Cuff Placement Research Articles

Unilateral Hypoglossal Nerve Palsy after the Use of a Novel Supraglottic Airway Device

Background: The LMA® Protector™ Airway is a new supraglottic airway device with Cuff Pilot™ Technology that enables visual monitoring of intra-cuff pressure, to reduce the risk of complications from an overinflated device. Case: We present a case of unilateral hypoglossal nerve injury after its use. In our knowledge, this is the first reported case of hypoglossal nerve injury after LMA® Protector™ use. Learning Points: Hypoglossal nerve injury is a rare but distressing complication of LMA use. The greater horn of the hyoid bone is a potential site of injury, as the cuff of the LMA may compress the nerve against bone. In our patient, possible contributing factors included cuff overinflation with/without failure of the Cuff Pilot™ technology, inappropriate sizing and placement of an unfamiliar device. Fortuitously, injury is often neuropraxia with complete recovery in 6 months following conservative management. Consideration should be given to down-sizing the device for Asian patients who tend to have smaller jaws for their weight range. We caution that whilst the green zone of the Cuff Pilot™ corresponds to 40 - 60 cm H2O cuff pressure, it may be more than the “just-seal” pressure required and the cuff may still be overinflated relative to the size of the patient’s airway.

Blood Pressure Reference Intervals for Ketamine-sedated Rhesus Macaques (Macaca mulatta).

Appropriate calculation and use of reference intervals have widespread clinical and research implications. Unfortunately, reference intervals for blood pressure in one of the most commonly used NHP species, rhesus macaques (Macaca mulatta), have never been calculated. Although anesthetic drugs and noninvasive methods of blood pressure measurement both have known effects on blood pressure values, their use provides the safest, fastest, and most widely used approach to clinical evaluation and blood pressure collection in this species. We analyzed noninvasive blood pressure measurements from 103 healthy, ketamine-sedated, adult (age, 8 to 16 y) rhesus macaques, representing both sexes, with various body condition scores by using 2 types of sphygmomanometers at 3 different anatomic locations. Reference intervals were calculated for each device, in each location, thus establishing normative data beneficial to clinical veterinarians assessing animal health and encouraging researchers to use noninvasive methods. Age, body condition score, sex, type of sphygmomanometer, and location of cuff placement were all found to influence blood pressure measurements significantly, providing important information necessary for the appropriate interpretation of noninvasive blood pressure values in rhesus macaques.

Neurophysiological monitoring of tongue muscle activation during hypoglossal nerve stimulation.

Upper airway stimulation for obstructive sleep apnea (OSA) via implantable hypoglossal nerve stimulation (HGNS) reduces airway obstruction by selectively stimulating nerve fibers that innervate muscles that produce tongue protrusion, while avoiding fibers that produce tongue retraction. This selective stimulation likely depends upon the location, intensity, and type of electrical stimulation delivered. This study investigates the impact of changing stimulation parameters on tongue muscle activation during HGNS using intraoperative nerve integrity monitoring in conjunction with electromyography (EMG). Prospective case series. Ten patients undergoing unilateral HGNS implantation for OSA in a university hospital setting were studied. Data included EMG responses in tongue muscles that produce protrusion (genioglossus), retraction (styloglossus/hyoglossus), and stiffening (transverse/vertical) in response to intraoperative bipolar probe electrical stimulation of lateral and medial branches of the hypoglossal nerve (HGN) and to implantable pulse generator (IPG) unipolar and bipolar settings after placement of the stimulation cuff. Stimulation of medial division HGN branches resulted in EMG responses in genioglossus muscles, but not in styloglossus/hyoglossus muscles, whereas stimulation of the lateral division HGN branches drove responses in styloglossus/hyoglossus muscles. Variable responses in transverse/vertical muscles were observed with stimulation of lateral and medial division branches. After electrode cuff placement, unipolar and bipolar HGN stimulation configurations of IPG resulted in unique patterns of muscle activation. The relative activation of extrinsic and intrinsic tongue musculature by HGNS is determined by stimulus location, intensity, and type. Intraoperative neurophysiological monitoring of tongue muscle activation enables proper electrode cuff placement and may provide essential data for stimulus optimization. 4 Laryngoscope, 130:1836-1843, 2020.

Increasing Blood Pressure by Greater Splanchnic Nerve Stimulation: a Feasibility Study.

