Postprocedure Day Research Articles

P186 In search of lost time

Abstract Arrhythmogenic right ventricular dysplasia (ARVD) is one of the most difficult to diagnose and manage of the cardiomyopathies. Physical exercise can be a contributing factor and may accelerate the progression of the disease. We present the case of a 49-year-old, a former professional football player, with a history of cardiac arrest in 2011 by ventricular tachycardia (VT) (normal coronary arteries). Between 2011 and 2019 the patient didn"t present for reevaluation and resumed endurance sports activity in spite of doctor recommendation. In 2019 he was directed to our clinic for a syncope followed by constrictive anterior chest pain and palpitations, the clinical expression of a VT with LBBB morphology and inferior axis, most likely originated in the RVOT, for which cardioversion was required. Upon admission, the patient was hemodynamically and respiratory stable, at sinus rhythm 60/min with left anterior hemiblock and negative T waves in V1-V2. Biologically, myocardial and hepatic cytolysis enzymes were within normal limits, with mild hypokalemia. Echocardiography showed significant dilatation of RV and RVOT with RV dysfunction (TAPSE 16 mm, FAC 20%, s" 8.6 cm/s). LV was nondilated, with normal systolic function and kinetic, but with trabeculation of the apex. To confirm the diagnosis of ARVD, cardiac MRI was performed and confirmed fat infiltration in the RV free wall with biventricular involvement. Given the high arrhythmic risk (two resuscitated VT episodes, syncope), a two-chamber ICD was implanted, without immediate post-procedural complications. In the second postprocedural day, the patient suddenly installed important epigastric pain with thoracic irradiation. The ECG showed sensing and pacing malfunction and radioscopy showed evidence of ventricular probe displacement. The echocardiography confirmed the myocardial perforation. Emergency surgery by median thoracotomy was performed, with successful extraction of the electrode and myocardial suture. Postoperative progression was favorable under treatment with beta-blocker and amiodarone. A subcutaneous ICD will be implanted as soon as available. In conclusion, this case is a very particular one. First of all, we’ve documented two distinct phases in the evolution of the ARVD (electrical phase – 2011 and structural phase - 2019). Moreover, by resuming endurance sports activity and in concordance with the literature data, we can only assume that the progression of the disease was accelerated and the arrhythmic risk was greater. Complications related to probe stability are common in this population, but myocardial perforation is a very rare and dangerous one. The therapeutic management of patients with ARVD has evolved over the years and continues to be an important challenge. To further improve risk stratification and treatment of patients, more information is needed on the natural history, long-term prognosis, and risk assessment. Abstract P186 Figure. Echocardiografic and MRI aspect

The Lama Trial – A Randomized Controlled Trial Comparing Endovenous Laser Ablation Versus Mechanochemical Ablation in the Treatment of Superficial Venous Incompetence

Introduction - Endovenous thermal ablation, such as endovenous laser ablation (EVLA), is the recommended first-line treatment for superficial venous incompetence (SVI). However such thermal technique requires tumescent anaesthesia, which can be uncomfortable for the patient. Newer non-thermal techniques such as mechanochemical ablation (MOCA) aim to remove or reduce the need for tumescent and thus reduce pain. This randomized controlled trial compares the two treatments with six months’ follow-up. Methods - Patients undergoing ablation for symptomatic primary unilateral SVI were randomized to EVLA or MOCA. Concomitant phlebectomy was performed on symptomatic visible varicosities. Primary outcome was intra-procedural pain scores on 100mm Visual Analogue Scale. Secondary outcomes included post-procedural pain scores, clinical severity scores, general and disease-specific quality of life measurements, recovery time, and duplex ultrasound assessment. Analysis was performed on an intention to treat basis. Data were analysed using parametric and non-parametric statistical tests as dictated by the distribution of data. Results - 82 patients were randomised (41 MOCA and 41 EVLA). The mean age was 53 and 59% were female. Both groups were well matched at baseline. Patients in the MOCA group experienced significantly less pain during truncal ablation (MOCA median 10 mm (interquartile range 9-24 mm) vs EVLA median 28 mm (interquartile range 19-59 mm), P=0.01). However this benefit was lost following concomitant phlebectomy and there was no significant difference in the overall pain scores by the end of the procedure (P=0.441). Patients in the MOCA group also experienced less pain during the next six post-procedural days (by 5-14 mm, P<0.05). There was no significant difference between the groups for either return to work (MOCA median 7 days (interquartile range 4-14 days) vs EVLA median 6 days (interquartile range 4-14 days), P=0.812) or return to normal activities (MOCA median 2 days (interquartile range 1-3 days) vs EVLA median 3 days (interquartile range 1-7 days), P=0.169). Technical success (MOCA 92% vs EVLA 94%), clinical severity scores, disease-specific quality of life scores were similar between groups at six weeks and six months. There were no significant complications. Conclusion - During truncal ablation, MOCA is less painful than EVLA, but this benefit is lost if concomitant phlebectomy is performed. MOCA appears less painful during the first post-procedural week. Both have similar recovery time, clinical improvement, short-term technical success, quality of life improvement and safety outcomes. Longer follow-up is required.

