Percutaneous Ligation Research Articles

Abstract 10920: Cost-Effectiveness of Pulmonary Vein Isolation with Epicardial Left Atrial Appendage Ligation for the Treatment of Non-Paroxysmal Atrial Fibrillation

Introduction: Electrical isolation of the left atrial appendage (LAA) using percutaneous epicardial ligation may improve catheter ablation outcomes for non-paroxysmal atrial fibrillation (AF) patients. Little is known regarding the cost effectiveness of this procedure. Hypothesis: We hypothesized that cost-effectiveness between pulmonary vein isolation (PVI) + LAA epicardial ligation using a percutaneous LARIAT ® Suture Delivery Device would be cost effective (CE) compared to PVI alone over 5 years. Methods: A Markov model simulated outcomes for a population with annual stroke risk of 4.6% (CHA 2 DS 2 -VASc score 3). Model inputs for procedure efficacy, stroke and bleed events, health utility, and event costs were estimated from literature. Procedure costs from Medicare rates were used. The model had a 5-year time-horizon and US payer perspective. Univariate and probabilistic sensitivity analyses (PSA) were performed. Outcomes were health care costs and quality-adjusted life-years (QALYs). In the base case, PVI + LAA ligation efficacy from published studies was 67% after 1-year, with an estimated 25% oral anticoagulant (OAC) utilization in PVI + LAA ligation patients in normal sinus rhythm 13-60 months after the index procedure. Cost effectiveness thresholds were evaluated with alternative PVI + LAA ligation efficacy and OAC utilization rates, including 1-year PVI + LAA ligation efficacies of 67%, 70%, 75%, and 80% and OAC utilization of 20-60%. Results: In the base case, PVI + LAA ligation had a mean 5-year cost of $72,865 with 3.25 QALYs and PVI alone had mean cost of $69,936 with 3.19 QALYs. The incremental cost-effectiveness ratio was $46,716; PVI + LAA ligation was CE at $50,000 per QALY gained. In PSA, 64% and 82% of simulations were CE at $50,000 and $100,000 per QALY gained, respectively. In various scenarios, procedure efficacy of 75% combined with OAC utilization of 50% or below yielded CE at $50,000 per QALY gained. Reduction of OAC utilization to 30% yielded CE at $50,000 per QALY gained, regardless of efficacy. Conclusions: In the base case, PVI + LAA ligation was CE at $50,000 per QALY gained when compared to PVI alone. The CE threshold for efficacy was 75% and OAC utilization was 30%. Cost savings were driven by reductions in OAC use and increased efficacy.

Persisterende zwelling na enkelartroscopie: pseudoaneurysma van de arteria tibialis anterior als zeldzame complicatie

Persistent swelling after ankle arthroscopy: pseudoaneurysm of the anterior tibial artery as a rare complication A patient was admitted to a geriatric rehabilitation ward following a septic arthritis for which she received an antibiotic treatment and arthroscopic irrigation. She had a normal kidney function and received a prophylactic dose of enoxaparin for the prevention of a deep venous thrombosis (DVT). During the hospitalization, a progressive, painless swelling of the ankle was seen. The ultrasonography showed a pseudoaneurysm of the anterior tibial artery measuring 4.2 cm by 4 cm by 1.7 cm. Following the surgical consultation, compression therapy was started. The follow-up ultrasonography after 4 weeks showed absence of flow in the pseudoaneurysm. A pseudoaneurysm is a rare complication (0.008%) of foot and ankle surgery. Risk factors are malnutrition, immunosuppression, diabetes mellitus and trauma or infection. Abnormal coagulation may contribute to the development of a pseudoaneurysm. The diagnosis is mostly based on clinical clues, confirmed by means of color-flow Doppler imaging. The treatment options include non-surgical methods (external compression, ultrasound-guided compression and ultrasound-guided thrombin injections), percutaneous endovascular therapy (coil, stenting) or surgical ligation with an aneurysmectomy and an arterial reconstruction. Although pseudoaneurysms are a rare complication, their possibility should be considered in the period following the commencement of mobilization and weight-bearing after ankle surgery, especially if risk factors are present.

O35: THE MANAGEMENT OF PATENT DUCTUS ARTERIOSUS IN LOW BIRTH WEIGHT AND PREMATURE NEONATES: WHO, WHAT, WHEN AND HOW?