The splanchnic vascular compartment is the major reservoir for intravascular blood volume, and dysregulation of the compartment was implicated in a series of cardiovascular conditions. We explored feasibility and effectiveness of an implantable cuff system on the greater splanchnic nerve (GSN) in healthy canines for short- and long-term neuromodulation to affect the circulation. Five mongrel hounds underwent minimally invasive right-sided unilateral GSN cuff placement. All animals underwent same day GSN stimulation and repeat stimulation at 9-30 days. Stimulation parameter optimization was conducted both acutely and chronically. Parameters ranged from 1-250 Hz, 0.25 mA-35 mA, 0.1-0.5 ms, and 30-s pulse duration. Two animals were survived for 9 days and 3 animals for 30 days. Stimulation of the right GSN increased mean arterial blood pressure by 36.9 mmHg ± 13.4 (p < 0.0001), central venous pressure by 6.9 mmHg ± 1.7 (p < 0.0001), and mean pulmonary arterial pressure by 6.3 mmHg ± 2.0 (p < 0.0001). Peak effects were observed within 30 s, and magnitude of effects was comparable between stimulation cycles (p = 0.4). Stimulation-induced changes in hemodynamics were independent of afferent nerve fibers (pain response) or the adrenal gland. Necropsy showed no evidence of nerve damage on histologic studies up to 30 days after implantation. GSN stimulation via an implanted nerve cuff provided a reproducible and rapid method to increase arterial, central venous, and pulmonary arterial pressures. The neuromodulation cuff was well tolerated and elicited a response up to 30 days after implantation. The clinical application of GSN stimulation as a tool to change central and peripheral cardiovascular hemodynamics needs to be explored.

P2580Changes in extracellular vesicles during and after STEMI and potential influences of remote ischemic conditioning

Abstract Background Due to their role in transportation of different molecules, such as microRNAs and mRNAs, extracellular vesicles (EVs) enable inter-cellular communication. Therefore, they are potential biomarkers in several kinds of disease. Information on their kinetics during acute and subacute ST-elevation myocardial infraction (STEMI) is limited and potential influence of remote ischemic conditioning (RIC) has not been investigated in humans so far. Methods We conducted a randomized, controlled trial in patients with first-ever STEMI; all patients received primary percutaneous coronary intervention (PCI). Additionally, the interventional group received a protocol of RIC (5 min inflation of a blood pressure cuff on the left upper arm to 200mmHg, 5 min deflation, 4 repetitions in total), whereas controls received sham-intervention (cuff placement). Citrate-plasma for EV analysis was taken prior to (baseline) and immediately after PCI, as well as after 24 hours, 4 days and 1 months. EVs were characterized by a high-sensitive flow cytometer using fluorescence-triggering. EVs were defined as being positive for the intra-vesicular marker CalceinAM or superficial expression of phosphatidylserine (PS; target of Lactadherin) in addition to another superficial epitope. Mixed-models were used to investigate changes over time; time and RIC were treated as fixed effects, patients were treated as random effects to account for the multiple testing design. Results We included 32 patients (16 RIC, 16 control). There was a significant impact of RIC on the changes in platelet (CD41) EVs from baseline (P=0.03, Figure). Furthermore, pro-coagulatory platelet EV (PS+/CD41+) were influenced by time after STEMI (after PCI P=0.017; 24h P=0.005) with significant interaction with RIC immediately and 24h after PCI (P for interaction of time with RIC; after PCI P=0.024, after 24h P=0.008). Likewise, monocyte (CD14) EVs increased significantly with time (4 days P=0.005, 1 Month P&lt;0.001) with significant reduced levels of monocyte EVs by RIC at these time points (P for interaction at 4 days = 0.0493; and 1 month &lt;0.001). There was also a significant change from baseline without any effect of RIC observed in inflammatory/leucocyte EVs (CD66b+; P for change from baseline for all time points &lt;0.001). Pro-coagulatory and inflammatory (PS+/CD15+) EVs were significantly reduced over time (at 24h P=0.007; at 4 days P=0.049, at 1 month P=0.002). Finally, endothelial (CD31+/CD41-) EVs were significantly increased at 1 month after STEMI (P=0.032). Conclusion Several circulating EV sub-population are influenced by the acute phase of STEMI. RIC significantly impacts on the changes in platelet EVs during the initial phase after STEMI. Future studies are needed to clarify the functional importance of theses changes and whether this influence is part of a cardioprotective effect of RIC. Acknowledgement/Funding LBC for Cardiovascular Research Vienna; ATVB Vienna, a grant of the “Medical Scientific Fund of the Mayor of the City of Vienna”

Broad-spectrum chemokine inhibition blocks inflammation-induced angiogenesis, but preserves ischemia-driven angiogenesis.

