Reintervention Group Research Articles

Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter?

BackgroundSurgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention. MethodsWe performed a single center retrospective (2018–2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal. ResultsFrom 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal. ConclusionThis study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.

Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study.

Inadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up. Data were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact. The study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group. The staged reintervention strategy for treating RAD is safe and provides promising early results.

Proteomic Profiles Associated With Postsurgical Progression in Nonfunctioning Pituitary Adenomas.

There is a lack of reliable biomarkers capable of predicting postoperative tumor progression of nonfunctioning pituitary adenomas (NFPAs). To discover proteomic profiles associated with postoperative tumor progression in patients with NFPAs. This was a case-controlled exploratory study at a tertiary university hospital. Tissue samples were obtained from 46 patients with residual tumor following surgery for NFPAs of gonadotroph lineage. Two patient groups were compared: patients requiring reintervention due to residual tumor progression (cases; reintervention group, n = 29) and patients with a residual tumor showing no progression for a minimum of 5 years (controls; radiologically stable group, n = 17). Differentially expressed proteins (DEPs) between patient groups were measured. Global quantitative proteomic analysis identified 4074 proteins, of which 550 were differentially expressed between the 2 groups (fold change >80%, false discovery rate-adjusted P ≤ .05). Principal component analysis showed good separation between the 2 groups. Functional enrichment analysis of the DEPs indicated processes involving translation, ROBO-receptor signaling, energy metabolism, mRNA metabolism, and RNA splicing. Several upregulated proteins in the reintervention group, including SNRPD1, SRSF10, SWAP-70, and PSMB1, are associated with tumor progression in other cancer types. This is the first exploratory study analyzing proteomic profiles as markers of postoperative tumor progression in NFPAs. The findings clearly showed different profiles between tumors with indolent postoperative behavior and those with postoperative tumor progression. Both enriched pathways involving DEPs and specific upregulated proteins have previously been associated with tumor aggressiveness. These results suggest the value of proteomic profiling for predicting tumor progression in patients with NFPAs.

Analyzing the role of reoperation in recurrent glioblastoma: a 15-year retrospective study in a single institution

BackgroundMultiple treatment options at glioblastoma progression exist, including reintervention, reirradiation, additional systemic therapy, and novel strategies. No alternative has been proven to be superior in terms of postprogression survival (PPS). A second surgery has shown conflicting evidence in the literature regarding its prognostic impact, possibly affected by selection bias, and might benefit a sparse subset of patients with recurrent glioblastoma. The present study aims to determine the prognostic influence of salvage procedures in a cohort of patients treated in the same institution over 15 years.MethodsThree hundred and fifty patients with confirmed primary glioblastoma diagnosed and treated between 2005 and 2019 were selected. To examine the role of reoperation, we intended to create comparable groups, previously excluding all diagnostic biopsies and patients who were not actively treated after the first surgery or at disease progression. Uni- and multivariate Cox proportional hazards regression models were employed, considering reintervention as a time-fixed or time-dependent covariate. The endpoints of the study were overall survival (OS) and PPS.ResultsAt progression, 33 patients received a second surgery and 84 were treated with chemotherapy only. Clinical variables were similar among groups. OS, but not PPS, was superior in the reintervention group. Treatment modality had no impact in our multivariate Cox regression models considering OS or PPS as the endpoint.ConclusionsThe association of reoperation with improved prognosis in recurrent glioblastoma is unclear and may be influenced by selection bias. Regardless of our selective indications and high gross total resection rates in second procedures, we could not observe a survival advantage.

Impact of Reintervention During Stage 1 Palliation Hospitalization: A National, Multicenter Study

BackgroundStage 1 palliation (S1P) for hypoplastic left heart syndrome remains associated with high morbidity and mortality. Previous studies on burden of reinterventions did not include patients who remain hospitalized before stage 2 palliation (S2P). This study described the rate of reintervention during S1P hospitalization and sought to determine the impact of reintervention on outcomes. MethodsAll participants enrolled in phase II of the National Pediatric Cardiology Quality Improvement Collaborative after S1P were included in this study. The primary outcome was the rate of reintervention during hospitalization after S1P and before hospital discharge or S2P. Reintervention was defined as 1 or more unplanned interventional cardiac catheterizations or surgical reoperations. ResultsBetween March 1, 2016 and October 1, 2019, 1367 participants underwent S1P and 339 (24.8%) had a reintervention; most commonly to address the source of pulmonary blood flow. Gestational age, weight at S1P, atrioventricular septal defect, heterotaxy, preoperative pulmonary artery bands, hybrid S1P, and an additional bypass run or early extracorporeal membrane oxygenation were significantly associated with reintervention. Participants in the reintervention group experienced higher rates of nearly all postoperative complications, were less likely to be discharged before S2P (57.1% vs 86%; P < .001), and more likely to experience in-hospital mortality (17% vs 5%; P < .001). ConclusionsUnplanned reintervention during hospitalization after S1P palliation occurred in 25% of participants in a large, registry-based national cohort. Participants who underwent reintervention were more likely to remain as inpatient and were less likely to survive to S2P. Reintervention was associated with a multitude of postoperative complications that affect survival and long-term outcome.

