Percutaneous Balloon Dilatation Research Articles

Percutaneous transhepatic papillary balloon dilation combined with dual-frequency double-pulse laser lithotripsy for large-diameter common bile duct stones

Objective: To evaluate the safety and efficacy of percutaneous transhepatic papillary balloon dilation (PTPBD) combined with flexible ureteroscopy-guided dual-frequency double-pulse ND:YAG (FREDDY) laser lithotripsy (PTPBD-FREDDY) for the treatment of giant (>1.5 cm diameter) common bile duct stones. Methods: A retrospective analysis was conducted on 26 patients with large-diameter difficult choledocholithiasis admitted to two medical centers from December 2017 to October 2021. Among these patients, four could not tolerate surgery or endoscopic treatment, six experienced failure of endoscopic treatment, and 16 refused to undergo endoscopic or surgical treatment. All patients underwent the PTPBD-FREDDY procedure. The FREDDY laser lithotripsy was performed under ureteroscopic guidance, followed by a balloon to push the stones into the duodenum. The primary endpoint was the technical success rate, and the secondary endpoints included the rate of stone recurrence and related complications. Results: All 26 patients successfully completed the operation, achieving a technical success rate of 100%. The average lithotripsy frequency and operation time for bilirubin stones were significantly higher than those of mixed stones and cholesterol stones (P<0.01). The main postoperative complications included mild fever (n=3), abdominal pain (n=3), nausea (n=2) and vomiting (n=1). One patient experienced biliary tract bleeding, which improved after conservative treatment. No serious complications such as pancreatitis, sepsis, or biliary perforation were observed. After 2 years of follow-up, no cases of stone recurrence were observed. Conclusions: PTPBD-FREDDY is a safe and effective treatment for patients with giant common bile duct stones. It provides a new therapeutic option for patients with giant choledocholithiasis who can not tolerate surgery or have failed endoscopic treatment, demonstrating promising prospects.

Outflow Graft Tamponade: An Underrecognized Cause of Obstruction

BackgroundLeft ventricular assist device (LVAD) outflow graft obstruction can result in severe clinical deterioration. Underlying mechanisms may vary depending on the location. Outflow graft tamponade due to external compression can be under recognized. Management of this complication varies across institutions and a uniform approach has yet to be elucidated. ObjectivesReport a single center experience with outflow graft tamponade in patients with LVAD with the purpose of developing an optimal algorithm for the diagnosis and treatment of LVAD-related outflow graft tamponade. Methods and ResultsRetrospective chart review between July 2011 and July 2020. A total of 351 LVADs were implanted at our center, with outflow graft tamponade identified in 26 patients with LVAD. Fourteen (53.8%) had HeartMate II™, 8 (30.8%) had HeartMate3™ and 4 (15.4%) had HeartWare™. Individuals presented with heart failure symptoms, an audible precordial murmur and LVAD alarms after a median duration of 862 days of support (IQR 327 - 1455). Of the 26 patients, 15 (57.7%) underwent mini thoracotomy with outflow graft relief, 4 had percutaneous balloon dilatation and stenting, 2 were bridged directly to transplant and 1 had a pump exchange. No intervention was made on the remaining due to mild symptoms (n=4). ConclusionsOutflow graft tamponade is a form outflow graft obstruction with a variable presentation that can result in significant hemodynamic compromise. It is amenable to both surgical and percutaneous interventions that restore LVAD function.

Comparing percutaneous transhepatic papillary balloon dilation with endoscopic retrograde cholangiopancreatography in elderly patients for common bile duct stones: a 3-year retrospective study.

