Reintervention Rate Research Articles

Long-term Outcome of Conjunctival Transposition Flaps for Contracted Sockets.

To assess the efficacy, and reintervention rate, of a conjunctival transposition technique in the treatment of contracted fornices in anophthalmic sockets. Retrospective case-note review of patients with contracted anophthalmic sockets who received a novel conjunctival mucosal transposition flap for augmentation of socket lining. Contracted anophthalmic sockets were categorized as grade 1 (minimal contraction), grade 2 (inferior and/or superior fornix), grade 3 (advanced scarring of the entire upper and lower fornices), and grade 4 (severe palpebral phimosis, recurrent cases, and irradiated sockets). Of 32 patients (56% male), 53% had mild-to-moderate contracted anophthalmic sockets (grades 1 or 2). The transposition flap was combined with secondary ball implantation (3 cases), ball exchange (1 case), primary orbital floor (1 case), or revisional floor (3 cases) implantation. By an average follow up of 9.2 years, 16% (5 cases with grade 3 or 4) required additional relining, with another patient declining further surgery; this yielding an overall anatomic success of 81% (100% in grades 1 and 2; 60% in grades 3 and 4). At the last follow up, 91% of patients had adequate socket lining and 94% reported a comfortable socket with stable prostheses. Having results similar to free grafting but without remote donor-site morbidity, this novel transposition flap satisfactorily addresses mild-to-moderate fornix contracture, and most patients achieve stable and comfortable prosthetic wear. Some patients with severe contracted anophthalmic sockets required further autologous grafting: this generally arose because the transposition flap included tissue from above the socket's horizontal raphé (with later contracture of the upper fornix).

Outcomes of balloon-assisted maturation with large-diameter balloons.

Balloon-assisted maturation (BAM) is a well-established technique for maturation of inadequate arteriovenous fistulas (AVF). The objective of this study was to evaluate outcomes of initial BAM using large-diameter angioplasty balloons. Charts of patients who underwent BAM between 2018 and 2021 at a single academic institution were reviewed. AVF maturation rate was the primary outcome. Secondary outcomes included procedural complications, re-intervention rates, post-procedure vein diameter, and time to catheter-free hemodialysis (HD). Outcomes of patients that underwent initial BAM with ⩾7 mm diameter balloons (Group I) were compared to those of patients that had initial BAM with <7 mm balloons (Group II). Group I (n = 149) was a significantly younger cohort and had more men compared to Group II (n = 90). There were no significant differences associated with procedural details and complication rates. Median vein diameter was larger (5.9 mm, IQR: 5-6.4) in Group I compared to Group II (5.1 mm, IQR: 4.2-5.9; p = 0.03) on post-procedure Duplex ultrasound. There was also a higher incidence of vein stenosis in Group II. The overall maturation rate was higher in Group I (97% vs 88%, p = 0.003), and a larger proportion of patients in Group II required more than one BAM to achieve maturation (33% vs 16%, p = 0.002). The median time to catheter-free HD after first BAM was 29 days (IQR: 19-47) in Group I and 42 days (IQR: 24-75) in Group II (p = 0.002). At 60 days after first BAM, the incidence of catheter-free HD was 83% in Group I versus 67% in Group II (p = 0.001). Our study demonstrates that the ability to utilize large angioplasty balloons during initial BAM is associated with higher rates of AVF maturation with fewer re-interventions and shorter time to catheter-free dialysis. AVFs that can tolerate this procedure often have more favorable baseline characteristics.

Postnatal outcome following fetal aortic valvuloplasty for critical aortic stenosis.