M3 is a broad-spectrum chemokine-binding protein that inactivates inflammatory chemokines, including CCL2, CCL5, and CX3CL1. The aim of this study was to compare whether M3 could inhibit angiogenesis driven by inflammation or ischemia. Here, apolipoprotein E-/- mice were injected with adenoviral M3 (AdM3) or control adenoviral green fluorescent protein (AdGFP) 3 d prior to stimulating angiogenesis using 2 established models that distinctly represent inflammatory or ischemia-driven angiogenesis, namely the periarterial femoral cuff and hind limb ischemia. AdM3 reduced intimal thickening, adventitial capillary density, and macrophage accumulation in femoral arteries 21 d after periarterial femoral cuff placement compared with AdGFP-treated mice (P < 0.05). AdM3 also reduced mRNA expression of proangiogenic VEGF, inflammatory markers IL-6 and IL-1β, and vascular smooth muscle cell (VSMC)-activated synthetic markers Krüppel-like family of transcription factor 4 (KLF4) and platelet-derived growth factor receptor β (PDGFRβ) in the inflammatory cuff model. In contrast, capillary density, VSMC content, blood flow perfusion, and VEGF gene expression were unaltered between groups in skeletal muscle following hind limb ischemia. In vitro, AdM3 significantly reduced human microvascular endothelial cell 1 proliferation, migration, and tubule formation by ∼17, 71.3, and 8.7% (P < 0.05) in macrophage-conditioned medium associating with reduced VEGF and hypoxia-inducible factor 1α mRNA but not in hypoxia (1% O2). Compared with AdGFP, AdM3 also inhibited VSMC proliferation and migration and reduced mRNA expression of KLF4 and PDGFRβ under inflammatory conditions. In contrast, AdM3 had no effect on VSMC processes in response to hypoxia in vitro. Our findings show that broad-spectrum inhibition of inflammatory chemokines by M3 inhibits inflammatory-driven but not ischemia-driven angiogenesis, presenting a novel strategy for the treatment of diseases associated with inflammatory-driven angiogenesis.-Ravindran, D., Cartland, S. P., Bursill, C. A., Kavurma, M. M. Broad-spectrum chemokine inhibition blocks inflammation-induced angiogenesis, but preserves ischemia-driven angiogenesis.

Re: Dorsolateral Fibromuscular Tissue Preservation during Artificial Urinary Sphincter Cuff Placement is Associated with Low Infection and Erosion Rates.

Re: Dorsolateral Fibromuscular Tissue Preservation during Artificial Urinary Sphincter Cuff Placement is Associated with Low Infection and Erosion Rates.

PC032. Long-term Outcomes and Interventions of Postoperative Type IA Endoleaks After Elective Endovascular Aneurysm Repair