Endosee for Office Cystoscopy: A Single Site Experience

Study Objective Demonstrate the safety and efficacy of an FDA approved handheld hysteroscope used as a newly FDA cleared handheld cystoscope in the office. Design Case series. Setting Busy outpatient urogynecology office private practice. Patients or Participants Thirty-nine consecutive women scheduled for office cystourethroscopy. Interventions Patients undergoing office cystourethroscopy in a single outpatient urogynecology office site were evaluated using the Endosee device with saline infusion without anesthesia. Measurements and Main Results Patient demographics, indications, findings, procedure length, volume of distention fluid, adequacy of the procedure and complications were analyzed. Digital images of all procedures were obtained and tabulated to illustrate the ability to diagnose a multitude of common bladder conditions in female patients with a variety common urogynecologic problems. 100% of procedures noted complete anatomic visualization and bilateral ureteral spillage. All patients were able to tolerate the procedure with no pre-procedure analgesia. Mean patient age 67.3 (SD=13.5, range 41-91), with common indications including hematuria (51.3%), urgency or incontinence (43.6%), recurrent UTI (20.5%), preoperative evaluation (10.3%). Average time of Endosee cystoscopy procedure was 206.5 seconds (SD=59.9) with average filling fluid volume 386.7 cc (SD=53.1). Procedure findings included trabeculations, hypervascularity, bladder stones, bladder and urethral polyps, hemangiomas, and cystitis cystica. One post-procedure day 2 fever was noted, culture negative who self-treated with Ciprofloxacin. Conclusion Endosee, which is FDA cleared for cystourethroscopy, is a safe, effective, well-tolerated alternative for office assessment of the bladder in female patients. The ability to portably perform office cystoscopy in flexible settings may make this modality more accessible to practitioners, without the need for a dedicated cystoscopy room or expensive tower. Further study may be warranted to determine whether Endosee may lead to earlier and more accurate diagnosis for a multitude of bladder problems.