To report our experience of fetal aortic valvuloplasty (FAV) for critical aortic stenosis (AS), with a focus on the postnatal evolution of the patients. This was a retrospective study including all fetuses with critical AS which underwent FAV in a single center between January 2011 and June 2022. FAV was performed under ultrasound guidance. Technical success was based upon balloon inflation across the aortic valve and improvement of the antegrade aortic flow across the aortic valve. At birth, a biventricular circulation (BVC) strategy was decided assuming the left ventricular (LV) systolic and diastolic function would ensure the systemic circulation. Sixty-three FAV procedures were performed in 58 fetuses, at a median (range) gestational age of 26.2 (20.3-32.2) weeks. The procedure was technically successful in 50/58 (86.2%) fetuses. There were 11/58 (19.0%) cases of in-utero demise and 9/58 (15.5%) terminations of pregnancy. No patient was liveborn after an unsuccessful procedure. Thirty-eight (65.5%) infants were liveborn, at a median (range) gestational age of 38.1 (29.0-40.6) weeks, of whom 21 (55.3%) required prostaglandin treatment. Twenty-eight of the 38 (73.7%) liveborn children (48.3% of the study population) entered the BVC pathway at birth. Among them, 20 (71.4%) required an aortic valvuloplasty procedure at birth (11 (55.0%) percutaneous balloon, nine (45.0%) surgical) and eight (28.6%) did not require any treatment at birth, but, of these, five (62.5%) underwent surgical valvuloplasty between day 26 and day 1200 of age. Eleven (39.3%) of the infants with BVC at birth required a second intervention and four (14.3%) of them required a third intervention. Two (7.1%) infants who entered the BVC pathway at birth underwent conversion to univentricular circulation (UVC). None of the surviving children with BVC developed pulmonary hypertension. The overall survival rate in those with BVC at birth was 22/28 (78.6%) at a median (range) follow-up of 23.3 (2.0-112.6) months. Ten of the 58 (17.2%) patients had UVC at birth. Among these, six (60.0%) received compassionate care from birth and four (40.0%) underwent surgery. Three of the 10 patients who had UVC at birth were still alive at the latest follow-up assessment, at a median (range) gestational age of 24.3 (8.3-48.7) months. FAV for critical AS led to increase of antegrade aortic flow in 86.2% of fetuses, with BVC being achieved in 48.3% (73.7% of the liveborn cases). Among patients with BVC at birth, the rate of reintervention was high, but 78.6% of these children were alive at the latest evaluation. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound-Guided High-Intensity Focused Ultrasound of Uterine Fibroids and Adenomyosis: An 11-Year Experience from a Single Center in Hong Kong.

Introduction: This study evaluated the efficacy and safety of ultrasound-guided high-intensity focused ultrasound (HIFU) in treating symptomatic uterine fibroids and adenomyosis. Methods: HIFU treatments performed in premenopausal women with symptomatic uterine fibroids and adenomyosis were analyzed retrospectively. Lesion volume reduction, change in symptoms of menstrual pain, and quality of life were examined. Major and minor complications, together with re-intervention rates, were evaluated. Results: Eighty-one HIFU treatments were performed in seventy-nine premenopausal women. The follow-up period was up to 95 months. A total of 65 women underwent treatment for uterine fibroids and 14 were treated for adenomyosis. For patients with uterine fibroids, the baseline fibroid volume median was 190.1 cm3 (18.5-1729.4 cm3). Fibroid volume was reduced by 50.1% (-26.2-97.8, p < 0.0001) at 6 months and 66.9% (-33.7-98.3, p < 0.0001) at 12 months after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores had decreased by 43.5% (0-62.5%, p < 0.0001) at 6 months and 50% (0-73%, p < 0.0001) at 12 months after treatment. In the adenomyosis arm, the median baseline uterine volume was 97.7 cm3 (43.7-367.4 m3). Uterine volume was reduced by 19.6% (range: 1.2-42.0, p = 0.28) at 6 months and 41.9% (18.9-69.2, p = 0.04) at 12 months after treatment. UFS-QOL scores were reduced by 38.1% (6-66.7%, p < 0.0001) at 6 months and 40% (0-70%, p < 0.0001) at 12s month after treatment. Fourteen (21.5%) patients with uterine fibroid and five (35.7%) patients with adenomyosis required subsequent interventions. Conclusions: HIFU provides symptomatic relief to most patients with uterine fibroids and adenomyosis. It is a promising uterus-sparing treatment for patients with these conditions.

Safety and Efficacy of Primary EUS-Guided Choledochoduodenostomy for Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for biliary drainage in malignant distal biliary obstruction (MDBO). Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is considered a rescue therapy for failed ERCP. This study aims to evaluate the safety and efficacy of this technique as the primary modality for MDBO biliary drainage. Methods: An electronic database search was conducted following PRISMA guidelines to identify studies on EUS-CDS for primary biliary drainage in MDBO. A meta-analysis was performed using random and fixed effects models. Results: We extracted data from 10 eligible studies comprising 519 patients. The mean age for the study was 70 years ± SD 2.66. The pooled technical success rate was 92.36% (95% CI = 88.39–95.56), and the clinical success rate was 88.91% (95% CI = 85.22–92.13). The pooled stent dysfunction rate was 13.66% (95% CI = 7.47–21.35), and the reintervention rate was 15.91% (95% CI = 11.00–21.54) of patients. The mean stent patency duration was 229.20 days ± SD 113.9. The total pooled adverse events rate was 17.50% (95% CI = 12.90–22.64), and 9.03% (95% CI = 4.43–15.05) was considered moderate to severe. Procedure-related pancreatitis had a pooled rate of 0%. The pooled adverse event rate of acute cholangitis was 6.84% (95% CI = 3.69–10.88), and for acute cholecystitis it was 2.61% (95% CI = 1.06–4.83). Conclusions: EUS-CDS demonstrates favorable outcomes when used as a primary approach in MDBO. With a long stent patency duration and no procedure-related acute pancreatitis, it may be considered the primary technique when expertise is available.

