 yrs. with mean age: In G I was 61.6 (±8.9) In G II was 62.2 (±12.9) were enrolled in this study, pre-procedural EF% (Mean±St) there was no significant difference between both groups. In G I, patients had a mean EF% 49.9±10.1 Versus 48.0±11.3 seen in G II. (P=0.54) In G I, there was no a significant difference between pre- procedural versus post-procedural mean EF%. (P=0.53) In G II, there was no a significant difference between pre-procedural versus post-procedural mean EF%. (P=0.14) We concluded that There were no significant differences between infarct-related artery revascularization and multivessel revascularization in the rates of 6-month MACE, Also, there were no differences as regard in-hospital mortality, stroke, cardiogenic shock and reinfarction, ejection fraction.

Technical and clinical outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in patients with COVID-19.

Background:The unprecedented situation caused by the coronavirus disease 2019 (COVID-19) pandemic has profoundly affected endoscopic practice in regard to access, volume, and workflow. We aimed to assess the potential changes in the technical outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures carried out in patients with confirmed SARS-CoV-2 infection.Methods:We conducted an international, multicenter, retrospective, matched case-control study of ERCP procedures carried out in patients with confirmed COVID-19. The main outcome was technical success of the procedure as assessed by the endoscopist, and the secondary outcome was the development of procedure-related adverse events. Each case was matched in a 1:4 ratio with controls extracted from each center’s database in order to identify relevant changes in outcome measures compared with the pre-pandemic era.Results:Eighteen procedures performed in 16 COVID-19 patients [14 men, 65 years (9–82)] and 67 controls were included in the final analysis. Technical success was achieved in 14/18 COVID-19 cases, which was significantly lower as compared with the control group (14/18 versus 64/67, p = 0.034), with an endoscopic reintervention required in 9/18 cases. However, the rate of procedure-related adverse events was low in both groups (1/18 versus 10/67, p = 0.44). On multivariable analysis, COVID-19 status remained the only risk factor for technical failure of the procedure [odds ratio of 19.9 (95% confidence interval 1.4–269.0)].Conclusions:The COVID-19 pandemic has affected the volume and practice of ERCP, resulting in lower technical success rates without significantly impacting patient safety. Prioritizing cases and following recommendations on safety measures can ensure good outcome with minimal risk in dedicated centers.

Relationship of chronic occlusion site of internal carotid artery to the outcome of recanalization

Objective To investigate the relationship of chronic occlusion site of internal carotid artery (ICA) to the outcome of recanalization. Methods The patients with chronic symptomatic occlusion of ICA who were treated by endovascular revascularization or hybrid surgery at Cerebrovascular Division of Interventional Therapy Center, Henan Provincial People's Hospital from May 2015 to May 2017 were retrospectively reviewed. According to the location of ICA occlusion, the patients were divided into 2 types: Type Ⅰ occlusion and Type Ⅱ occlusion. Type Ⅰ occlusion was located from cervical segment to the cavernous segment and below, whereas Type Ⅱ occlusion was originated from cervical segment to the clinoidal segment and beyond.Comparison was conducted on the rates of technical success and re-occlusion after operation between Type Ⅰ occlusion and Type Ⅱ occlusion. Results Forty-five patients with chronic symptomatic ICA occlusion had a total technical success rate of 91.1% (41/45). The technical success rate was 100.0% (25/25) in Type Ⅰ occlusion and 80.0% (16/20) in Type Ⅱ occlusion, and the difference was statistically significant (χ2=5.040, P=0.025). Among the 41 patients who were successfully recanalized, 40 acquired clinical follow-up with a median of 12 months(range: 4-36 months). The rate of re-occlusion was 0% (0/25) in Type Ⅰ occlusion and 26.7% (4/15) in Type Ⅱ occlusion with statistical difference (χ2=8.821, P=0.003). Conclusions Patients with Type Ⅰ occlusion seem to have high technical success rate and low re-occlusion rate, which can be treated to improve the outcome. Type Ⅱ occlusive patients have relatively low technical success rate whereas high re-occlusion rate, which should be comprehensively evaluated before operation. Key words: Carotid artery, internal; Arterial occlusive diseases; Endovascular procedures; Hybrid surgery; Treatment outcome

Predictors of outcome for endoscopic colorectal stenting: a decade experience.

Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting. A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome. Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90%) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22% of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95% confidence interval (CI) 0.1-0.8]; p=0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95% CI 1.4-10.3]; p=0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95% CI 1.0-10.0]; p=0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95% CI 1.5-11.7]; p=0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95% CI 2.6-71.2]; p=0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95% CI 1.3-16.2]; p=0.017). Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.