To assess the safety and effectiveness of PTPBD for CBD stones in the elderly population. Patients aged 60years or older, who underwent PTPBD or ERCP for CBD stones between January 2021 and December 2023, were included in this study and divided into either the PTPBD group or the ERCP group based on the procedure they underwent. Baseline characteristics, intraoperative and postoperative outcomes were collected and analyzed using SPSS 25.0. A total of 145 cases were enrolled in the study. In terms of intraoperative complications, one patient in the ERCP group experienced hemorrhaging, while one patient in the PTPBD group experienced acute pain. However, neither of these patients were in a serious condition and only required observation. Stone removal procedures were successfully conducted in approximately 95% of cases in both the PTPBD and ERCP groups (95.8 and 94.8%, respectively; P > 0.999). ERCP failures were observed in one patient with a previous Billroth II anastomosis and two patients with unconventional anatomy of the esophagus and stomach. There was no statistically significant difference in postoperative complications between the PTPBD group and the ERCP group (P > 0.05). The length of hospital stays did not differ between the PTPBD group and the ERCP group (P = 0.537 > 0.05). PTPBD can be used in patients who have complicated anatomical issues that make the ERCP procedure difficult. In comparison, PTPBD is a similarly safe, effective, and minimally invasive technique for extracting CBD stones in elderly patients.

A novel technique of percutaneous transhepatic treatment of biliary-enteric anastomotic occlusive strictures with compliant balloon-occluded distal cholangiography and large-bore catheter: a retrospective case series.

Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary balloon dilatation (PTBD) is a challenge in resolving biliary-enteric anastomotic occlusive strictures (BEAOS) and/or coexisting stones. The biliary-enteric anastomosis (BEA) often cannot be seen because of the surgically altered gastrointestinal anatomy. Here, a technique that combined percutaneous compliant-occluded distal cholangiography and the maintenance of a large-bore catheter is described to resolve this issue. A retrospective review of 10 patients who presented with BEAOS with/without coexisting stones who were treated with percutaneous compliant balloon-occluded distal cholangiography, bile duct stone removal, and the maintenance of a large-bore catheter between February 2017 and January 2021 was performed. Treatment response, laboratory examinations, including hepatic function tests, routine blood tests, and blood electrolytes, complications, and imaging data were evaluated. Paired t-tests were used to investigate the difference of laboratory examinations before and after the procedure. All 10 cases were technically successful. A total of 9 stones in 6 patients were successfully removed by the compliant balloon. All catheters were removed after the patency of the stricture was confirmed by percutaneous transhepatic cholangiography (PTHC) 6 months later. No severe adverse events occurred during the perioperative period. There were 2 patients who experienced episodes of cholangitis during the follow-up period (mean, 17 months; range, 4-24 months), and neither BEAOS nor bile duct stones recurred within 2 years after the procedure. White blood cells (WBC), total bilirubin (TB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were (6.0±1.4)×109/L and (6.0±1.6)×109/L (P=0.91), 31.4±15.7 and 29.6±10.3 µmol/L (P=0.74), 50.8±20.0 and 85.8±67.0 U/L (P=0.16), and 42.6±15.2 and 71.8±44.9 U/L (P=0.09) pre and postintervention, respectively. Percutaneous transhepatic compliant balloon-occluded distal cholangiography and the maintenance of a large-bore catheter probably provide an effective and safe alternative method for resolving BEAOS and/or coexisting stones.

Hemorrhagic pericardial tamponade in a hemodialysis patient with catheter-related superior vena cava syndrome: a case report

BackgroundIatrogenic complications of endovascular treatment for central venous stenosis have not yet been reported. Here we present a case of a patient on maintenance hemodialysis who developed catheter-related superior vena cava syndrome and subsequently suffered from hemorrhagic pericardial tamponade after undergoing percutaneous transluminal angioplasty and stenting.Case presentationA 72-year-old male patient presented with uremia, and had been receiving maintenance hemodialysis for the past five years. The patient initially presented with dysfunction of the dialysis catheter (a cuffed tunneled double-lumen catheter in the right internal jugular vein). Imaging examination revealed a segmental occlusion of the superior vena cava stretching from the distal end of the dialysis catheter up to right atrium entrance, apparent compensatory dilatation of the azygos vein, and abundant subcutaneous collaterals. The patient underwent percutaneous transluminal balloon dilatation and stenting (covered stent) of the superior vena cava in the Cath Lab. During the procedure, with forceful advancement of the guidewire, it was observed to progress for a distance before a “smoke” appeared, and an outward spillage of contrast agent was visible, which suggested a possible vessel puncture leading into the mediastinum. Unfortunately, postoperative hemorrhagic pericardial tamponade occurred and the patient developed cardiogenic shock. He experienced symptoms included chest tightness and breath shortness with a recorded blood pressure of 84/60mmHg. After draining 600 ml of bloody fluid through pericardiocentesis, the patient’s symptoms alleviated and his condition improved.ConclusionsThe case emphasizes the need for increased attention to iatrogenic endovascular injuries during catheter placement and endovascular treatment, such as causing pericardial hemorrhage leading to cardiac tamponade.