2166 Delayed Symptomatic Pneumoperitoneum After Peroral Endoscopic Myotomy (POEM)

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is as an effective and safe option for the treatment of achalasia. Symptomatic pneumoperitoneum, one of the most significant adverse events noted with POEM, generally presents during the periprocedural period and is treated with needle decompression. We report two cases of delayed symptomatic pneumoperitoneum that were recognized more than 24 hours after POEM, which has not been reported previously. CASE DESCRIPTION/METHODS: A 49-year-old female with history of achalasia presented with two-year history of dysphagia, 40lb weight loss, regurgitation, and chest pain that had been refractory to multiple esophageal dilations and botulinum toxin injections. She underwent an uncomplicated POEM and was admitted for observation. On post-procedure day 2, she complained of worsening shortness of breath and abdominal pain. Chest and abdominal radiographs revealed large volume pneumoperitoneum. Due to continued progression of pain and dyspnea, as well as persistence of pneumoperitoneum on imaging, she underwent CT-guided FNA decompression on post-procedure day 4, with 660 ml of air evacuated and improvement of pain and dyspnea. A 53-year-old female with history of achalasia presented with four-month history of dysphagia, 40lb weight loss, and regurgitation. She underwent an uncomplicated POEM and was admitted for observation. Approximately four hours after the procedure, she became febrile and tachycardic, concerning for perforation. She was transferred to the ICU, where physical exam revealed crepitus to the neck and chest, as well as diffuse abdominal tenderness without guarding or rebound. A chest radiograph revealed large volume pneumoperitoneum. Gastrograffin swallow showed no evidence of contrast extravasation or perforation. On post-procedure day 1, she underwent bedside ultrasound-guided needle decompression using a 16-gauge angiocatheter, which led to a rush of air and improvement in abdominal pain. DISCUSSION: While symptomatic pneumoperitoneum is the second most common adverse event associated with POEM, it has been reported exclusively in the immediate periprocedural period. The etiology of delayed symptomatic pneumoperitoneum in these cases is unclear. No precipitating factors were identified in the first case; in the second case, it is possible that the symptoms were due to a microperforation not detected on imaging. These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period.

2114 Pharyngo-esophageal Perforation During Endoscopic Ultrasound: Case Report and Literature Review

INTRODUCTION: EUS related serious complications such as luminal perforation, pancreatitis and bleeding are rare. We report a case of EUS-related pharyngo-esophageal perforation, successfully managed conservatively and brief literature review. CASE DESCRIPTION/METHODS: A 75-year-old male presented with elevated LFTs without jaundice. CA 19-9 was elevated (112 U/mL). CT revealed a double duct sign and a 3 cm pancreatic head mass (Figure 1). Decision was made to proceed with EUS with FNA. Diagnostic EGD noted no luminal esophageal narrowing. The linear array echoendoscope was inserted into the oropharynx but was difficult to pass into the esophagus secondary to cervical osteophytes. The gastroscope was reinserted into the esophagus. Minimal pharyngeal mucosal trauma was noted. A savary guidewire was passed into the stomach; the gastroscope was removed. The echoendoscope was backloaded onto the wire and reinsertion attempted. Despite gentle maneuvers and multiple attempts, resistance to passage was encountered, esophageal intubation was not possible; the echoendoscope was removed. Repeat EGD revealed a 2 cm deep mucosal tear extending from the posterior pharynx to the esophageal inlet without full-thickness perforation or significant bleeding (Figure 2). The gastroscope and the guidewire were removed and the procedure was terminated. Patient complained of throat pain, especially with swallows. CT showed pneumomediastinum and extraluminal air and edema adjacent to the right aspect of the pharynx &amp; esophagus (Figure 3), consistent with a pharyngo-esophageal microperforation. Thoracic surgery was consulted, antibiotics started, patient kept NPO. The patient remained hemodynamically stable with improved pain and no need for surgical intervention, discharged home on post-procedure day 4. DISCUSSION: EUS is a safe procedure with complication rates comparable to EGD. The rate of esophageal perforation is very low, ranging from 0.03-0.04%. The treatment for pharyngo-esophageal perforation depends upon the degree, location, timing of diagnosis, hemodynamic status and clinical status of the patient. In a case series of 16 cervical esophageal perforations, 44% of patients had history of difficult intubation with endoscopic procedures. 81% were managed conservatively.1 Early recognition and timely management is critical for ensuring an excellent outcome with conservative management. JOURNAL/ajgast/04.03/00000434-201910001-02115/figure1/v/2023-08-15T171636Z/r/image-tiff JOURNAL/ajgast/04.03/00000434-201910001-02115/figure2/v/2023-08-15T171636Z/r/image-tiff JOURNAL/ajgast/04.03/00000434-201910001-02115/figure3/v/2023-08-15T171636Z/r/image-tiff