Endoscopic ultrasound- versus ERCP-guided primary drainage of inoperable malignant distal biliary obstruction: systematic review and meta-analysis of randomized controlled trials.

We assessed efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. endoscopic retrograde cholangiopancreatography (ERCP) as first-line intervention in malignant distal biliary obstruction (MDBO). PubMed/Medline, Embase, and Cochrane databases were searched until 01 /12 /2023 for randomized controlled trials of EUS-BD vs. ERCP for primary biliary drainage in patients with inoperable MDBO. The primary outcome was technical success. Secondary outcomes were clinical success, adverse events, mean procedure time, 1-year stent patency, and overall survival. Relative risk (RR) with 95 %CI were calculated using a random effects model. Five studies (519 patients) were included. RR (95 %CI) for EUS-BD was 1.06 (0.96 to 1.17; P = 0.27) for pooled technical success and 1.02 (0.97 to 1.08; P = 0.45) for clinical success. 1-year stent patency was similar between the groups (RR 1.15, 0.94 to 1.42; P = 0.17), with lower reintervention with EUS-BD (RR 0.58, 0.37 to 0.9; P = 0.01). The RR was 0.85 (0.49 to 1.46; P = 0.55) for adverse events and 0.97 (0.10 to 0.17; P = 0.98) for severe adverse events. On subgroup analysis, EUS-guided placement of lumen-apposing metal stent (LAMS) outperformed ERCP in terms of technical success (RR 1.17, 1.01 to 1.35; P = 0.03). Procedure time was lower with EUS-BD (standardized mean difference -2.36 minutes [-2.68 to -2.05; P < 0.001]). EUS-BD showed a statistically significant lower reintervention rate than ERCP, but with similar technical success, stent patency, clinical success, and safety. Technical success of EUS-BD with LAMS was better than ERCP.

Comparing embolic particles for prostatic artery embolization to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia.

Compare the safety and efficacy of polyvinyl alcohol particles (PVA) versus trisacryl gelatin microspheres (Embospheres) versus hydrogel microspheres coated with polyzene-F (Embozenes) for prostatic artery embolization (PAE) to treat patients with benign prostatic hyperplasia (BPH). A single-center prospective cohort study from 2019 to 2023, including patients with international prostate symptom score (IPSS) ≥ 15 and/or quality of life score (QoL) ≥ 4. Allocation to embolic agents was performed chronologically: 100-300 µm PVA (n = 53), followed by 300-500 µm Embospheres (n = 50), and finally, 400 µm Embozenes (n = 50). All patients were evaluated at baseline and at 1 and 6 months after PAE with IPSS/QoL; peak urinary flow rate, post-void residual volume, and prostate volume with ultrasound and prostate-specific antigen. Adverse events and the need for prostatic re-interventions were assessed. There were no significant baseline differences between the three groups except for patient age (62.5 years PVA; 66.1 years Embospheres and 66.6 years Embozenes; p = 0.019). There were no major adverse events and no differences between groups regarding minor adverse events. All outcome measures improved significantly from baseline, with no significant differences between groups. Mean ± standard deviation IPSS/QoL improvement at 6 months: -10.7 ± 7.9/-2.2 ± 1.7 PVA; -10.4 ± 7.3/-2.0 ± 1.5 Embospheres; -10.4 ± 7.0/-2.2 ± 1.6 Embozenes (p = 0.987). Re-intervention rates after 6 months: 9% (n = 5/53) PVA; 14% (n = 7/50) Embospheres; 8% (n = 4/50) Embozenes (p = 0.591). PAE with PVA particles, Embospheres, and Embozenes is equally safe and effective in treating BPH-related lower urinary tract symptoms. This is the first prospective study showing equivalence between the most frequently used embolic agents for prostatic artery embolization. Different particles can be used interchangeably for prostatic artery embolization. The improvements in measured metrics were the same between groups, with no differences in adverse events. The need for prostatic medication and re-intervention rates were the same at 1 and 6 months after embolization.

Comprehensive review of pulmonary vein stenosis post-atrial fibrillation ablation: diagnosis, management, and prognosis.