Abstract Objectives The management of patent ductus arteriosus (PDA) in neonates is a contentious issue with variations between many centres. Does timing PDA management prophylactically, fare better than waiting for haemodynamic compromise? Are medical approaches safer and more effecitve than an interventional approach? How should medical or surgical interventions be approached? Should clinicians intervene at all? This review aims to navigate through the current literature. Method Keywords "Patent ductus arteriosus", "neonate", "premature", "preterm" and "low birth weight" were searched on PubMed, the Cochrane Library and Medline. Referenced articles were also included. Outcome measures such as time to closure, rate of closure, morbidity and mortality were observed. Result Studies observing conservative management showed that PDAs close spontaneously in up to 73%. Complication rates in conservative management compared to indomethacin use were similar, with conservative measures taking longer to reach closure. Indomethacin was shown to have better outcomes when used prophylactically compared to symptomatic cases. However, paracetamol and oral ibuprofen was shown to be safer than indomethacin in symptomatic patients with less renal and gastrointestinal effects. Successful medical management was demonstrated to be dependent on ductal diameter and gestational age. Outcomes following prophylactic surgery were similar to those undergoing conservative management. Morbidity and mortality were similar in those undergoing percutaneous occlusion and open ligation. Conclusion Many studies were observational, retrospective, single-centre studies and had not reported important outcome measures. Robust evidence from randomised, multi-centre studies are needed, as well as studies comparing treatment disciplines. Future studies should look to report long-term outcome measures. Take-home message Despite the range of studies meta-analyses available, there is a lack of robust and definitive evidence out there to suggest when and how to approach a PDA in premature/low-birthweight neonates which is reflected in the heterogeneity of management options for PDA patients between different centres. Observational studies show that conservative management, management using paracetamol and an interventional approach (either thoracotomy or endovascular) are all viable options, however the lack of randomised, interventional studies fail to show which method is superior.

One-Trocar Trans-Umbilical Laparoscopic Hernia repair with Intraperitoneal knot in Children

Background: Recently laparoscopic repair of pediatric inguinal hernia has been mainly oriented to video-assisted percutaneous ligation of peritoneal sac. Assessment of contralateral defect and a better cosmesis are recognized benefits of this procedure, however there are still some drawbacks often related to the subcutaneous knot. As an alternative to open surgery we propose an original one-access technique with intraperitoneal knot.

Understanding the Pathophysiology, Implications, and Treatment Options of Patent Ductus Arteriosus in the Neonatal Population.

Patent ductus arteriosus (PDA) is the persistence of a fetal shunt between the pulmonary artery and the aorta. This structure normally closes in the first 3 days after birth; however, closure is delayed in up to 80% of infants born at 25 to 28 weeks of gestation. Persistent PDA results in pulmonary overcirculation and systemic hypoperfusion. The purpose of this article is to review pathophysiology and treatment options for PDA. A literature review was conducted using PubMed, CINAHL, and Google Scholar (2013-2018). Search terms included neonate, PDA, pathophysiology, pharmacotherapy, nursing, ligation, indomethacin, ibuprofen, and acetaminophen (paracetamol). Optimal treatment remains contentious. Options include conservative/medical, pharmacologic, and surgical management. Conservative/medical management includes mild fluid restriction, increased airway pressures, and supportive care. Pharmacologic treatment is accomplished using indomethacin, ibuprofen, or acetaminophen. Surgical intervention is by direct closure or by percutaneous ligation. Treatment may be prophylactic, presymptomatic, or symptomatic. Long-term morbidities associated with PDA include chronic lung disease, retinopathy of prematurity, and neurodevelopmental delay. Absence of a universal scoring system for severity of PDA limits accuracy of comparisons among research studies. Lack of a consistent definition also makes it difficult to aggregate data for meta-analyses. Adoption of a consistent scoring system for hemodynamic significance would facilitate comparisons of outcomes among research studies. Clinicians should be aware of treatment options for PDA and their implications on neonatal outcomes. For nurses, anticipation of possible side effects is important for performance of focused assessments.

Left Atrial Appendage Electrical Isolation as a Target in Atrial Fibrillation.