Percutaneous Intervention for a Stuck Mechanical Prosthetic Valve at Mitral Position as a Bailout Procedure in a High Surgical Risk Candidate

Mechanical heart valves are the preferred choice for younger individuals when the native valves cannot undergo repair, primarily due to their exceptional durability. It is crucial to meticulously manage the international normalized ratio (INR) within the range of 2.5 to 3.5 to ensure optimal valve function and minimise the risk of thromboembolic complications. Our case report serves to demonstrate the effectiveness of percutaneous balloon dilatation through transcatheter methods as an innovative and promising approach to release a stuck valve, representing a noteworthy addition to the spectrum of treatment options.

Simultaneous Double Balloon Dilatation for Supravalvar Pulmonary Obstruction After Arterial Switch Operation.

The optimal approach for supravalvar right ventricular outflow tract obstruction(RVOTO) after arterial switch operation(ASO) is unclear. The results of percutaneous balloon dilatation have been variable. We report the results of simultaneous double balloon dilation for RVOTO after ASO. Sixteen patients (1.3(0.7-3.8) years; 9.8(8.1-15.1) kgs underwent the procedure at 14(8-44.5) months after ASO. Salient technical features included placement of balloons over stiff guide-wires positioned in both branch pulmonary arteries to enable dilation of the distal-most main pulmonary artery (MPA) with high inflation pressures (~ 12-14 atmospheres) and short inflation-deflation cycles. Effective balloon size was based on the PA annulus or MPA distal to the narrowing. The final balloon: narrowest segment diameter ratio was 2.7. Following dilation, the right ventricle to systemic systolic pressure ratio decreased from 0.9 ± 0.18 to 0.52 ± 0.16 (p < 0.001) and mean RVOT gradient from 78 ± 18 to 34 ± 13.9mmHg (p < 0.001). Narrowest diameter improved from 5.4 ± 2.2 to 9.2 ± 2.2mm. There were no major complications. Two patients with inadequate relief (final RV-systemic ratios: 1.03 and 0.7) were referred for surgery. At median follow up of 9months, IQR 7-22, range 5-73, others are free of re interventions with median RVOT gradient of 42, IQR 27-49, range 21-55mmHg. The immediate and short-term follow up results of double balloon dilatation for supravalvar RVOTO is encouraging and may avoid the need for repeat surgery in the majority of patients. Further follow up is needed to determine the long-term durability of the results.

Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study.

The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors. To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years. Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups. Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor. The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

A Rare Case of Focal Renal Fibromuscular Dysplasia Treated With Angioplasty: A Case Report.

Fibromuscular dysplasia is an idiopathic, segmental, nonatherosclerotic, noninflammatory vascular disease that can lead to arterial stenosis, tortuosity, occlusion, aneurysms, and dissection. Fibromuscular dysplasia is a rare cause of hypertension that can easily be missed. To date, there has been no definitive treatment for fibromuscular dysplasia. In this report, we present an uncommon case of renovascular hypertension in a 21-year-old non-white female with a 3-year history of hypertension secondary to fibromuscular dysplasia involving bilateral renal arteries. Computed tomography angiography during the arterial phase revealed distal focal narrowing of the right main renal artery, distal focal narrowing of the left main renal artery, and proximal focal narrowing of the left accessory lower renal artery. Percutaneous balloon dilatation of the stenotic lesion was performed successfully up to 1year After the procedure, the arterial blood pressure was within the normal range (110/70 to 125/75mmHg) without medication. After 1year of follow-up, CTA revealed re-stenosis in left main renal artery without clinical symptoms and normal blood pressure. Repeated procedure was done successfully. This case report highlights the difficulty in the diagnosis and treatment of focal fibromuscular dysplasia in young non-white female patients. Computerized tomographic angiography is a useful tool for identifying the cause and showing the benefit of percutaneous transluminal renal angioplasty treatment for this rare entity, as an early percutaneous angioplasty intervention may have a clinical cure for hypertension.