Pulmonary vein stenosis (PVS) can occasionally occur in the follow-up after pulmonary vein isolation (PVI) for atrial fibrillation (AF). During PVI, ablation is performed at the PV ostium or distal part, leading to tissue damage. This damage can result in fibrosis of the necrotic myocardium, proliferation, and thickening of the vascular intima, as well as thrombus formation, further advancing PVS. Mild-to-moderate PVS often remains asymptomatic, but severe PVS can cause symptoms, such as dyspnea, cough, fatigue, decreased exercise tolerance, chest pain, and hemoptysis. These symptoms are due to pulmonary hypertension and pulmonary infarction. Imaging evaluations such as contrast-enhanced computed tomography are essential for diagnosing PVS. Early suspicion and detection are necessary, as underdiagnosis can lead to inappropriate treatment, disease progression, and poor outcomes. The long-term prognosis of PVS remains unclear, particularly regarding the impact of mild-to-moderate PVS over time. PVS treatment focuses on symptom management, with no established definitive solutions. For severe PVS, transcatheter PV angioplasty is performed, though the risk of restenosis remains high. Restenosis and reintervention rates have improved with stent implantation compared with balloon angioplasty. The role of subsequent antiplatelet therapy remains uncertain. Dedicated evaluation is essential for accurate diagnosis and appropriate management to avoid significant long-term impacts on patient outcomes.

Comparative Evaluation of the Short-Term Outcome of Different Endovascular Aortic Arch Procedures.

Objectives: There are several endovascular treatment options to treat aortic arch and thoracic aortic pathologies with custom-made or surgeon-modified aortic stent grafts. This study seeks to assess endovascular treatment methods for aortic arch and thoracic aortic pathologies with no acceptable proximal landing zone for standard thoracic endovascular aortic repair (TEVAR), comparing different treatment methods and evaluating technical success, intraoperative parameters and short-term outcomes. Methods: All patients undergoing elective or emergency endovascular treatment of aortic arch and thoracic aortic pathologies, with no acceptable landing zone for standard TEVAR, between 1 January 2010 and 31 March 2024, at the University Hospital Düsseldorf, Germany were included. An acceptable landing zone was defined as a minimum of 2 cm for sufficient sealing. All patients were not suitable for open surgery. Patients were categorized by an endovascular treatment method for a comprehensive comparison of pre-, intra- and postoperative variables. IBM SPSS29 was used for data analysis. Results: The patient cohort comprised 21 patients, predominantly males (81%), with an average age of 70.9 ± 9 years with no acceptable proximal landing zone for standard TEVAR procedure. The most treated aortic pathologies were penetrating aortic ulcers and chronic post-dissection aneurysms. Patients were sub-grouped according to the applied procedure as follows: five patients with chimney thoracic endovascular aortic repair (chTEVAR), seven patients with in situ fenestrated thoracic endovascular aortic repair (isfTEVAR), six patients with custom-made fenestrated thoracic endovascular aortic repair (cmfTEVAR) and three patients with custom-made branched thoracic endovascular aortic repair (cmbTEVAR). Emergency procedures involved two patients. There were significant differences in the total procedure and fluoroscopy time, as well as in contrast agent usage among the treatment groups. cmfTEVAR had the shortest total procedure time, while chTEVAR exhibited the highest contrast agent usage. The overall mortality rate among all procedures was 9.5% (two patients) and 4.7% for elective procedures, respectively. Deaths were associated with either retrograde type A dissection or stent graft infection. Both patients were treated with chTEVAR. There was one minor and one major stroke; these patients were treated with isfTEVAR. No endoleak occurred during any procedure. The reintervention rate for chTEVAR was 20% and 0% for all other procedures during the in-hospital stay. The patients who were treated with cmfTEVAR had no complications, the shortest operating and fluoroscopy time, and less contrast agent was needed in comparison with other treatment methods. Conclusions: Complex endovascular procedures of the aortic arch with custom-made or surgeon-modified aortic stent grafts offer a safe solution, with acceptable complication rates for patients who are not suitable for open aortic arch repair. In terms of procedure-related parameters and complication rates, a custom-made fenestrated TEVAR is potentially advantageous compared to the other endovascular techniques.