Long-Term Outcomes of Endoscopic Intervention in the Treatment of Symptomatic Pancreas Divisum.

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of patients with symptomatic pancreas divisum (PD) and to discuss the possible risk factors of endoscopic reintervention for symptomatic PD. A total of 50 patients with symptomatic PD who underwent ERCP from January 2010 to December 2019 were finally brought into study. All patients were divided into the nonage and the adult group according to their ages. Meanwhile, all patients were also divided into the intervention and the reintervention group according to times of ERCP. The long-term outcome of each patient was collected during the follow-up by phone call. The total success rate of ERCP was 94.7% (89/93), and the effective rate of first ERCP was 58% (29/50). There were no statistical differences on the outcomes of ERCP treatment between the adult and nonage group. There were 17 patients with complete pancreas divisum and 19 patients with chronic pancreatitis in the reintervention group, which were more than 6 patients and 8 patients in the intervention group (P < 0.05). In bivariate regression analysis, chronic pancreatitis and complete pancreas divisum might be significant risk factors for endoscopic reintervention for patients with symptomatic PD (OR, 8.010, 95% CI, 1.483–43.276, P=0.016; OR, 8.869, 95% CI, 1.450–54.254, P=0.018, respectively). ERCP in treating adult and nonage patients with symptomatic PD are effective and safe. But, many patients may need endoscopic reintervention. Complete pancreas divisum and chronic pancreatitis may be risk factors of ERCP reintervention for patients with symptomatic PD.

Outcomes after endovascular reintervention for aortic interventions

ObjectiveEndovascular reinterventions are often performed after previous open or endovascular aortic procedures. We used the GREAT (Global Registry for Endovascular Aortic Treatment) database to compare the outcomes between these groups. We also compared reintervention of any type with a group of patients who had undergone primary endovascular abdominal aortic aneurysm repair (EVAR). MethodsAll patients enrolled in GREAT were grouped according to a previous EVAR or open abdominal aortic procedure (OAP). Univariate analysis was performed using the χ2, Wilcoxon rank sum, and Fisher exact tests. Cox proportional analysis was used to test the predictors for all-cause and aorta-related mortality. ResultsA total of 3974 subjects who had undergone EVAR with follow-up data available were included in the GREAT. Of the 3974 procedures, 196 (4.9%) were reinterventions (49 after OAP and 147 after previous EVAR). Reintervention after previous EVAR showed a trend toward a greater endoleak rate through 2 years (13.6% vs 4.1%; P = .07), although no difference was found in the occurrence of the intervention (12.2% vs 17.7%; P = .37). Reintervention after OAP resulted in higher all-cause mortality through 2 years of follow-up (32.7% vs 17.7%; P = .0.03). The predictors of mortality included prior OAP, renal insufficiency, and the use of cutdown for access. Compared with the patients who had undergone primary endovascular repair, patients in the reintervention cohort were older (75.3 years vs 73.3 years; P = .0005), had had only femoral artery access used (95.8% vs 90.3%; P < .0001), and were more likely to have undergone aortic branch vessel procedures (32.3% vs 13.3%; P < .0001). Both all-cause and aorta-related mortality through 2 years was higher in the reintervention group than in the primary EVAR group (21.4% vs 12.5% [P = .0003; and 4.6% vs 1% [P < .0001], respectively). On multivariate analysis, the predictors of aortic-related mortality included reintervention, renal insufficiency, chronic obstructive pulmonary disease, underweight body mass index, increasing aortic diameter, and the use of brachial artery or other arterial access sites. ConclusionsEndovascular reintervention for aortic pathology was associated with higher mortality than was primary EVAR. Reinterventions after prior OAPs were associated with higher mortality than were prior EVARs.