1771 Eosinophilic Esophagitis Presenting With Esophageal Wall Dissection

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated, inflammatory disease with a wide spectrum of presentation from mild dysphagia to food impaction. We describe the presentation and management of a patient whose initial presentation of EoE included the rare complication of esophageal dissection. CASE DESCRIPTION/METHODS: A 30-year old Caucasian male presented to the emergency department after 10 days of dysphagia and odynophagia. His physical exam was normal. Initial laboratory evaluation revealed mildly elevated troponin I and leukocytosis. CT imaging with IV contrast showed an air-fluid level within the distal esophagus. EGD could only be completed with a pediatric gastroscope (5.4-mm) due to severe, diffuse narrowing of the esophagus. The entire esophagus had findings of EoE including edema, furrowing, and circumferential rings. The lumen of the proximal esophagus was 12-15 mm with acute narrowing to 7mm at 27-cm. Most notable was a 1-cm x 2-cm hole at 25-cm which communicated with a fluid-filled, granulation tissue lined space that paralleled the distal esophagus (Figure 1). Biopsies showed &gt;50 Eos/hpf consistent with EoE. The patient was started on broad-spectrum antibiotics, IV proton pump inhibitor therapy, topical steroid and kept NPO. CT imaging with IV and gastrograffin contrast demonstrated a long segment intramural dissection with a double-barreled esophageal lumen (Figure 2). Following consultation with cardiothoracic surgery, endoscopic management was pursued. Endoscopic suturing was not attempted given severe luminal narrowing. The tissue proved too fibrotic for hemostasis clips. A through-the-scope, fully-covered self-expanding esophageal stent (FCSEMS) was deployed across the defect and a feeding tube was inserted. An elemental diet was started. Follow-up imaging showed obliteration of the false lumen by post-procedure day 9 (Figure 3). Repeat EGD one month later showed an intact lumen but with delicate-appearing granulation tissue at the location of the previous hole (Figure 4), thus another FCSEMS was placed and elemental diet was resumed with plans for repeat EGD in 4 weeks. DISCUSSION: Intramural esophageal dissection is a rare, potentially life-threatening complication of EoE which can be medically and endoscopically managed. “The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Air Force, the Department of the Navy, Department of Defense, or the U.S. Government.”

CONSERVATIVE TREATMENT OF ACUTE OMENTAL HEMATOMA AFTER PEG WITH T-FASTENER TECHNIQUE: A CASE REPORT

PEG is an endoscopic operative procedure used for feed and nutritional support. We report a case of conservative treatment of a big omental hematoma due to PEG placement with T-fastener technique. A 69-years old man with SLA was admitted to our Institute to undergo PEG placement with T-fastener technique. Following the procedure, after some hours, appeared moderate anemia, hypotension, tachycardia and lower abdominal pain. There was no blood from the PEG tube but gastric secretion. There were no signs of peritonitis. Due of the worsening of anemia and pain a CT scan was performed in the evening with evidence of coarse acute hematoma of the greater omentum with venous bleeding of gastrocolic ligament. The PEG tube was in the correct position. The hemodynamic stability permitted not to proceed with immediate surgical treatment but conservative mode. Erythrocyte suspention was transfused. A new CT scan was performed after six days with evidence of reduction in hematoma volume. The patient was discharged in 11th post-procedural days. Introducer T-fastener technique is a it is a safe, effective technique, widely used in patients in serious general clinical conditions. In this case the complication was probably due to use of gastropexis technique with T-fastener nylon wires before trans-abdominal introduction of PEG tube. Post-operative bleeding is not frequent but serious complication after PEG procedure. Intraperitoneal hematoma is rare and difficult to diagnose because of lack of intragastric bleeding. This tecnique, associated with gastropexy with nylon threads (T-fastener gastropexis), however, it remains a safe, rapid and selected technique.

Treatment of superior vena cava syndrome using AngioJet\u2122 thrombectomy system

BackgroundSuperior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration.Case presentationA 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava.ConclusionsAcute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient’s clinical condition necessitates treatment.