50 National trends in the surgical management of renal cell carcinoma in Germany

Abstract Background The incidence of RCC is increasing worldwide. For most patients with localized RCC, surgery remains the preferred treatment option. We aimed to investigate whether international trends towards minimally invasive procedures and nephron-sparing surgery are reflected in Germany. Methods Pseudonymized inpatient billing data from the AOK (Allgemeine Ortskrankenkassen), a non-profit oriented health insurance organization in Germany, was used for the conduct of the study. A total of 43,936 RCC cases were identified in which either a partial nephrectomy (PN, n = 20,030) or radical nephrectomy (RN, n = 21,906) was performed between 2012 and 2021. The proportions of different surgical procedures over time, as well as mortality (90 days), transfusion rate, reinterventions, and general postsurgical complications (30 days), were evaluated. Due to the use of pseudonymized data, no ethics vote was required. Results During the period of observation, there was a significant shift from RN to PN, with an increase in the proportion of PN among all procedures from 41.0% (1,918/4,684) in 2012 to 57.4% (2,274/3,960) in 2021 (p &amp;lt;0.001). Open surgery decreased for PN and RN but still accounted for the majority of all procedures (2021: 53.2% of PN and 65% of RN). Mortality was higher among patients with RN compared to PN (in hospital: 1.9% vs. 0.6%, 90 days: 4.7% vs. 1.2%). While general complication rates were similar (19.4% after PN versus 20.4% after RN), the reintervention rate was slightly higher after PN at 10.7% than after RN at 7.9%. Transfusion rates decreased significantly in several subgroups, favoring PN and minimally invasive approaches. Open surgical procedures were associated with higher unadjusted complication rates. Conclusions Despite shifts in favor of nephron-sparing surgery and minimally invasive surgery during the study period, open surgery remained the dominant surgical option for the treatment of renal cell carcinoma in Germany as of 2021. The adoption of laparoscopic and robotic-assisted techniques appears to reduce overall perioperative morbidity and consequently improve the quality of care in Germany. Further studies are required to examine patient level trends between type of surgical procedure, complication rates, and oncologic outcomes. Optimizing the assessment of the quality of care would enable further improvement of the quality itself.

A Single-Center Review of Clinical Outcomes After Transcatheter Relief of Superior Vena Cava Stenosis in a Pediatric and Young Adult Population

BackgroundThe suspected etiology of superior vena cava (SVC) obstruction is predominantly iatrogenic. Transcatheter interventions relieve stenosis with good long-term results, although there is a paucity of published data in pediatrics. We aim to describe patient characteristics and clinical outcomes after transcatheter SVC intervention at a single-center pediatric quaternary care center. MethodsSingle-center, retrospective study of all pediatric and young adult patients who underwent transcatheter SVC intervention from December 2006 to January 2020. SVC gradients and changes in vessel diameter were compared using paired-sample t-tests. Balloon and stent cohorts were compared using the Wilcoxon rank sum test or Fisher exact χ2 test. Reintervention was compared between balloon and stent cohorts using the McNemar test to determine if initial procedural type was associated with reintervention. Time to reintervention was compared between balloon vs stent cohorts using Kaplan-Meier survival analysis with a log-rank test. ResultsA total of 42 patients (median age, 1.5 years; IQR, 0.31-15; 64.2% male) underwent 81 procedures with 1 minor complication and no mortality attributed to the procedure. Most (71.4%) patients were asymptomatic. Affected patient subgroups include those with a history of central venous line (92.9%), congenital heart disease (76.2%), postorthotopic heart transplant (42.9%), post-ECMO (31.0%), and history of surgical baffling or SVC surgery (9.5%). Those who underwent initial balloon angioplasty were significantly younger and smaller than those with an initial stent. Significantly lower pressure gradients and larger SVC dimensions were achieved after stenting. The majority of patients (54.8%) resolved after initial balloon angioplasty and reintervention rates were similar between initial balloon angioplasty and stent, although reintervention trended toward being earlier after the balloon. ConclusionsTranscatheter SVC intervention in pediatrics is acutely effective and safe in relieving SVC obstruction in all subgroups. Reintervention rates are similar between balloon and stenting, with balloon tending to be earlier, with the majority resolving after initial intervention. Further research is necessary to investigate the most effective transcatheter intervention for each patient subgroup.

Anastomotic metabolic and bariatric surgeries with same-day discharge: 30-day outcomes of a cohort from a high-volume center in Canada

BackgroundOn the basis of our extensive experience in same-day discharge (SDD) sleeve gastrectomy, we extended this management strategy to anastomotic metabolic and bariatric surgeries (MBS). ObjectivesTo retrospectively analyze early outcomes (≤30 d) after anastomotic MBS with planned SDD (≤12 hr). SettingUniversity Hospital, Canada; Public Practice. MethodsSDD anastomotic MBS were proposed with strict preoperative criteria and included single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), and single-anastomosis sleeve ileal bypass (SASI). Enhanced recovery after bariatric surgery protocols and post-anesthesia care unit criteria were followed. Unplanned overnight stay, emergency department (ED) visit, readmission, morbidity-mortality, and reintervention rates were analyzed. ResultsSince 2021, 208 patients (191 female and 17 male) have undergone SDD anastomotic MBS, with 76% conversion procedures: 92 SADI-S, 72 RYGB, 35 OAGB, and 9 SASI (mean age = 41.4 yr and mean preoperative body mass index = 41.9 kg/m2). Unplanned overnight stays and ED visits were 4.8% and 4.3%, respectively. Readmission rate was 5.8% (5 SADI-S, 5 RYGB, 1 OAGB, and 1 SASI). Overall morbidity rate was 14.9%, including 3.9% major complications. Within 30 days postoperatively, there were 2 duodenal leaks, 1 intrabdominal collection, 1 common bile duct stenosis, and 1 acute appendicitis in the SADI-S group. There were 2 occlusions on the jejunojejunal anastomosis and 1 bleeding on the gastrojejunal anastomosis in the RYGB group. Five (2.4%) required reintervention with no mortality. ConclusionsWe report low and acceptable rates of unplanned overnight stay, readmission, and reintervention. Early outcomes suggest that SDD anastomotic MBS seems safe and feasible with an experienced team, selective criteria, and appropriate postoperative follow-up.