Although the benefit of catheter ablation of the pulmonary veins is well established in paroxysmal atrial fibrillation (AF), the optimal ablation strategy for persistent AF is yet to be determined. Pulmonary vein isolation in persistent AF often results in AF recurrence and the success rate may be low even after multiple procedures. Recurrent AF risk may besecondary to non-pulmonary vein triggers, and adjunctive therapies to better control persistent AF are under investigation. The left atrial appendage (LAA) is a complex structure with distinct physiological and electrical properties, and multiple studies have implicated the LAA as a potential contributor to persistence of AF. Therapies targeting the LAA for electrical isolation have demonstrated potential efficacy in freedom from AF. The overarching concept of this therapy is to isolate the atria electrically from the LAA via catheter ablation, surgical excision or ligation, or percutaneous ligation. LAA electrical isolation has already demonstrated benefit in reducing AF recurrence and AF burden. LAA electrical isolation has the potential to form a foundational piece in the optimal rhythm control management of AF and thereforewarrants further study and is the focus of this review.

Assessing the Adequacy of Absorbable Braided Suture for Laparoscopic High Ligation in Rabbits.

Our previous work demonstrated that intentional peritoneal injury reduces the incidence of recurrence of a patent processus vaginalis even after removal of the suture. Therefore, the necessity of permanent suture has been brought into question because of the risk of suture granuloma formation. The purpose of this study was to evaluate the efficacy of absorbable, braided versus permanent, braided suture in a rabbit survival model of laparoscopic percutaneous ligation of the processus vaginalis with intentional peritoneal injury. Eighteen New Zealand White rabbits underwent bilateral subcutaneous endoscopically assisted ligation (SEAL) of the internal ring. Before SEAL, peritoneal injury was caused with endoscopic shears. Each animal was randomized to receive absorbable braided suture on one side and permanent braided suture on the contralateral side. The rabbits were survived for 8 weeks to allow for complete hydrolysis of the absorbable suture. Necropsy was performed during which the integrity of the repair was assessed with insufflation of carbon dioxide up to 30 mm Hg. McNemar's test for paired data was performed for statistical analysis. Seventeen rabbits survived 8 weeks. One rabbit died in the early postoperative period because of urinary tract obstruction. After insufflation, four (24%) recurrences were present in the absorbable group and two (12%) recurrences were present in the permanent group. This difference was not statistically significant (P = .50). Both rabbits with a recurrence on the side with permanent suture also had a recurrence with absorbable suture on the contralateral side. In all rabbits, the permanent suture was identified, whereas there was no visual evidence of absorbable suture. A trend toward a higher recurrence rate with the use of absorbable braided suture was present, although, in this study, the finding was not statistically significant. Caution should be used when considering implementation of absorbable suture for laparoscopic inguinal hernia repair.

Percutaneous Ligation of the Saphenous Veins With Ultrasound Guided Foam Sclerotherapy And Miniphlebectomies

Percutaneous Ligation of the Saphenous Veins With Ultrasound Guided Foam Sclerotherapy And Miniphlebectomies

Left atrial appendage ligation with the next generation LARIAT+ suture delivery device: Early clinical experience

BackgroundThe purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure with a micropuncture pericardial access approach and the new LARIAT+ suture delivery device. MethodsSeventy-two patients with atrial fibrillation were enrolled to undergo telescopic micropuncture pericardial access and percutaneous ligation of the LAA with the LARIAT+ device. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 30days and 90days post-LAA ligation. Patients were monitored for 12months by an independent clinical research organization for adverse events, stroke, embolic events and death of any cause. Results72 patients were screened for the LARIAT+ procedure. Fourteen patients were screened failures (7 patients due to unfavorable anatomy and 7 patients with LAA thrombus). Fifty-eight patients underwent successful LAA ligation. All 58 patients had complete acute closure of the LAA. At 1month 52 of 54 patients (96.3%) had LAA closure, while at 3months 48 of 52 patients (92.3%) had LAA closure. There were no leaks greater than 3mm at both 1 and 3months. There were no device or procedural related complications, and only 1 30day adverse event involving late pericardial effusion. There were no strokes, embolic events or deaths after 12months. ConclusionsLAA closure with the micropuncture pericardial access approach and the LARIAT+ device can be performed effectively with acceptably lowperiprocedural adverse events.

Single-port laparoscopic percutaneous double ligation for pediatric inguinal hernias: report of a new technique and early results.