Hemostatic spray powder TC-325 for GI bleeding in a nationwide study: survival and predictors of failure via competing risks analysis

TC-325 (Hemospray, Cook Medical, Winston-Salem, NC) is an inorganic hemostatic powder recently approved by the U.S. Food and Drug Administration. This study aimed to examine the effectiveness, safety, and predictors of TC-325 failure in a large real-life cohort. This was a retrospective study conducted at 21 Spanish centers. All patients treated with TC-325 until September 2018 were included. The primary outcome was treatment failure, defined as failed intraprocedural hemostasis or recurrent bleeding within the first 30 postprocedural days. Secondary outcomes included safety and survival. Risk and predictors of failure were assessed via competing-risk models. The cohort comprised 261 patients, of whom 219 (83.9%) presented with upper gastrointestinal bleeding (GIB). The most common causes were peptic ulcer (28%), malignancy (18.4%), and therapeutic endoscopy-related GIB (17.6%). TC-325 was used as rescue therapy in 191 (73.2%) patients. The rate of intraprocedural hemostasis was 93.5% (95% confidence interval [CI], 90%-96%). Risks of TC-325 failure at postprocedural days 3, 7, and 30 were 21.1%, 24.6%, and 27.4%, respectively. On multivariate analysis, spurting bleeding (P= .004), use of vasoactive drugs (P= .02), and hypotension (P= .008) were independent predictors of failure. Overall 30-day survival was 81.9% (95% CI, 76%-86%) and intraprocedural hemostasis was associated with a better prognosis (adjusted hazard ratio, 0.29; P= .006). Two severe adverse events were noted. TC-325 was safe and effective for intraprocedural hemostasis in more than 90% of patients, regardless of the cause or site of bleeding and its use as rescue therapy. In this high-risk cohort treated with TC-325, the 30-day failure rate exceeded 25% and was highest with spurting bleeding or hemodynamic instability.

Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting.

Background and Purpose- Novel double layer micromesh stents have recently been introduced for treatment of patients with significant carotid stenosis. Strict evaluation of safety and patency of such novel devices is required both in elective and in emergency interventions. We report a single center experience with double layer mesh stents for carotid artery revascularization. Methods- Consecutive patients who underwent carotid artery stenting with a double layer mesh stent between June 2015 and September 2018 in our tertiary vascular referral center were included. Treatment indications were emergent carotid artery stenting for intracranial or extracranial carotid stenosis in patients undergoing intraarterial thrombectomy for acute ischemic stroke in the anterior circulation, or elective carotid artery stenting for significant symptomatic or asymptomatic stenosis. End points were postprocedural thrombotic stent occlusion and procedural stroke or death. Results- Fifty-four patients were included; 27 were treated for acute stroke with intracranial and extracranial (tandem) lesions and 27 for elective stenting. Follow-up imaging was available for 9/27 (33%) patients with acute stroke, and 19/27 (70%) electively treated patients. Five stent occlusions occurred, of which 2 were symptomatic with clinical deterioration within one day. Another patient deteriorated on postprocedural day one, but imaging of the carotids was not performed, and the stent turned out occluded on the 30-day duplex. All stent occlusions occurred in patients treated for acute stroke. Conclusions- This study suggests that occlusion of novel double layer mesh stents occurs in a considerable proportion of carotid artery stenting procedures performed in the emergency setting for acute stroke, with occlusion-related symptoms in half the cases. Future prospective studies should clarify the role of double layer mesh stents in this high-risk patient population.

Concertina Phenomenon in the Left Anterior Descending Artery: An Unexpected Circumstance in an Unexpected Vessel

The concertina phenomenon is the occurrence of new and transient angiographic series of pseudolesions in a tortuous vessel induced mainly by a stiff guide wire. Here, we describe a 53-year-old man who experienced a concertina effect in the left anterior descending coronary artery (LAD) during an elective percutaneous coronary intervention. After the diagnosis of the concertina phenomenon in the LAD, a percutaneous coronary intervention was performed following the withdrawal of the soft guide wire to the mid level of the LAD. After the intervention, the patient remained in very good clinical status and was discharged on the third postprocedural day.

Metabolic and endocrinal effects of epidural glucocorticoid injections.

Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.