Employing magnetic resonance histology for precision chronic limb-threatening ischemia treatment planning

ObjectiveRecent randomized controlled trials have demonstrated a notable prevalence of immediate technical failures in percutaneous vascular interventions (PVIs) for complex arterial lesions associated with chronic limb-threatening ischemia. Current imaging modalities present inherent limitations in identifying these lesions, making it challenging to determine the most suitable candidates for PVI. We present a novel preprocedural magnetic resonance imaging (MRI) histology protocol for identifying lesions that might present a higher rate of immediate and midterm PVI failure. MethodsWe enrolled 22 patients (13 females, average age 65.8 ± 9.72 years) scheduled for PVI were prospectively and underwent 3T MRI using ultrashort echo time and steady-state free precession contrasts to characterize target lesions before PVI. Lesions were scored as hard if >50% of the lumen was occluded by hard components (calcium/dense collagen) on MRI in the hardest cross-section. Two readers evaluated MRI datasets. Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC)/Global Limb Anatomic Staging System (GLASS)/Wound, Ischemia and Foot infection scoring was performed based on intraprocedural angiograms and chart review. The relationship between MRI scoring, TASC/GLASS scoring, and procedural outcomes was investigated using univariate analysis. Midterm follow-up (revascularization and amputation rates) was recorded at 3 and 6 months after the intervention. ResultsOur cohort of 22 patients yielded 40 target lesions. Five lesions were excluded (two for nondiagnostic image quality; three PVIs were ultimately diagnostic only). Six lesions (17%) were scored as hard. MRI-scored hard lesions had a higher proportion of immediate technical failure (hard vs soft 83% [5/6] vs 3% [1/29]; P < .001). Hard vs soft MRI scoring was the only factor significantly associated with immediate PVI technical success (P < .001), as opposed to TASC/GLASS scoring. Both at 3 months and 6 months after PVI, the reintervention rate was significantly higher among those lesions which were scored hard on MRI (3 months hard, 80% vs soft, 16% [P =.011]; 6 months hard, 80% vs soft, 27%; P = .047). ConclusionsMRI histology could be a valuable tool for optimizing PVI patient selection and treatment strategies.

Ten years of physician-modified endografts

ObjectivesPhysician-modified endografts (PMEGs) have expanded the scope of endovascular abdominal aortic repair beyond the infrarenal aorta. Patients with prohibitively high surgical risk and visceral segment disease are often candidates for this intervention, which mitigates much of the morbidity and mortality associated with conventional open repair. Here we present the institutional PMEG experience of a high-volume aortic center. MethodsWe studied all PMEGs performed at our institution from 2012 to 2023. We included cases that were submitted to the US Food sand Drug Administration in support of an investigational device exemption (IDE) trial, as well as those in the subsequently approved IDE trial. Over this 11-year period, we assessed the changes in operative characteristics and perioperative outcomes over time. Additionally, we compared the outcomes from PMEG cases to those of Zenith fenestrated (ZFEN) grafts (done by the surgeon with the PMEG IDE), an alternative device used for aneurysms involving the lower visceral segment. Here we assessed operative characteristics, perioperative outcomes, and 5-year survival and reintervention rates. ResultsWhen assessing the change over time for PMEG operative characteristics, we found a trend toward decreased fluoroscopy time and decreased proportions of completion type I and type III endoleaks (all P < .05). Perioperative outcomes have remained stable over this period, with an overall perioperative mortality rate of 4.9% (noting that this registry also includes cases that were urgent and emergent). Despite the increased complexity of PMEGs relative to ZFENs, we found comparable perioperative outcomes with regard to mortality (4.9% vs 4.3%; P = .86), permanent spinal cord ischemia (1.1% vs 0%; P = .38), postoperative myocardial infarction (4.3% vs 2.9%; P = .60), postoperative respiratory failure (7.1% vs 4.3%; P = .43), and new dialysis use (2.2% vs 4.3%; P = .35). Additionally, 5-year survival (PMEG 54% vs ZFEN 65%; P = .15) and freedom from reintervention (63% vs 74%; P = .07) were similar between these cohorts. ConclusionsThroughout our >10-year experience with PMEGs, we have noted improvements in operative outcomes, which can likely be attributed to technological advances and increased physician experience. Additionally, we have found that PMEGs perform well when compared with ZFENs, despite being a more complicated repair that is able to treat a larger segment of the aorta. PMEGs are crucial for the comprehensive care of vascular patients with complex aortic disease. As further operative advancements are made, we only expect the use of this intervention to increase.