Acute Changes in Right Ventricular Function in Pediatric Patients with Pulmonary Valve Stenosis Undergoing Percutaneous Valvuloplasty: A Speckle-Tracking Study.

Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities. This study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS). Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV. After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (∆50 ± 32.23 and ∆31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV (p = 0.007). The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV (40.11% vs. 44.42%, p = 0.01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments. Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.

Abstract No. 55 Evaluating Percutaneous Transhepatic Biliary Drainage (PTBD) Factors Associated with Better Outcomes in the Treatment of Post-Surgical Benign Biliary Strictures

To report outcomes of post-surgical benign biliary strictures treated with percutaneous transhepatic biliary drainage (PTBD) and balloon dilation. Patients with a history of surgery and who developed a benign biliary stricture were included in this retrospective, IRB-approved study (n = 44). Patients having biliary leaks, or with complete occlusion of the bile duct due to surgical clips were excluded (n = 28). Drain size, type (internal-external or external), balloon dilation, and type and size of balloon used was evaluated for all biliary procedures. These characteristics were compared between patients needing (n = 8) and not needing (n = 36) surgical revision. Continuous variables are reported as median (IQR) and compared with Wilcoxon rank sum test, categorical variables as numbers with percentages and compared using chi-square test. Patients were 59 (42-67) years old with 67% being female. Hepaticojejunostomy was the most common surgery (30%) followed by Roux-en-Y gastric bypass (16%), pancreaticoduodenectomy (14%), transplant (14%), Billroth II (9%), cholecystectomy (7%) and others (9%). Duct to enteric anastomosis was present in 52%, duct to duct in 11% and no anastomosis in 36%. Prior non-PTBD interventions included ERCP dilation and stent placement in 9 (20%) and failed ERCP in 10 (23%) patients. The first PTBD was done 28 (6-98) months after surgery, with a drain size of ≥10F in 20 (45%) and < 10F in 24 (55%) patients. The drain was internal-external in 41 (93%) patients. Patients underwent a total of 4 (3-8) procedures before drain removal, with drain upsizing performed in 23 (52%) patients, leading to a largest drain size of ≤8F in 10 (23%), 10F in 17 (39%), 12F in 14 (32%) and ≥14F in 3 (6%) patients. Balloon dilation was performed in 40 (91%) patients, with the largest balloon size being ≤8 mm in 13 (30%), 10 mm in 20 (45%), 12 mm in 6 (14%), and 14 mm in 1 (2%) patient. A cutting balloon was used in 19 (43%) patients. Surgical revision was needed in 8 (18%) patients, with a repeat PTBD performed in 5 (11%) patients. The rate of surgical revision was lower in patients who received a largest drain of ≥10F (12%) compared with those who received a largest drain of <10F (40%, P = 0.042). The rate of surgical revision was 7.4% in patients who were dilated with a balloon of ≥10 mm compared with 30.7% in those who were dilated with a balloon of <10 mm (P = 0.053). The median drain-free survival was 41 (11-57) months for the entire cohort. Postsurgical benign biliary strictures treated with PTBD with a drain of ≥10F and dilated with a balloon of ≥10 mm are less likely to need surgical revision.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence.