Several single-port laparoscopic hernial repair methods have been designed to treat inguinal hernia in children, but reliable and safe ligation of the hernial sac should be further investigated. This study aimed to investigate a new technique for laparoscopic percutaneous double ligation for pediatric inguinal hernias with a set of home-made instruments. Before each operation, a set of home-made instruments were prepared, including a curved puncture needle, a lasso suture, a dual ligation suture, and occasionally, a flat-headed puncture needle for obese patients. After a series of operational steps, the hernial sac was doubly extracorporeally ligated, leaving only one puncture point in the inguinal region and one incision in the navel. Between October 2011 and September 2013, 236 children (211 boys and 25 girls) underwent hernial repair using this novel technique. In 38.8% (85/219) of patients with the preoperative diagnosis of unilateral inguinal hernia, contralateral patent processus vaginalis was confirmed during the laparoscopic surgery and subsequent repair was performed. In 134 cases of unilateral repair, the mean operative time was 11min (range 5-16min), and it was 19min (range 13-29min) in 102 cases of bilateral repair. No recurrence or complications have been observed to date. This study shows a unique technique of percutaneous double ligation of the hernial sac using a minimally invasive technique with the aid of a transabdominal 5-mm telescope and a set of home-made instruments. Single-port laparoscopic hernial repair using this technique is feasible and appears to be safe.

Non-absorbable sutures are associated with lower recurrence rates in laparoscopic percutaneous inguinal hernia ligation

Laparoscopic hernia repair with percutaneous ligation of the patent processes vaginalis is a minimally invasive alternative to open inguinal herniorrhaphy in children. With the camera port concealed at the umbilicus, this technique offers an excellent cosmetic result. It is also faster than the traditional laparoscopic repair with no differences in complication rates or hospital stay. The goal of this study was to describe a series of consecutive patients, emphasizing the impact of suture materials (absorbable vs. non-absorbable) on hernia recurrences. A retrospective review was performed of consecutive transperitoneal laparoscopic subcutaneous ligations of a symptomatic hernia and/or communicating hydrocele by 4 surgeons. Patients > Tanner 2 or with prior hernia repair were excluded. The success of the procedure and number of sutures used was compared between cases performed with absorbable vs. non-absorbable suture. Risk factors for surgical failure (age, weight, number of sutures used, suture type) were assessed with logistic regression. 94 patients underwent laparoscopic percutaneous hernia ligation at a mean age of 4.9 years. Outcomes in 85 (90%) patients with 97 hernia repairs at a mean of 8 months after surgery revealed 26% polyglactin vs 4% polyester recurrences (p = 0.004) which occurred at mean of 3.6 months after surgery, Table 1. Repairs performed with non-absorbable suture required only 1 suture more often than those performed with absorbable suture (76% vs 60%, p = 0.163). Logistic regression revealed suture type was an independent predictor for failure (p = 0.017). Weight (p = 0.249), age (p = 0.055), and number of sutures (p = 0.469) were not significantly associated with recurrent hernia. Our review of consecutive hernia repairs using the single port percutaneous ligation revealed a significantly higher recurrent hernia rate with absorbable (26%) versus non-absorbable (4%) suture. This finding remained significant in a logistic regression model irregardless of number of sutures placed, age, and weight. Though the authors acknowledge the drawback of the potential for learning curve to confound our data, we still feel these findings are clinically important as this analysis of outcomes has changed our surgical practice as now all providers involved perform this procedure with exclusively non-absorbable suture. We thus suggest that surgeons who perform this technique, especially those newly adopting it, use non-absorbable suture for optimal patient outcomes. Recurrent hernia after laparoscopic percutaneous hernia ligation was significantly lower in repairs performed with non-absorbable suture. Based on this data, we recommend the use of non-absorbable suture during laparoscopic ligation of inguinal hernias in children.

Early results with the LARIAT device for left atrial appendage exclusion in patients with atrial fibrillation at high risk for stroke and anticoagulation

To evaluate early outcomes of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach with the SentreHeart LARIAT(™) snare device. Atrial fibrillation increases the risk of stroke 4-5 fold, which can have devastating outcomes. Exclusion of the LAA is believed to decrease the risk of embolic stroke. Twenty-seven patients with atrial fibrillation, a high risk of stroke, and contraindication or intolerance for anticoagulation therapy underwent percutaneous ligation of the LAA with the LARIAT device. Initial LAA closure was confirmed with TEE and contrast fluoroscopy. The acute procedural success was 92.6%. One patient sustained a perforation of the LAA and was treated conservatively. The patient underwent LAA closure surgically the next day. In one patient the attempt to advance the LARIAT over the LAA was unsuccessful. Patients were followed for a mean of 4 months. Preserved LAA closure was confirmed with a 45 day follow-up TEE in 22 of 25 patients completing the procedure. Peri-operative complications included three cases of pericarditis and one case of a periprocedural CVA due to thrombus formation on the transseptal sheath. During follow-up, there was one stroke thought to be noncardioembolic and one pleural effusion. There were no deaths. These results show that percutaneous LAA exclusion can be achieved successfully with an acceptable rate of periprocedural and short-term complications. Further studies and longer follow-up are needed to determine whether LAA exclusion lowers the long-term risk of thromboembolic events in patients with AF and contraindications to anticoagulation.