Markers of optimal medical therapy are associated with improved limb outcomes after elective revascularization for intermittent claudication

BackgroundOptimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC). MethodsUsing the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR). ResultsThere were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively. ConclusionsPreintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes.

Unexpected positive cultures in revision total knee arthroplasty after unicompartmental knee arthroplasty.

Unexpected positive cultures are defined as a single positive culture in intraoperative samples taken during revision surgery after prosthetic joint infection was preoperatively ruled out. This study aims to determine the prevalence of unexpected positive cultures (UPC) in revision total knee arthroplasty (TKA) after unicompartmental knee arthroplasty (UKA). As a secondary objective, this study aims to compare the re-intervention rate in this specific group, between UPC and non-UPC patients. The hypothesis is that the UPC prevalence in patients who undergo a revision TKA after UKA is not higher than in other TKA revision cases and this does not increase the risk of re-intervention. This is a retrospective study where all patients who underwent a UKA revision from January 2016 to February 2023 in a high-volume arthroplasty centre, were analyzed. Unexpected positive culture prevalence in this group of patients was obtained. During the included period, 270 UKA revision surgeries were performed. Eight cases had at least two positive cultures and were therefore excluded. The final analysis included 262 patients. Of these, 8 (3.05%) patients presented UPCs and the isolated microorganisms were low-virulence organisms. None of the UPC patients received any treatment. No statistical differences were found between UPC and non-UPC groups in the analyzed variables. The prevalence of unexpected positive cultures in patients following revision of unicompartmental knee arthroplasty is lower than in patients who undergo a revision of total knee arthroplasty. In UKA patients a UPC does not seem to increase the risk of a re-intervention, so it can be safely ignored if ICM criteria are not met.

Comparison of femoral neck system versus cannulated cancellous screws for the fixation of femoral neck fracture: a single-center retrospective cohort study

IntroductionThe dynamic hip screw (DHS) and cannulated compression screws (CCS) have been the two implants most frequently employed for the fixation of femoral neck fractures. The objective of this study is to compare clinical and radiographic outcomes between patients treated with the FNS and those treated with CCS.Material and methodsWe conducted a retrospective analysis of a consecutive series of femoral neck fractures treated with FNS or CCS between May 2019 and June 2022. The study included 144 patients who met the inclusion criteria. Collected data encompassed age, sex, Garden fracture classification, Pauwels classification, duration of surgery, length of hospital stays, Harris Hip Score (HHS), complications, and injured side.ResultsThe FNS group comprised 70 patients, while the CCS group consisted of 74 patients. The operation time was 43.6 ± 12.09 min for the FNS group and 56.47 ± 22.42 min for the CCS group. At the end of the follow-up, the mean HHS was 87.07 ± 11.77 for the FNS group and 76.20 ± 13.64 for the CCS group. The mean reduction in hemoglobin levels from pre- to post-surgery was 1.05 mg/dl in the FNS group and 0.87 mg/dl in the CCS group. The reintervention rate was 8.1% for the CCS group and 2.85% for the FNS group.ConclusionThe FNS does not demonstrate superiority over CCS regarding femoral neck shortening, complication rate, and reduction in hemoglobin levels. However, FNS does appear superior to CCS in terms HHS, operation time, and reoperation rate.

Impact of operative approach and patient frailty on outcomes for aorto-iliac occlusive disease with critical limb threatening ischemia.