This study evaluated the incidence and long-term outcomes of postoperative type IA endoleak (PT1A) after endovascular aneurysm repair (EVAR). Following Institutional Review Board approval, a retrospective review of consecutive aortoiliac EVARs performed at a single institution between June 2006 and June 2012 was conducted. Patients with an indication of nonruptured infrarenal abdominal aortic aneurysm were included, and those without follow-up were excluded from the study. Patients' demographics, comorbidities, preoperative evaluation, intraoperative details, and postoperative complications were collected. PT1A was identified by postoperative imaging follow-up. PT1A patients were compared with those who had persistent intraoperative type IA endoleak (IT1A) on completion angiography during initial EVAR that had resolved on initial follow-up imaging. There were 627 patients who underwent EVAR at our institution during the designated period, with a final cohort of 389 patients after inclusion and exclusion criteria were applied. Average length of follow-up was 68.8 months (0-194 months). The incidence of PT1A was 8.2 % (n = 32). Compared with the total cohort, those who developed PT1A were statistically more likely to be male (P = .03) and to have a higher all-cause mortality (P < .001) and aorta-related mortality (P = .03). Mean time to presentation was 52.3 months. Of the 32 PT1A patients, 5 (15.6%) presented with aortic rupture, of whom 3 underwent extension cuff placement, 1 had open graft explantation, and 1 declined intervention. Six patients in total (18.7%) declined intervention. Within the 26 PT1A patients who had intervention, 21 (80.7%) showed resolution of PT1A and 5 (19.2%) had recurrence. For patients with recurrent PT1A, three refused further intervention and two had extension cuff placement. Patients with PT1A who had intervention with resolution had significantly increased all-cause mortality compared with the total EVAR cohort (P = .02). Within the PT1A cohort, six (18.7%) had IT1A on completion angiography, with a mean time to presentation of 39 months. Four underwent intervention, all with resolution of the type IA endoleak. IT1A was associated with a significantly decreased median survival (P = .003), but there was no aorta-related mortality. The development of PT1A after elective EVAR is associated with increased aorta-related mortality and presented an average of 52 months postoperatively within our cohort. This underscores the importance of long-term follow-up surveillance. Patients with PT1A who had a successful intervention still demonstrated an increase in all-cause mortality. The incidence of IT1A may decrease median survival but was not associated with aorta-related mortality.

Mid- and Long-Term Effects of Endovascular Surgery and Hybrid Procedures for Complex Aortic Diseases.

Objective To assess the efficacy and short- and mid-term results of endovascular surgery and hybrid surgical procedures in treatment of complex aortic dissection. Methods Clinical data of 90 patients with complex aortic dissection admitted from June 2012 to June 2018 were retrospectively analyzed. Among the patients, 60 cases were male and 30 cases were female, and their ages were ranged from 32 to 79, with an average age of 55 years old; different endovascular techniques and/or hybrid procedures were performed in these patients. Results Technical success rate was 100% for the entire group of patients. Type I endoleak occurred in 8 patients immediately after stent-graft placement, which in 2 cases disappeared after a proximal Cuff placement, and the other cases received no special treatment. Follow-up was conducted from 1 month to 72 months, with an average of 36.3 months, and no stent-graft migration or organ ischemia was noted. In the follow-up patients, no type I endoleak occurred but type II endoleak was found in 2 cases, which were cured without treatment; no patient had paraplegia. Conclusion Endovascular surgery and hybrid procedures have demonstrable mid- and long-term efficacy in treatment of complex aortic diseases. However, this conclusion still requires multicenter, large-sample studies to further confirm.

Genetic Deficiency of T‐bet Protects Against Chronic Renal Injury in Murine Renal Artery Stenosis

AimTh1 cells have potent pro‐inflammatory properties and have been shown to play an important role in the development and progression of acute renal injury to chronic renal disease. The aim of this study is to test the hypothesis that chronic renal damage in mice with renal artery stenosis (RAS) would be ameliorated in mice with homozygous deletion of the Th1 transcription factor T‐bet.MethodsC57BL6/J (WT) and C57BL6/J mice with homozygous deletion of T‐bet (KO) were obtained from Jackson Laboratory. Renal artery stenosis surgery (RAS) was performed by placement of a polytetrafluoroethylene cuff on the right renal artery of KO (KO RAS group, n=5) and WT mice (WT RAS group, n=6). Sham (SH) surgery was performed with manipulation of the right renal artery without cuff placement in KO (KO SH group, n=4) and WT mice (WT SH group, n=5). Renal blood perfusion and oxygenation (R2*) were measured using 16.4T MRI. Blood pressure measurements were done using tail‐cuff method. Kidneys were harvested at 28 days after RAS for assessment of histology.ResultsBaseline intra‐renal perfusion in both KO RAS and WT RAS mice was reduced to a similar extent following cuff placement. In KO RAS group, baseline intra‐renal perfusion (795 ± 57 ml/100g/min) was reduced to 234 ± 22 ml/100g/min (p&lt;0.0001 vs baseline, mean reduction 71%) and in WT RAS group, baseline intra‐renal perfusion (836 ± 87 ml/100g/min) was reduced to 220 ± 21 ml/100g/min (p=0.002 vs baseline, mean reduction 74%). Both KO RAS and WT RAS mice developed hypertension, which persisted throughout the 4 week study. WT RAS group showed significant elevation in cortical R2*, a measure of hypoxia, following RAS compared to their baseline (p=0.002). KO RAS mice showed slightly higher R2* value, which was not significantly different from their baseline values. The weight of the stenotic kidney of the KO RAS group (105 ± 11.6 mg) was significantly lower than the KO SH mice (178 ± 14.1 mg, p=0.0021) but significantly higher than the WT RAS group (51.7 ± 7.9 mg, p=0.0010). On histologic and immune‐histochemical analysis, we observed that the stenotic kidney of the KO RAS group had significantly lower (%) cortical tubular atrophy (15% ± 6.7, p&lt;0.0001) compared to WT RAS mice (81.7% ± 7). KO RAS group had significantly lower macrophage (MQ) (p=0.0016) and T cell influx (p=0.0052) compared to the WT RAS, as assessed by the % of cortical surface areas staining positive for F4/80 (MQ) and CD3 (T cell). When compared to their respective shams, KO RAS showed no significant differences in the % cortical tubular atrophy, MQ and CD3+ T cell influx.ConclusionWe conclude that deficiency of Th1 transcription factor T‐bet, protects against chronic renal injury as evidenced by the less cortical atrophy in KO RAS compared to WT RAS group, despite a similar elevation in blood pressure and reduction in perfusion. This model may provide a novel therapeutic target to prevent renal disease progression in patients with renovascular hypertension.Support or Funding InformationNational Institutes of Health Grant AI 100911This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Abstract WP533: Chronic Cerebral Damage Aggravates Vascular Remodeling in Cuff-Induced Vascular Injury Mouse Model