Nonclosure Versus Closure of Buccal Mucosal Graft Harvest Site: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes

To compare the postprocedural oral pain scale and other patient reported oral morbidities for nonclosure vs closure of buccal mucosal graft (BMG) harvest sites through systematic review and meta-analysis of comparative studies. A systematic literature search was performed in September 2018. Nonrandomized comparative studies were summarized and randomized controlled trials were evaluated according to the Cochrane Collaboration recommendations. The outcomes assessed were: pain, perioral numbness, mouth opening tightness, and impairment of oral intake. Standardized mean difference, and relative risk with corresponding 95% confidence intervals were extrapolated. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed according to the shape of the BMG harvested. PROSPERO registry (CRD42016043502). A total of 269 patients from 4 randomized controlled trials were included for meta-analysis. Overall pooled effect estimates on the reported pain score assessed on postprocedural day 1, day 3-7 and 6 months, have shown no significant difference between the closure and nonclosure treatment groups. Subgroup analysis showed that rectangular shaped BMG harvest sites that were not closed had lower pain scores (standardized mean difference-0.90, 95% confidence interval -1.70, -0.10) on postoperative day 1. No reported short or long-term oral morbidities required further surgical intervention in either treatment group. The evidence suggests that at 6-month follow-up, there is no overall significant difference between nonclosure and closure of BMG harvest sites. However, among rectangular shaped BMG, not closing the harvest site may lead to less immediate postoperative pain when compared to closure of the harvest site.

Prevalence and Characteristics of Venous Thrombosis after Catheter Ablation of Atrial Fibrillation in Patients Receiving Periprocedural Direct Oral Anticoagulants.

Periprocedural venous thromboembolisms (VTEs) area rare occurrence but a critical complication after catheter ablation of atrial fibrillation (AF).The aim of this study was to investigate the incidence of symptomatic deep vein thromboses (DVTs) and pulmonary thromboembolisms (PTEs) in patients who underwent AF catheter ablation and received periprocedural oral anticoagulation with direct oral anticoagulants (DOACs). A total of 2,193 consecutive patients undergoing AF catheter ablation with periprocedural DOACs were retrospectively analyzed.Two patients (0.091%) experienced symptomatic DVTs after the ablation, and no patients had any PTEs. One patient was a 72-year-old female who underwent cryoballoon ablation with periprocedural apixaban at a dose of 2.5 mg twice daily. The other patient was a 74-year-old male who underwent a Hot Balloon ablation and thereafter radiofrequency catheter ablation for recurrent AF with edoxaban at30 mg once daily. Both DVT patients underwent AF ablation by the right femoral vein approach, and after discharge had right leg pain and swelling on post-procedural days 4 and 8, respectively. TheDVT was treated by increasing the dose of apixaban and changing it from 30 mg/day of edoxaban to 15-30 mg/day of rivaroxaban, and the thrombi completely disappeared in both patients without any thromboembolic and hemorrhagic complications. AF catheter ablation with periprocedural DOAC treatment revealed anextremely low incidence of symptomatic VTEs, which may be successfully treated by increasing the DOAC dose or changing the DOAC type.

Stroke After Surgical Versus Transfemoral Transcatheter Aortic Valve Replacement in the PARTNER Trial

BackgroundTransfemoral-transcatheter aortic valve replacement (TF-TAVR) is increasingly used to treat aortic stenosis, but risk of post-procedure stroke is uncertain. ObjectivesThe purpose of this study was to assess stroke risk and its association with quality of life after surgical aortic valve replacement (SAVR) versus TF-TAVR. MethodsThe authors performed a propensity-matched study of 1,204 pairs of patients with severe aortic stenosis treated with SAVR versus TF-TAVR in the PARTNER (Placement of AoRTic TraNscathetER Valves) trials from April 2007 to October 2014. Outcomes were: 1) 30-day neurological events; 2) time-varying risk of neurological events early (≤7 days) and late (7 days to 48 months) post-procedure; and 3) association between stroke and quality of life 1 year post-procedure by the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score. ResultsThirty-day stroke (5.1% vs. 3.7%; p = 0.09) was similar, but 30-day major stroke (3.9% vs. 2.2%; p = 0.018) was lower after TF-TAVR than SAVR. In both groups, risk of stroke peaked in the first post-procedure day, followed by a near-constant low-level risk to 48 months. Major stroke was associated with a decline in quality of life at 1 year in both SAVR (KCCQ score median [15th, 85th percentile]: 79 [53, 94] without major stroke vs. 64 [30, 94] with major stroke; p = 0.03) and TF-TAVR (78 [49, 96] without major stroke vs. 60 [8, 99] with major stroke; p = 0.04). ConclusionsDespite similar early-peaking (<1 day post-procedure) neurological risk profiles, SAVR is associated with a higher risk of early major stroke than TF-TAVR. Periprocedural strategies are needed to reduce stroke risk after aortic valve procedures. (Placement of AoRTic TraNscathetER Valve Trial [PARTNER]; NCT00530894)