Patients with cyanotic complex congenital heart defects (CHDs) commonly undergo palliation with interposition of systemic-to-pulmonary shunts (SPSs). These palliative shunts are rarely found in adults with CHDs and can be complicated with progressive obstruction or total occlusion during follow-up. The best treatment option for shunt re-permeabilization is challenging and case-oriented because most patients are high risk candidates for redo surgeries. We aimed to review the current evidence on percutaneous stent implantation to treat failed SPSs. We performed a comprehensive literature review on percutaneous stent implantation to treat failed and occluded SPSs. We also reported the case of a 33-year-old man with cyanotic CHD and a occluded central aorto-pulmonary shunt, who was successfully treated with percutaneous balloon dilatation and subsequently stent implantation at our institution. We identified and included 31 articles reporting on 150 patients and 165 stent implantations in failed SPSs. The age of patients at the time of stent implantation ranged from 6 days to 47 years. The time between the surgical shunt creation and transcatheter intervention ranged from 1 day to 17 years. Overall, 161/165 (97.5%) stent implantations were successful. The most common clinical presentation was cyanosis and decreased atrial oxygen saturations and the indication for stent implantation was shunt obstruction and stenosis. This review highlights the benefits of endovascular stenting to permeabilize failed SPSs in children and adults with complex CHD who are classified as poor candidates for re-surgical repair.

Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation

Percutaneous balloon dilation with or without placement of an external biliary drain is a nonoperative alternative method for treating benign bilioenteric anastomotic strictures. Although this procedure has a high technical success rate, outcomes are less optimal when attempting to dilate refractory tight strictures. For the stricture, cutting balloon can be an option. We present four patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation. To the patients, a peripheral cutting balloon over-the-wire system was inflated, following subsequent conventional non-compliant balloon dilation. After the balloon dilation treatment, an external drainage catheter was placed through the stricture site and maintained for up to 30 days. Technical and end-treatment success was achieved in all four patients. In conclusion, the use of cutting balloon dilation may appear to be a safe and effective alternative method of treatment in patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation.

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures.

Background and objectivePercutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.Patients and methodsA total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.ResultsAmong the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.ConclusionBiliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Diagnosis and treatment standardizations on percutaneous transhepatic papillary balloon dilation for common bile duct stones

Common bile duct (CBD) stone is a prevalent disease. As a novel treatment for CBD stone in China, percutaneous transhepatic papillary balloon dilation (PTPBD) has shown some advantages compared with other modalities. However, many components of the procedure remains unclear, including indications, contraindications, patient preparation, bile duct puncture, papillary dilation, imaging interpretation, and complication management.In order to standardize the clinic practice of PTPBD, Chinese College of Interventionalists organized a committee, including interventional radiologists, digestive physicians and general surgeons, and commissioned this criterion.

Bailout stenting in femoropopliteal arterial segment.

Background: Disabling peripheral arterial disease (PAD) of femoropopliteal segment is usually treated with percutaneous balloon dilatation, and when this is not successful, stent is placed. Long-term patency of stent is often compromised due to in-stent restenosis (ISR). We aimed to identify factors associated with bailout stenting, and to recognise risk factors for ISR in procedures without paclitaxel application. Patients and methods: We analysed 592 consecutive successful femoropopliteal interventions performed in patients with either disabling intermittent claudication or chronic critical limb ischemia (CLI). In patients with stent implantation, clinical and ultrasound (US) examination were performed one year after the intervention to establish the presence of ISR, defined as>50% stenosis on US imaging. Results: Bailout stenting was required in 133 (22.5%) procedures. Patients with stent placement were younger (70±10 vs 72±11years, p=0.007) and less often presented with CLI (29.3% vs 40.5%, p=0.019). They more often reported smoking (63.2% vs 49.2%, p=0.005), less often had diabetes mellitus (35.3% vs 47.5%, p=0.013) and arterial hypertension (82.0% vs 90.8%; p=0.004). Stenting was also dependent on lesion complexity (TASCII C>B>A; p<0.001). Subgroup analysis of 110 procedures with bare metal stent (BMS) placement performed in 107 patients revealed ISR in 46.4% of stents, in half of cases it was symptomatic. Neither clinical nor lesion characteristics proved to differ between the group of procedures with ISR and group of procedures without ISR. Conclusions: Factors associated with bailout stenting were age, diabetes mellitus, arterial hypertension, smoking, clinical picture of PAD and complexity of treated lesions. We did not find any risk factors influencing development of ISR in BMS.