Introduction: Distant organ dysfunction has been highlighted whereby acute or chronic damage in one organ may induce dysfunctions of the other organs such as cardiorenal syndrome. Vascular injury is an important process in various vascular diseases. However, the relationship cerebral ischemic damage and peripheral vascular disorder is still unclear. Therefore, we have investigated the possible pathophysiological interactions between brain ischemia and vascular remodeling. Methods: Eight-week-old male C57BL/6 mice underwent permanent cerebral brain ischemia by permanent occlusion of the left middle cerebral artery occlusion (MCAO) by electrocoagulation using a subtemporal approach. Four weeks after MCAO, vascular injury was induced by polyethylene cuff placement on the femoral artery. Neointima formation was determined 14 days after cuff placement by evaluating intima/media ratio. Mice were administrated 0.5% tempol, antioxidant agent, in drinking water from after MCAO. Macrophage fractions in spleen two weeks after MCAO were examined and M1 and M2-polarized macrophages were separated by flow cytometry and analyzed. Results: Cerebral ischemia did not influence the intima/media ratio 6 weeks after MCAO compared with sham-operated mice. Neointima formation in the injured artery was significantly increased 2 weeks after cuff placement. Interestingly, the neointima formation 2 weeks after cuff placement was more marked in MCAO-operated mice compared with sham-operated mice. We observed that treatment with tempol did not improve increased neointima formation in MCAO-operated mice. Next, we examined the macrophage fractions in spleen 2 weeks after MCAO. The macrophage fraction in SVF evaluated by F4/80 staining did not differ between sham- and MCAO-operated mice. There was no significant difference in M1 and M2 fraction with/without MCAO. Conclusion: These results suggest that cerebral ischemic injury aggravate peripheral vascular disorders, and we are addressing the possible roles of renin-angiotensin system and inflammation etc. involved in these interesting results, which could provide us with the discovery of new pathological mechanisms concerning the distant organ dysfunctions between brain and peripheral vasculature.

Proximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial.