Percutaneous ligation of the left atrial appendage results in atrial electrical substrate modification

Debulking of electrically active atrial tissue may reduce the mass of fibrillating tissue during atrial fibrillation, eliminate triggers, and promote maintenance of normal sinus rhythm (NSR). We investigated whether left atrial appendage (LAA) ligation results in modification of atrial electrical substrate. Healthy male mongrel dogs (N = 20) underwent percutaneous epicardial LAA ligation. The ligation system grabber recorded LAA local electrograms (EGM) continuously before, during, and after closure. Successful ligation with a preloaded looped suture was confirmed intraprocedurally by LAA Doppler flow cessation on transesophageal echocardiography (TEE) and loss of LAA electrical activity, and after procedure by direct necropsic visualization. P-wave duration on surface electrocardiograms was measured immediately before and after LAA closure. Percent P-wave duration reduction was correlated with preclosure LAA internal dimensions measured by TEE and external dimensions measured on necropsy specimens to investigate associations of LAA geometry with the extent of electrical substrate modification. LAA ligation was successful in all dogs and accompanied by loss of LAA EGM. P-wave duration reduced immediately on ligation (mean 75 ms preligation to 63 ms postligation; mean difference ± standard error, 12 ± 1 ms; P < 0.0001). Percent P-wave reduction was associated with larger LAA longitudinal cross-sectional area (R(2) = 0.263, P = 0.04) and smaller external circumference (R(2) = 0.687, P = 0.04). All dogs were in sinus rhythm. Percutaneous LAA ligation results in its acute electrical isolation and atrial electrical substrate modification, the degree of which is associated with LAA geometry. These electrical changes raise the possibility that LAA ligation may promote NSR by removing LAA substrate and triggers.

Left Atrial Laceration With Epicardial Ligation Device

Many new devices and techniques are being developed to attempt a reduction in embolic stroke risk for patients with atrial fibrillation who are either unable or unwilling to maintain long-term anticoagulation. One of these new devices (LARIAT®, SentreHEART Inc., Redwood City, California, USA) employs delivery of an epicardial suture to ligate the left atrial appendage after percutaneous pericardial and transseptal access. This series presents three clinical cases that demonstrate a serious and recurrent complication of left atrial laceration and cardiac tamponade shortly following delivery of an epicardial suture ligation to the left atrial appendage. Three clinical cases are described in detail with pre- and postprocedure angiography and echocardiography as well as illustrations reflecting the surgeon's findings on direct visualization of the left atrial lacerations postligation. Potential hypotheses of each injury are examined in light of the case timelines and findings at sternotomy. There was no suggestion that tamponade was related to pericardial or transseptal access, but rather a complication with device delivery. These three patients quickly progressed to clinical cardiac tamponade despite attempted drainage, stressing the importance of cardiovascular surgery backup, including a cardiopulmonary bypass pump, when delivering novel, percutaneous ligation devices for the left atrial appendage.

Percutaneous Left Atrial Appendage Suture Ligation Using the LARIAT Device in Patients With Atrial Fibrillation: Initial Clinical Experience

The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach. Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke. Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation. Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤ 2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤ 3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks. LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

Comparative Evaluation of Three In Situ Castration Techniques for Sterilizing Donkeys: Incision–Ligation (a Novel Technique), Section–Ligation–Release, and Pinhole