Percutaneous Balloon Dilatation for Hepaticojejunostomy Stricture Following Paediatric Liver Transplantation: Long-Term Results of an Institutional "Three-Session" Protocol.

The aim of this study was to report the long-term results of an institutional protocol of percutaneous biliary balloon dilatation (PBBD) on paediatric patients with benign anastomotic stricture after liver transplantation. As a secondary objective, we evaluated risk factors associated with post-treatment re-stricture. Fourteen paediatric, post-liver transplant patients with benign anastomotic stricture of Roux-en-Y hepaticojejunostomy were included. All patients underwent the same treatment protocol of three PBBD procedures with 15-day intervals. Clinical outcome was analysed using the Terblanche classification. Primary patency rate was assessed with the Kaplan-Meier test. All patients had an initial successful result (Terblanche grade, excellent/good) after PBBD. At the end of the follow-up time of 35.7 ± 21.1months (CI95%, 23.5-47.9), 10 patients persisted with excellent/good grading, while the remaining 4 had re-stricture, all of the latter occurring within the first 19months. Patency rate after percutaneous treatment at 1, 3, and 5years were 85.7%, 70%, and 70%, respectively. History of major complication after liver transplantation was associated with 5 times higher risk of re-stricture, HR 5.48 [95% CI, 2.18-8.78], p = 0.018. In paediatric patients with benign anastomotic stricture of hepaticojejunostomy after liver transplantation, the "Three-session" percutaneous biliary balloon dilatation protocol is associated with a high rate of long-term success. In this limited series, the history of post-liver transplant major complication, defined as complications requiring a reintervention under general anaesthesia or advanced life support, seems to be an independent risk factor for stricture recurrence.

Long Non-Coding RNA MEG8 Suppresses Hypoxia-Induced Excessive Proliferation, Migration and Inflammation of Vascular Smooth Muscle Cells by Regulation of the miR-195-5p/RECK Axis

It has been recognized that rebalancing the abnormal proliferation and migration of vascular smooth muscle cells (VSMCs) helps relieve vascular injury. Presently, we aim to investigate whether long non-coding RNA (lncRNA) maternally expressed 8 (MEG8) plays a role in affecting the excessive proliferation and migration of VSMCs following hypoxia stimulation. A percutaneous transluminal angioplasty balloon dilatation catheter was adopted to establish vascular intimal injury, the levels of MEG8 and miR-195-5p in the carotid artery were tested by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Hypoxia was used to stimulate VSMCs, then the cell counting kit-8 (CCK-8) assay, Transnwell assay, and wound healing assay were conducted to evaluate the proliferation, and migration of VSMCs. The protein levels of RECK (reversion inducing cysteine rich protein with kazal motifs), MMP (matrix metalloproteinase) 3/9/13, COX2 (cytochrome c oxidase subunit II), macrophage inflammatory protein (MIP)-1beta, VCAM-1 (vascular cell adhesion molecule 1), ICAM-1 (intercellular adhesion molecule 1), and HIF-1α (hypoxia inducible factor 1 subunit alpha) were determined by western blot or cellular immunofluorescence. As the data showed, MEG8 was down-regulated in the carotid artery after balloon injury in rats and hypoxia-treated VSMCs, and miR-195-5p was overexpressed. Forced MEG8 overexpression or inhibiting miR-195-5p attenuated hypoxia-promoted cell proliferation and migration of VSMCs. In addition, miR-195-5p up-regulation reversed MEG8-mediated effects. Hypoxia hindered the RECK expression while boosted MMP3/9/13 levels, and the effect was markedly reversed with MEG8 up-regulation or miR-195-5p down-regulation. Mechanistically, MEG8 functioned as a competitive endogenous (ceRNA) by sponging miR-195-5p which targeted RECK. Moreover, the HIF-1α inhibitor PX478 prevented hypoxia-induced proliferation, and migration of VSMCs, upregulated MEG8, and restrained miR-195-5p expression. Overall, lncRNA MEG8 participated in hypoxia-induced excessive proliferation, inflammation and migration of VSMCs through the miR-195-5p/RECK axis.