Background:Blood flow restriction (BFR) training involves low-weight exercises performed under vascular occlusion via an inflatable cuff. For patients who cannot tolerate high-load exercises, BFR training reportedly provides the benefits of high-load regimens, with the advantage of less tissue and joint stress.Hypothesis:Low-load BFR training is safe and efficacious for strengthening muscle groups proximal, distal, and contralateral to tourniquet placement in the lower extremities.Study Design:Randomized controlled trial.Level of Evidence:Level 1.Methods:This was a randomized controlled trial of healthy participants completing a standardized 6-week course of BFR training. Patients were randomized to BFR training on 1 extremity or to a control group. Patients were excluded for cardiac, pulmonary, or hematologic disease; pregnancy; or previous surgery in the extremity. Data collected at baseline and completion included limb circumferences and strength testing.Results:The protocol was completed by 26 patients, providing 16 BFR and 10 control patients (mean patient age, 27 years; 62% female). A statistically greater increase in strength was seen proximal and distal to the BFR tourniquet when compared with both the nontourniquet extremity and the control group (P < 0.05). Approximately twice the improvement was seen in the BFR group compared with controls. Isokinetic testing showed greater increases in knee extension peak torque (3% vs 11%), total work (6% vs 15%), and average power (4% vs 12%) for the BFR group (P < 0.04). Limb circumference significantly increased in both the thigh (0.8% vs 3.5%) and the leg (0.4% vs 2.8%) compared with the control group (P < 0.01). Additionally, a significant increase occurred in thigh girth (0.8% vs 2.3%) and knee extension strength (3% vs 8%) in the nontourniquet BFR extremity compared with the control group (P < 0.05). There were no reported adverse events.Conclusion:Low-load BFR training led to a greater increase in muscle strength and limb circumference. BFR training had similar strengthening effects on both proximal and distal muscle groups. Gains in the contralateral extremity may corroborate a systemic or crossover effect.Clinical Relevance:BFR training strengthens muscle groups proximal, distal, and contralateral to cuff placement. Patients undergoing therapy for various orthopaedic conditions may benefit from low-load BFR training with the advantage of less tissue stress.

Magnetization Transfer Imaging Is Unaffected by Decreases in Renal Perfusion in Swine.

Multiparametric renal magnetic resonance imaging (MRI), including diffusion-weighted imaging, magnetic resonance elastography, and magnetization transfer imaging (MTI), is valuable in the noninvasive assessment of renal fibrosis. However, hemodynamic changes in diseased kidneys may impede their ability to measure renal fibrosis. Because MTI assesses directly tissue content of macromolecules, we test the hypothesis that MTI would be insensitive to renal hemodynamic changes in swine kidneys with acute graded ischemia. Seven domestic pigs underwent placement of an inflatable silicone cuff around the right renal artery to induce graded renal ischemia. Multiparametric MRI was performed at baseline, 50%, 75%, and 100% renal artery stenosis as well as reperfusion. Measurements included regional perfusion, R2*, apparent diffusion coefficient (ADC), stiffness, and magnetization transfer ratio (MTR) using arterial spin-labeled MRI, blood oxygenation-dependent MRI, diffusion-weighted imaging, magnetic resonance elastography, and MTI, respectively. Histology was performed to rule out renal fibrosis. During graded ischemia, decreases in renal perfusion were accompanied with elevated R2*, decreased ADC, and stiffness, whereas no statistically significant changes were observed in the MTR. No fibrosis was detected by histology. After release of the obstruction, renal perfusion showed only partial recovery, associated with return of kidney R2*, ADC, and stiffness to baseline levels, whereas cortical MTR decreased slightly. Renal MTI is insensitive to decreases in renal perfusion and may offer reliable assessment of renal structural changes.

Artificial urinary sphincter implantation with a periprostatic cuff placement for urinary incontinence in men

IntroductionArtificial urinary sphincter (AUS) implantation is the treatment of choice for male urinary incontinence (UI). The aim of the present study was to evaluate treatment outcomes of UI in men using an AUS with a cuff placed around the prostatic urethra.Material and methodsForty-three men with preserved prostatic urethra were selected for AUS implantation due to UI. Twenty patients had the cuff implanted around the prostate using the retropubic approach (Group 1), and 23 had the cuff placed around the bulbous urethra (Group 2). Both groups were compared in terms of continence quality as well as intra- and postoperative complications.ResultsThe groups were comparable with respect to age and duration of follow-up. Median time to complications was 90.3 and 10.7 months in Group 1 and Group 2, respectively (p = 0.007). The complication rate was 40% and 58.3% in Group 1 and 2, respectively (p = 0.001). Complete continence was obtained in 80% of patients from Group 1 and 33.3% of men from Group 2A (p = 0.001).ConclusionsThe analysis indicates that cuff placement around the prostatic urethra results in better continence and is characterised by fewer complications. This method is dedicated for patients who have not had the prostate gland removed. Due to the retrospective nature of this analysis and small groups of patients, it is not possible to formulate ultimate recommendations.

A User's Guide for Surgery Involving the Artificial Urinary Sphincter.