Multiple treatment modalities exist for the management of aorto-iliac occlusive disease (AIOD) including endovascular (endo), extra-anatomic bypass (EAB), and anatomic bypass (AB). The goal of this study was to examine the impact of revascularization strategy and patient frailty on outcomes for AIOD in patients with critical limb threatening ischemia (CLTI). Patients undergoing revascularization for CLTI and AIOD were identified from the NSQIP database over 5years. Demographics, procedural characteristics, and outcomes were recorded. Modified frailty index (mFI-5) was calculated for each patient. Patients were compared based on the type of procedure and frailty (mFi>0.6). From 2017 to 2021, 1777 patients underwent revascularization for CLTI from AIOD. Patients were majority male (56%) with a mean age of 68. A total of 1346 patients (76%) underwent an open operation of which 669 were EAB. When endo (431 patients) was compared with open repair, endo was associated with a higher incidence of tissue loss at presentation (42% vs 33%, p < 0.001), lower rates of bleeding (6.5% vs 15.5%, p < 0.001), fewer MI/stroke (1.6% vs 4.6%, p = 0.004), and fewer wound complications (2.6% vs 11.2%, p < 0.001). There was no difference in re-intervention, amputation, or death based on frailty. For frail patients (184 patients), type of repair did not impact re-intervention, major amputation, or mortality, though there was increased MI/stroke with EAB and increased wound complications with AB/EAB. AIOD revascularization strategies for patients with CLTI have similar 30-day re-intervention, major amputation, and mortality rates. Endovascular repair has less surgical wound complications and is better suited for frail patients.

High-intensity focused ultrasound ablation in the treatment of fumarate hydratase-deficient uterine leiomyoma

Objective This study aimed to explore the efficacy and safety of high-intensity focused ultrasound (HIFU) ablation for treating fumarate hydratase (FH)-deficient uterine leiomyomas. Method Ten patients with FH-deficient uterine leiomyomas treated with HIFU ablation at the Third Xiangya Hospital from July 2017 to January 2023 were enrolled in this study. The effectiveness and adverse effects of HIFU were analyzed. Results The median age of the patients who received HIFU was 32.0 years (range: 28–41 years). Only 2 patients had solitary uterine leiomyomas, whereas the remaining 8 patients had multiple uterine leiomyomas. The median diameter of the largest myoma was 56 mm (range: 41–99 mm). Magnetic resonance imaging showed that the FH-deficient uterine leiomyomas of 8 patients presented as mixed intensity on T2WI, that of one patient was hypointense, and that of another patient was hyperintense on T2WI. All patients successfully underwent HIFU ablation in one session without severe adverse effects. The median nonperfusion volume ratio (NPVR) was 40% (30.0%–78.0%) after HIFU treatment. Four patients had NPVR ≥70%. At 3-month follow-up after HIFU ablation, the clinical symptoms of 5 of the 8 patients with symptoms before treatment were relieved. Six months after treatment, 4 of the 8 patients with symptoms were still in remission. All patients received reintervention by March 2024. The reintervention rates were 20%, 70%, and 90% at 12, 24, and 36 months, respectively, after HIFU ablation. Conclusion HIFU is a safe and feasible treatment for FH-deficient uterine leiomyomas, and most patients show effective results in the short term after treatment. However, the reintervention rates are high, and the long-term effects are limited.

Approaches for hysterectomy and implementation of robot-assisted surgery in benign gynaecological disease: A cost analysis study in a large university hospital

BackgroundAs a minimally invasive technique, robot-assisted hysterectomy (RAH) offers surgical advantages and significant reduction in morbidity compared to open surgery. Despite the increasing use of RAH in benign gynaecology, there is limited data on its cost-effectiveness, especially in a European context. Our goal is to assess the costs of the different hysterectomy approaches, to describe their clinical outcomes, and to evaluate the impact of introduction of RAH on the rates of different types of hysterectomy. MethodsA retrospective single-centre cost-analysis was performed for patients undergoing a hysterectomy for benign indications. Abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), laparoscopically assisted vaginal hysterectomy (LAVH) and RAH were included. We considered the costs of operating room and hospital stay for the different hysterectomy techniques using the “Activity Centre–Care program model”. We report on intra- and postoperative complications for the different approaches as well as their cost relationship. ResultsBetween January 2014 and December 2021, 830 patients were operated; 67 underwent VH (8%), 108 LAVH (13%), 351 LH (42%), 148 RAH (18%) and 156 AH (19%).After the implementation and learning curve of a dedicated program for RAH in 2018, AH declined from 27.3% in 2014–2017, to 22.1% in 2018 and 6.9 % in 2019–2021.The reintervention rate was 3–4% for all surgical techniques. Pharmacological interventions and blood transfusions were performed after AH in 28%, and in 17–22% of the other approaches.AH had the highest hospital stay cost with an average of €2236.40. Mean cost of the hospital stay ranged from €1136.77-€1560.66 for minimally invasive techniques.The average total costs for RAH were €6528.10 compared to €4400.95 for AH. ConclusionImplementation of RAH resulted in a substantial decrease of open surgery rate. However, RAH remains the most expensive technique in our cohort, mainly due to high material and depreciation costs. Therefore, RAH should not be considered for every patient, but for those who would otherwise need more invasive surgery, with higher risk of complications. Future prospective studies should focus on the societal costs and patient reported outcomes, in order to do cost-benefit analysis and further evaluate the exact value of RAH in the current healthcare setting.