Balloon dilation versus surgery for severe neonatal aortic valve stenosis: A matched comparison

Two therapeutic approaches exist for first-line treatment of neonatal severe/critical aortic valve stenosis: percutaneous balloon dilatation and surgical valvuloplasty. For both interventions, the early and long-term results are satisfactory. Previous reports have failed to show clear superiority of one versus the other procedure. In la Timone university hospital (Marseille), balloon dilation is the usual therapeutic approach for neonatal critical/severe aortic valve stenosis. In Necker university hospital (Paris), surgical valvuloplasty remains the preferred option. The aim of our current study is to compare the 2 populations using propensity scores matching. Patients aged < 1 month who underwent percutaneous aortic valve balloon dilation for aortic valve stenosis in Marseille between 2003 and 2020, are included. Patients with borderline left ventricle or hypoplastic left heart syndrome are excluded. Balloon patients will be matched based on age, weight, duct-dependency, left ventricular function, aortic valve morphology and mitral function, with patients who underwent surgical aortic valvuloplasty in Necker (Paris). Early complications, survival, freedom from reintervention, residual stenosis and regurgitation will be retrospectively collected from hospital charts. Initial diagnosis and residual lesions will be confirmed by reviewing echocardiography studies. The primary outcome will be the all-cause mortality. The secondary outcomes will be reintervention, aortic valve replacement, presence of significant valve stenosis or insufficiency at latest follow-up. The results will be available in June 2021. Balloon dilation and surgical valvuloplasty are both efficient procedures for early relief of neonatal aortic stenosis. In case of superiority of one of the techniques, our current practice may need to be questioned and adapted. The complementary aspect of the 2 treatment strategies may also be highlighted.

Elective Melody valve insertion in mitral position: What have we learnt from our first and successful case?

Melody valve insertion in mitral position is no longer an experimental procedure and is now an acceptable option for severe mitral valve disease in infants and neonates. Although there are more and more publications outlining the outcome, our first and successful case taught us a couple of points that we would like to share. A 20 days-old baby with severe congenital mitral insufficiency underwent Melody valve implantation. The stent was fashioned to avoid left ventricular outflow tract obstruction and expanded with a 14 mm balloon. A small ASD was created to allow further percutaneous balloon dilation. The baby was discharged after 6 weeks and treated with antiplatelet therapy. Postoperative management consisted in close transthoracic echocardiographic follow-up. Two percutaneous balloon dilatations of the stent (14 and 16 mm) were performed, respectively 9 and 16 months after the initial surgery. The patient presented infective endocarditis (Haemophilus influenzae) 26 months after surgery. TTE showed moderate Melody valve regurgitation and stenosis (mean gradient: 11 mmHg) with post-capillary pulmonary hypertension. Mitral valve replacement was performed after 6 weeks of antibiotic therapy. The stent was explanted and a 19 mm mechanical prosthetic valve was inserted. Postoperative course was uneventful. Melody valve in mitral position is now an accepted option but morbidity and mortality remain significant. Post-implantation management is challenging and guidelines are missing. Percutaneous stent dilation, hybrid valve in valve implantation and mechanical mitral valve replacement are 3 possible options in case of valve dysfunction. The per-operative pictures ( Fig. 1 , Fig. 2 ) help to understand why, in our case, the first 2 options would have failed. Fig. 1 shows non-calcified and mobile leaflets. One leaflet had a small 2 mm perforation. The stent itself, in contrast, was so thickened that dilatation or valve in valve procedure would have failed at this stage. Major endothelialization of the stent might significantly limit post-implantation management options. We believe that heart teams have to be aware of this potential evolution of the stent in order to establish the best procedural strategy in these patients.