The artificial urinary sphincter (AUS) has long been regarded as the gold standard for surgical correction of male stress urinary incontinence (SUI). Despite impressive rates of initial success for restoration of continence, durability may wane to the point of considering revision surgery. To provide a review of existing data as well as personal experience regarding patient selection, surgical technique, and postoperative troubleshooting for the AUS. A systematic review of the peer-reviewed literature was performed to identify relevant and contemporary articles regarding perioperative and long-term management of the AUS. Additional input is presented based on clinical experience of the senior author. The main outcome measures are durability, patient satisfaction, mechanical failure, and urethral erosion. In addition to a thorough history and examination, preoperative screening should include office cystoscopy to rule out bladder neck contracture in patients with a history of radical prostatectomy. Perineal cuff placement appears superior to alternative approaches. Prior radiation and use of the 3.5-cm cuff are risk factors for future erosion. Newer findings suggest that subsequent recurrence of SUI may be due to restrictive encapsulation, rather than true atrophy, with implications for revision surgery. The AUS remains an excellent option for surgical correction of moderate to severe male SUI. Detailed preoperative evaluation and patient selection are critical. The challenge of downstream recurrent SUI after AUS can be effectively managed for most patients with a structured approach. Chouhan JD, Terlecki RP. A User's Guide for Surgery Involving the Artificial Urinary Sphincter. Sex Med Rev 2019;7:167-177.

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation.

ObjectiveThis study investigated the safety and efficiency of thoracic endovascular aortic repair (TEVAR) plus an aortic extender cuff placement in treating Stanford Type B aortic dissections (TBADs).MethodsClinical data on 157 patients with TBADs who underwent TEVAR in two tertiary medical centers from February 2013 to March 2018 were analyzed retrospectively. An estimated mismatch rate >120% was the indication for placement of an aortic extender cuff. Results in the perioperative and follow-up periods (≥3 months) were analyzed, especially those of aortic remodeling.ResultsIn total, 106 patients (67.5%) underwent standard TEVAR, and 51 (32.5%) received TEVAR plus an aortic extender cuff placement. The primary technical success rate was 96.8% (152/157). Perioperative adverse events included endoleak (2%, 3/157), spinal cord ischemia (SCI) (1.3%, 2/157), and transient renal failure (0.6%, 1/157), with no between-group differences. The median follow-up was 15 months (range 3–71 months). Ten cases of late stent complications were observed, including three endoleak, one upper limb ischemia, one stent distortion, and five stent graft-induced distal re-dissection (SIDR). Patients with a cuff had less distal re-dissection and fewer second interventions, but the differences lacked significance. In the last follow-up, the TEVAR+Cuff group were found to have better true lumen recovery and false lumen shrinkage, and increased complete false lumen thrombosis in the thoracic and abdominal segments; however, no statistical difference was evident in comparison with the TEVAR group (P>0.05).ConclusionTEVAR plus an aortic extender cuff implantation improves remodeling of the dissected thoracic aorta, thus reducing the potential of SIDR. Furthermore, the covered stent with a length of 250 mm does not increase the rate of SCI or paraplegia. However, these results should be confirmed in a larger series of patients with longer follow-up.

Evaluation of indirect blood pressure measurements in bats (Pteropus vampyrus) under isoflurane anesthesia: effects of cuff size, cuff placement, blood pressure state, and monitoring technique

Introduction: Doppler (DBP) and oscillometric (OBP) methods of indirect blood pressure (IBP) measurement were compared with arterial blood pressure (ABP) in anesthetized bats.

Arm and finger measurements in the third trimester: Implications for blood pressure measurement.

To obtain arm and finger measurements of women ≥32 weeks gestation to determine: the requirement for different arm cuff sizes; the suitability of available finger cuffs in this population; the best predictor of arm conicity; the frequency of cuff placement on the forearm or leg. Prospective observational pilot study. Right and left mid-arm circumference (MAC) and to compare these to the recommended cuff sizes; right and left finger circumference; right and left arm conicity; the responses of women to a three-point Likert scale regarding cuff placement. Measurements were obtained for 450 women at an Australian tertiary hospital with a median (IQR) gestation of 35.7 (34.0-37.0); 299 (66.4%) were Caucasian and 35 (7.8%) had gestational hypertension. The median (IQR) body mass index (BMI) was 29.6 kg/m2 (26.2-33.4), range 18.0-62.2. Median (IQR) right MAC was 29.9 cm (27.4-33), range 19.6-53.2. Based on right MAC, 58 (12.9%) required a large cuff and 6 (1.3%) a thigh cuff. Maximum right finger circumference was 7.0 cm. BMI, weight and right MAC were positively correlated with right arm conicity: r = 0.51, 0.42 and 0.45, p < 0.001 for all. R2 for each were 0.26, 0.17 and 0.20. Fourteen (3.1%) reported cuff placement on the forearm or leg. A small percentage of women are likely to be unsuited to traditional arm cuffs. Available finger-cuffs would suit this population. BMI could potentially be used to select women with cone-shaped arms for future studies of alternative devices.