Castration is one of the most common surgical procedures performed in equines and is associated with various complications, such as severe hemorrhage and evisceration. Using clinical, hormonal, and histopathological findings, this study aimed to evaluate a novel in situ castration technique and compare it with two other in situ techniques, namely, “section–ligation–release” (SLR) and “pinhole” (PH), to choose the most compatible and safe technique for sterilizing donkeys. Fifteen adult male donkeys were divided into three groups (five animals each). The vascular and the nonvascular parts of the spermatic cord were double ligated separately after opening the skin and the tunica vaginalis at the scrotal neck in the first group (incision–ligation [IL] technique, IL group). In the second group, donkeys were subjected to in situ castration using SLR technique, where both parts of the spermatic cord were triple clamped, ligated, and transected (SLR group). In the third group, percutaneous ligation of the spermatic vessels was performed without opening the skin (PH technique, PH group). The PH technique was less effective and failed to induce necrosis in the testes in situ. Also, Testosterone hormone levels remained elevated 60 days after this procedure. Although the IL and SLR techniques result in convincing reductions in resting and human chorionic gonadotropin–stimulated testosterone levels in treated donkeys, IL and SLR techniques were conducted under narcosis and strict asepsis. We concluded that the PH technique should not be recommended for sterilizing donkeys. Meanwhile, the IL and SLR techniques can be considered as an alternative to other conventional methods used for sterilizing donkeys.

Cost-effectiveness of pharmacologic and invasive therapies for stroke prophylaxis in atrial fibrillation

Atrial fibrillation is an abnormal heart rhythm characterized by rapid, disorganized activation (fibrillation) of the left and right atria of the heart, and is responsible for 15% of 700,000 strokes in the United States each year. There are multiple pharmacologic and nonpharmacologic therapies used for stroke prevention in atrial fibrillation, including vitamin K antagonists such as warfarin, antiplatelet agents such as aspirin and clopidogrel, and newer agents such as dabigatran, rivaroxaban and apixaban. Nonpharmacologic therapies involve excluding the left atrial appendage from the systemic circulation by surgical ligation or excision, percutaneous ligation, or endovascular implantation of a left atrial occlusion device. Because atrial fibrillation-related stroke is preventable, a comparison of the value of these interventions by cost-effectiveness analysis (CEA) could inform clinical and health policy recommendations. In this article, we review the principles of CEA and identify 11 articles that examine CEA of stroke prophylaxis strategies in atrial fibrillation. Although most studies evaluate aspirin and warfarin across a variety of atrial fibrillation stroke risk profiles, we also review new literature on new pharmacologic therapies such as direct thrombin inhibitors and discuss the potential value of device-based therapies.

Laparoscopic-assisted percutaneous internal ring ligation in children

Aim To evaluate the feasibility and safety of laparoscopic ligation of internal ring in congenital inguinal hernia in children. Patients and methods Laparoscopic percutaneous ligation of internal inguinal ring has been performed on 97 children with 133 hernias. The age ranged between 6 months and 11.5 years. The procedure was carried out under general anesthesia, through skin puncture opposite to the lateral edge of the internal ring. The needle was passed under direct vision to encircle the internal ring without touching the vas or testicular vessels. The heel of the needle is backed through the subcutaneous tissue and out of the original stab puncture. The contralateral side was examined and the internal ring was closed if it was patent. Results All children were subjected to a follow-up schedule for 1 year to evaluate both efficacy and reliability of the technique. The mean operative time in our series was 15 (± 3) and 20 (± 5) min for bilateral cases, without anesthesia time. Of 133 hernias repaired, two hernias recurred at 1 and 2 months postoperatively. Conversion rate was 0% in our hands. Five (3.8%) cases developed minimal extraperitoneal hemorrhage during surgery. Six (4.5%) cases developed mild hydrocele, which was successfully treated conservatively. Conclusion Laparoscopic percutaneous ligation of internal inguinal ring repair of congenital hernia is proved to be a safe, simple, and easy procedure and can be performed routinely. The procedure has better cosmetic effect because we use a single umbilical port only. The high safety of the procedure we devised is because the cord contents remained untouched during the procedure. Keywords: extracorporeal, inguinal hernia, laparoscopy, subcutaneous ligation

Fistula Salvage by Endovascular Therapy

Fistulas are considered superior to synthetic grafts as a hemodialysis vascular access; however, fistulas are not without problems. To maximize the number of fistulas being used in prevalent patients, it is important to have a program designed to salvage early failures or fistulas that fail to mature and those that become dysfunctional during the course of usage. Endovascular techniques have proven to be very effective in the management of both of these problems. These fistulas should be aggressively evaluated and treated because treatment carries with it a high expectation of successful salvage of what would have otherwise been an abandoned access.

POS-03.31: Needleoscopic percutaneous high ligation of inguinal hernia in children

POS-03.31: Needleoscopic percutaneous high ligation of inguinal hernia in children