Abstract 17605: Cost-Effectiveness of Contemporary Endovascular Treatment Compared to Open Surgical Revascularization for Cardioembolic Acute Limb Ischemia

Introduction: Treatment of acute limb ischemia (ALI) has a high morbidity and mortality given patients’ multiple comorbidities, poor physiologic reserve, and the need for emergent intervention. Traditionally ALI of embolic origin has been treated with open revascularization (OR), however with increasing experience with thrombolytic therapy and adjuvant techniques, endovascular revascularization (ER) for ALI has become a more common treatment due to the lower associated morbidity and mortality. Hypothesis: Although associated with higher initial costs and lower technical success rates, ER will be cost effective given the decreased adverse event rate and mortality in a frail patient population. Methods: A Markov state-transition model was created to simulate patient oriented outcomes, including technical success, adverse events, limb salvage, discharge facility and quality adjusted life years (QALY) for patients presenting with Rutherford Classification I/IIa/IIb ALI secondary to cardiac embolism. A societal perspective was assumed with a 10-year time horizon. Parameter estimates were derived from published literature and primary data of cardioembolic ALI patients treated at our institution from 2005-2011 with either ER or OR. Costs were adjusted to 2013 U.S. dollars. Results: In the model, OR was technically successful in 87% patients, with a $23,881 cost for the initial hospitalization and a 11.5% perioperative mortality rate; ER was technically successful in 71% of patients, with a $39,619 initial cost, and a 4% mortality rate. At 10 years, the ER strategy cost $92,659/QALY gained compared to OR. Sensitivity analyses demonstrated that ER was favorable at a willingness to pay (WTP) threshold of $100,000/QALY when ER technical success was &gt;70%, initial ER hospitalization cost was &lt;$41,052 or if OR mortality was &gt;10%. At a WTP of $50,000/QALY, ER was cost effective if technical success reached 79%, if ER cost was &lt;$31,287 or if OR mortality was &gt;23%. Conclusions: Contemporary endovascular treatment of cardioembolic ALI carries a greater cost compared to open revascularization, however it is associated with a decreased mortality rate. ER is potentially cost-effective in patients who are at high risk of post-operative mortality following OR.

Endoscopic approaches to enteral feeding and nutrition core curriculum

Endoscopic approaches to enteral feeding and nutrition core curriculum

Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry

ObjectiveTo investigate the impact of prior coronary artery bypass graft (CABG) surgery on the outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).DesignObservational retrospective study.SettingThree tertiary hospitals in...

Endoscopic ultrasound-guided fine needle aspiration in cystic pancreatic lesions: is it still controversial?

We read with great interest the article by K. de Jong et al. entitled “Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study” [1]. The authors performed endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in 128 patients with pancreatic cystic lesions of varying sizes. The authors reported a very low technical success rate for FNA in their consecutive patients because adequate cellular material and sufficient fluid for biochemical analysis were obtained in only 44 out of 128 patients (34 %) and 68 out of 128 (53 %) respectively. They reported no significant difference between the sizes of the cysts in cases with or without a classifying diagnosis, or between cases from which sufficient fluid for biochemical analysis was or was not obtained. Nevertheless, they indicated that EUS-FNA was a safe technique that could be performed with a very low complication rate (2.4 %).

Stenting as a bridge to surgery for colorectal cancer

We read with interest the article by Jeanin van Hooft and colleagues, and congratulate them on their accomplishment, especially in an emergency setting. However, this trial raises ethical and oncological dilemmas that deserve comment. First, in 1996, the American Society of Clinical Oncology stated that overall survival and quality of life should be regarded as the main patient outcomes in clinical oncology. Quality of life is particularly important when survival is equivalent for diff erent treatments. Van Hooft and colleagues did not justify the omission of survival data in their trial. Second, the trial was stopped early because of safety concerns; there was a high perforation rate, six of 47 patients (12·8%), and low technical success rate (70%, 33 of 47 patients) in the stenting group. The investigators discussed the various reasons for these poor outcomes. However, those in favour of the use of stents could argue that better external validity of the data is needed; do 20 stent placements represent suffi cient surgical experience? What is the mean number of stents placed per month per endoscopist? The uncertainty principle, or equipoise, is a fundamental scientifi c and ethical principle for randomised clinical trials. From the results of existing trials it would seem that uncertainty regarding colonic stenting versus surgery no longer exists because, to our knowledge, three of the four previous randomised clinical trials in this discipline were stopped for safety reasons. In these three trials, the cumulative mortality rates were similar after stenting as a bridge to surgery and surgery alone (7·9% [eight of 105 patients] vs 5·7% [six of 105], respectively). Systematic reviews of stenting show a median clinical perforation rate of 4% (range 0–83%). This rate seems to be acceptable to most authors. However, if a surgeon reported such a rate of surgical perforation, he would almost certainly need to retrain. Cancer perforation can jeopardise the future of patients by changing a potentially curable disease into an incurable one. In addition to the clinical perforation, researchers have reported a high rate of silent perforation, which could compromise survival even if this risk has not yet been shown. Taking into account that stenting can lead to a high perforation rate (and the oncological consequences of that), along with the unknown oncological outcome after stenting, van Hooft and colleagues’ proposal of further randomised trials is troubling. Trials in such a setting would not respect the uncertainty principle. Before a new trial is undertaken, we should know the eff ect of stenting on survival and local recurrences, which could be achieved by establishment of a registry to include survival data for all patients receiving colonic stents. We suggest that colonic stenting as bridge to surgery should no longer be done routinely until such robust survival data are available.