Abstract P269: Chronic Cerebral Ischemic Injury Worsens Vascular Dysfunction

Introduction: Distant organ dysfunction has been highlighted whereby acute or chronic damage in one organ may induce acute or chronic dysfunctions of the other organs such as cardiorenal syndrome. Vascular remodeling is an important process in various vascular diseases. However, the relationship cerebral ischemic damage and peripheral vascular disorder is still unclear. Therefore, we have investigated the possible pathophysiological interactions between brain ischemia and vascular remodeling. Methods: Eight-week-old male C57BL/6 mice underwent permanent cerebral brain ischemia by permanent occlusion of the left middle cerebral artery occlusion (MCAO) by electrocoagulation using a subtemporal approach. Four weeks after MCAO, vascular injury was induced by polyethylene cuff placement on the femoral artery. Neointima formation was determined 14 days after cuff placement by evaluating intima/media ratio. Macrophage fractions in spleen two weeks after MCAO were examined and M1 and M2-polarized macrophages were separated by flow cytometry and analyzed. Results: Body weight after MCAO and cuff placement did not differ among all groups. Cerebral ischemia did not influence the intima/media ratio 6 weeks after MCAO (MCAO-Cuff (-), 0.123) compared with sham-operated mice (sham-Cuff (-), 0.120). Neointima formation in the injured artery was significantly increased 2 weeks after cuff placement (sham-Cuff (+), 0.258). Interestingly, the neointima formation 2 weeks after cuff placement was more marked in MCAO-operated mice (MCAO-Cuff (+), 0.369) compared with sham-Cuff (+). Next, we examined the macrophage fractions in spleen 2 weeks after MCAO. The macrophage fraction in SVF evaluated by F4/80 staining did not differ between sham- (7.5%) and MCAO-operated (7.6%) mice. There was no significant difference in M1 and M2 fraction with/without MCAO. Conclusion: These results suggest that cerebral ischemic injury aggravate peripheral vascular disorders, and we are addressing the possible roles of renin-angiotensin system and oxidative stress etc. involved in these interesting results, which could provide us with the discovery of new pathological mechanisms concerning the distant organ dysfunctions between brain and peripheral vasculature.

Dorsolateral fibromuscular tissue preservation during artificial urinary sphincter cuff placement is associated with low infection and erosion rates.

To present a modified technique in artificial urinary sphincter (AUS) placement that is associated with low rates of erosion and infection in a high-risk population. After Institutional Review Board approval, we identified patients who underwent primary AUS placement using the modified technique between January 2007 and November 2015. Our modification consists of preserving the dorsolateral fibromuscular tissue surrounding the bulbar urethra and horizontally transecting the ventral bulbospongiosus muscle during urethral cuff placement. Preoperative variables such as radiotherapy (RT) and bladder neck contractures were recorded. Effectiveness and complications including infections, erosions, and re-operations were recorded at follow-up. The new technique was used on 208 patients: 40% had a history of RT, including 15% who had had a salvage radical prostatectomy; 26% had had previous bladder neck contractures. No patients developed infection. Overall, erosion occurred in six (2.9%) patients and spontaneous erosions occurred in two (0.9%) during the study period. In all, 21 patients underwent re-operation for device failure. The probability of re-operation for 'any' reason was 7% (95% confidence interval [CI] 4-12%) at 1 year. The 1-year social continence rate was 74% (95% CI 67-81%). Preservation of dorsolateral fibromuscular tissue during AUS placement is an effective means to achieve a low risk of erosions. Our modified technique is safe with low infection and erosion rates, whilst maintaining good functional outcomes despite a high-risk population.