Use of REBOA to stabilize in-hospital iatrogenic intra-abdominal hemorrhage

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly...

Preponderance of microbial isolates among heart transplantation recipients requiring renal replacement therapy: a propensity score-adjusted analysis

AimTo assess the association between renal replacement therapy (RRT) and post-transplant infection incidence.MethodsThis single-center retrospective cohort study included 158 patients who underwent heart transplantation (HTx) in our center from 2008 to 2016, survived beyond the first post-procedural day, and had available microbial data. The patients were dichotomized according to the need for periprocedural RRT. Twenty-seven patients in RRT group had lower preoperative creatinine clearance, greater body mass index, and higher likelihood of having diabetes. Propensity score adjustment was used to account for multiple covariates. The primary outcome measure was the presence of bacteremia in patients with and without the need for RRT. The secondary outcome measures were the presence of microbial isolates from any culture and clinical outcome data.ResultsUnadjusted analysis showed that the RRT group had higher incidence of any positive microbial isolate (93% vs 73%; odds ratio [OR] 4.77, 95% confidence interval [CI] 1.01-30.53; P = 0.026) and an increased susceptibility to bacteremia (50% vs 22%; OR 3.50, 95% CI 1.28-9.67; P = 0.012). Propensity score-adjusted analysis corroborated the between-group difference in positive blood cultures (OR 3.97, 95% CI 1.28-12.32; P = 0.017). There was no difference in the incidence of total microbial isolates between the groups (OR 4.55, 95% CI 0.90-23.05; P = 0.067).ConclusionsPatients requiring RRT after HTx had an increased susceptibility to infections via various portals of entry, predominantly due to an increase in blood-borne infections. Understanding the underlying conditions leading to infection-related morbidity is important for infection control and prevention.

Endovascular and open surgical treatment of complications after endovascular aortic aneurysm repair: A single-center experience

While endovascular aortic aneurysm repair (EVAR) has proven to be a safer alternative to open surgical repair for infrarenal abdominal aortic aneurysms (AAA) repair, the development of stent-graft complications mandates follow-up computed tomography imaging to minimize AAA-related mortality. In this single-institution report, adverse EVAR events identified in 150 consecutive patients are detailed. Early morbidity was low (<3%), with only 1 patient death on post-procedure day 2. After discharge (mean follow-up of 24 months), 2 patients died from cancer and one AAA-related mortality occurred after open conversion for stent-graft migration. Although computed tomography imaging detected no EVAR endoleak at 30 days, 19 patients developed an endoleak, including three Type I and four Type III leaks. Our institutional series review confirmed that EVAR of infrarenal AAA is a safe and valid alternative to open surgical repair, but sac embolization at the primary procedure in patients judged to be at high risk for Type II endoleak should be considered.

Abstract No. 700 Which method of biliary drainage results in the most rapid decline in bilirubin levels, primary stent or drain placement?