The UK nephrostomy audit. Can a voluntary registry produce robust performance data?

To investigate the effectiveness of the Royal College of Radiologists Audit Sub-Committee's national prospective registry of percutaneous nephrostomy, which enables participants to audit their practice and compare performance with predetermined standards. Following a limited retrospective audit, which permitted setting of achievable targets, a dataset was developed and all UK NHS acute hospitals were invited to participate in web-based prospective data collection. Eighty-five out of 285 (29.8%) hospitals contributed 3262 cases over a 29 month period. A satisfactory level of performance was achieved with an overall technical success rate of 98% and a complication rate of 6.3%. Significant risk factors for complications included rigors, anaemia, and impaired renal function. Low frequency operators were shown to have a lower technical success rate and a higher complication rate than high frequency operators; however, target thresholds were exceeded in all groups. Sepsis was identified as a risk factor in the majority of serious complications and all deaths. Some anomalous results were found due to unusual interpretation of the data entry form in two centres, but no evidence of under-performance was identified at any centre. Some weaknesses of the registry are discussed. In view of the low response rate, the possibility of significant bias cannot be excluded. In addition, there is no objective verification of the data; therefore, the results have limited credibility. However, individual centres that accurately completed a representative sample of cases can have confidence that their performance achieves an acceptable standard.

Laser-assisted angioplasty for arterial occlusion of the lower limb: initial results and follow-up

A flashlamp-pumped pulsed dye laser operating at either 480 or 504 nm, coupled to an integral ball-tipped optical fibre, was used to recanalize occluded lower limb arteries. All channels created by the laser were augmented with balloon dilatation. We have treated 78 limbs in 71 patients; 46 limbs (59 per cent) had rest pain and 22 (48 per cent) of these had tissue loss. The median occlusion length was 18 (range 0.5-58) cm. Technical success was achieved in 58 limbs (74 per cent) with clinical success in 46 (59 per cent). Success rates fell with increasing length of occlusion. Two patients died in the perioperative period. A subgroup of 22 patients with marked discrete arterial calcification had a lower technical success rate than the subgroup without calcification (50 per cent versus 84 per cent, P less than 0.01). Both subgroups displayed a similar pattern of reclosure during follow-up. The cumulative patency rate after technical success was 67 per cent at 6 months and 45 per cent at 12 months. Forty-six (59 per cent) limbs avoided bypass surgery or amputation. Laser-assisted angioplasty may offer an alternative to femoropopliteal bypass, although the former procedure is not as durable.

Percutaneous bypass: subintimal recanalization of peripheral occlusive disease with IVUS guided luminal re-entry

Angioplasty of chronic total occlusions (CTOs) has lower technical success rates with longer procedure times and poorer outcomes. Subintimal recanalization remains limited by the lack of controlled re-entry into the true lumen of the target vessel. We report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound scanner to achieve controlled true lumen re-entry in patients with peripheral CTOs. In a 4-month period, 6 patients with lower extremity (LE) ischemia from CTOs were treated. Occluded segments were crossed subintimally, and controlled re-entry was secured using the CrossPoint TransAccess catheter. This 6.2 F dual-lumen catheter contains an integrated 64-element phased array intravascular ultrasound scanner enabling targeting of structures. Intravascular ultrasound-guided luminal re-entry was achieved by advancing a 24-gauge needle to a desired length and delivering a 0.014” guide wire into the target lumen. The occluded segments were balloon dilated and stented using self-expanding nitinol stents. Effective luminal re-entry and re-establishment of antegrade flow occurred in all 6 patients. Time to recanalization ranged from 5 to 10 minutes. All patients were free of ischemic symptoms at 1 to 5 month follow-up. There were no procedure-related complications. Our preliminary results demonstrate the feasibility of using this catheter system for subintimal recanalization with controlled re-entry in CTOs. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

Transluminal angioplasty of complete iliac obstructions.

Of 64 complete iliac obstructions, 50 (78%) were recanalized using the Gruntzig balloon catheter. Life-table analysis of the patency rate over a 4-year period gives a cumulative success rate of 78%. Only three of eight obstructions that involved both the common and external iliac arteries were successfully dilated. The only serious complication was distal embolization, which occurred in two cases (3.1%). Although the procedure is difficult, with a relatively low technical success rate, the high cumulative patency rate should make it an option in the treatment of all patients with totally occluded iliac artery segments.