Compare the rate of decline in the serum total bilirubin levels post biliary drainage with placement of a primary stent or drainage catheter. Medical record review of all primary biliary stents (PBS) and biliary catheter drainage (BD) placements from January 2016 till March of 2017 at a single institution identified 81 PBS and 118 BD procedure performed in 180 patients (107 males; median age 60.66 +/- 13.33, 73 females; median age 60.69 +/- 14.43, range 8-88). Procedures performed for cholangitis and for post procedure biliary complications were excluded. 70 PBS and 83 BD met these criteria. Procedure type and decision for drainage of the right or left biliary system was under the discretion of the primary operator. Available total bilirubin (t-bili) levels were collected for patients pre-procedure (n= 153), post procedure day (POD) one (n=146), POD two (n=102), POD seven (day 9 +/- 3.2) (n=132), and POD 30 (day 31.8 +/- 8.8)(n=113). Successful drainages with a decrease in the t-bili noted at all time points; PBS (n=49) vs BD (n=52) POD 1 (23.78 +/- 16.3 vs 25.43 +/- 16.8 p=0.62), PBS vs BD POD 2 (34.87 +/- 16.96 vs 43.02 +/- 16.57 p=0.06), PBS vs BD POD 7 (56.83 +/- 20.2 vs 57.41 +/- 19.88 p=0.88), PBS vs BD POD 30 (78.53 +/- 12.48 vs 71.61 +/- 21.41 p=0.07). All drainages including procedure failures; PBS vs BD POD 1 (14.39 +/- 27.49 vs 12.69 +/- 30.68 p=0.73), PBS vs BD POD 2 (23.39 +/- 28.1 vs 21.98 +/- 59.99 p=0.90), PBS vs BD POD 7 (45.62 +/- 36.55 vs 36.81 +/- 44.94 p=0.21), PBS vs BD POD 30 (69.29 +/- 31.18 vs 47.93 +/- 62.49 p=0.02). The rate of t-bili reduction is more rapid in PBS during the first 30 days after placement. At 30 days PBS has decreased the t-bili levels in all patients by 69.29, this is statistically significant compared to the decrease in t-bili with BD (47.93) p=0.02. BD tend to fail more often in lowering the t-bili. When initially successful, BD appears to decrease the t-bili at a slightly more rapid rate then PBS. At 30 days this appears to reverse with PBS again providing the greatest percent reduction.

4:12 PM Abstract No. 119 Are transjugular intrahepatic portosystemic shunts (TIPSs) effective and durable in pediatric patients?

To examine the efficacy of TIPSs in the pediatric and adolescent population. IRB-approved retrospective review of patients undergoing TIPSs placement at three large tertiary children’s hospitals from 2001-2017. Demographics, stent type, technical success, mean gradient reduction (MGR), complications and patency at 1, 6, 12, and 24 mo. are reported. Patients missing stent type information were excluded from analysis of this single variable. All 60 patients in the study period (mean age = 12.8y, range 2-20; mean MELD/PELD score = 12.4, range 6-33) had ePTFE covered (52/56) or uncovered (4/56) TIPS placed. Stent type was missing in 4 patients. Stent diameter ranged from 8-10 mm. Major indications were acute variceal bleed with and without portal vein thrombus (34/60; 3/34, and 31/34), primary (6/60) and secondary (11/60) prevention of variceal bleed, portal vein thrombosis without variceal bleed (5/60), and refractory ascites (2/60). Technical success = 91.3% (55/60). MGR = 8.2 mm Hg (range, 0-29). Patency rates at 1, 6, 12, and 24 mo = 97.9% (47/48), 97.6% (41/42), 93.7% (30/32), and 92.0% (23/25). Decrease in patient follow-up was due to: transplant within 1y (4/60), loss to follow-up before 1 mo (1/60), and stent age less than follow-up interval. Primary patency at 1, 6, 12, and 24 mo = 93.8% (45/48), 88.1% (37/42), 87.5% (28/32), and 84.0% (21/25). 4 patients had TIPS stenosis requiring intervention within: 1 mo = 1/48; 6 mo = 2/42; 24 mo = 1/25. 1 patient had occlusion with successful recanalization within 1 mo (1/48). 3 patients had occlusion with failed recanalization within: 1 mo = 1/48 and 12 mo = 2/32. Complications = 7 major (e.g., sepsis, hemoperitoneum, and death) (12.1%); 11 minor (e.g., encephalopathy) (18.3%). mortality = 5.0% (3/60), due to hepatic necrosis at postprocedure day (PPD) 10 (1/3), sepsis at PPD 8 (1/3), and uncontrolled hemorrhage at PPD 16 (1/3). TIPSs in children has comparable technical success, patency, and complication rates as in adults based on available peer-reviewed literature.