Genome-Wide DNA Methylation Differences in Patients With Non-Functioning Pituitary Adenomas With or Without Postsurgical Intervention

Background: More than half of all surgically treated patients with non-functioning pituitary adenomas (NFPA) experience tumor progression during their follow-up, with some of these adenomas exhibiting locally aggressive behavior. Tumor progression is strongly associated with excess morbidity and mortality. Tumor control is, therefore, of vital importance for the patient outcome. There is no reliable method to predict tumor behavior after the initial surgical treatment. The aim of this study was therefore to study associations between DNA methylation patterns and tumor progression in patients with NFPA. Methods: In a case-controlled trial, 43 patients operated for NFPA with immunohistochemical characteristics of gonadotroph subtype were selected. Cases included patients who needed reintervention due to tumor progression (Reintervention group, n = 26), and controls had residual tumor without tumor progression during at least five years of follow-up (Radiologically stable group, n = 17). Genome-wide methylation analysis of the tumor tissue from each patient was performed on the Infinium MethylationEPIC BeadChip platform. Results: Principal component analysis (PCA) showed that clinical course was a strong contributor to the difference in DNA methylation profiles between the two groups. Also, unsupervised hierarchical clustering of the top 5,000 most variable CpG sites revealed three methylation profiles corresponding to, (1) the Reintervention group, (2) the Radiologically stable group, and (3) a mix of the two groups. Although the overall average methylation levels in the two groups did not differ (P = 0.16), 142,521 Differentially Methylated Positions (DMPs) were identified. Of these, 650 showed a difference in beta value methylation larger than 0.2. Interestingly, among the genes harboring the most significantly DMPs was GABRA1, and among the genes containing the largest number of DMPs were GATA2, NUP93, and LGALS1. In addition, the three most hypomethylated and the three most hypermethylated DMPs were all significantly (P <0.05) independently associated with tumor progression free survival (Log-rank test, data not shown). Conclusion: In this novel explorative study, we found a methylation pattern associated with postoperative tumor progression requiring reintervention in patients with NFPA. Among the differently methylated genes we identified, some have previously been described to be involved in pituitary adenoma differentiation or cancer development. Our study is a step towards deciphering epigenetic mechanisms involved in tumor progression and finding epigenetic signatures that might be used to predict postoperative tumor progression in NFPAs.

MCM7 as a marker of postsurgical progression in non-functioning pituitary adenomas.

Current markers predicting tumour progression of pituitary adenomas after surgery are insufficient. Our objective was to investigate if minichromosome maintenance protein 7 (MCM7) expression predicts tumour progression in non-functioning pituitary adenomas (NFPAs). In a cohort study of surgically treated NFPAs, two groups with distinctly different behaviour of a residual tumour were selected: one group requiring reintervention due to tumour progression (reintervention group, n = 57) and one with residual tumours without progression (radiologically stable group, n = 40). MCM7, Ki-67, oestrogen receptor-α expression, mitotic index and tumour subtype were assessed by immunohistochemistry, and their association with tumour progression requiring reintervention was analysed. Median (IQR) MCM7 expression was 7.4% (2.4-15.2) in the reintervention group compared with 2.0% (0.6-5.3) in the radiologically stable group (P <0.0001). Cox regression analysis showed an association between high (>13%) MCM7 expression and reintervention (HR: 3.1; 95% CI:1.7-5.4; P = 0.00012). The probability for reintervention within 6 years for patients with high MCM7 was 93%. Ki-67 expression >3% (P = 0.00062), age ≤55 years (P = 0.00034) and mitotic index≥1 (P = 0.024) were also associated with reintervention. Using a receiver operating characteristics curve, a predictive model for reintervention with all the above predictors yielded an area under the curve of 82%. All eight patients with both high MCM7 and high Ki-67 needed reintervention. This cohort study shows that expression of MCM7 is a predictor for clinically significant postoperative tumour progression. Together with age, Ki-67 and mitotic index, MCM7 might be of added value as a predictive marker when managing patients with NFPA after surgery.

Long-term effects of an intensive prevention program (IPP) after acute myocardial infarction – the IPP Follow-up and Prevention Boost Trial

Abstract Background The effects of an intensive prevention program (IPP) for 12 months following 3-week rehabilitation after myocardial infarction (MI) have been proven by the randomized IPP trial. The present study investigates if the effects of IPP persist one year after termination of the program and if a reintervention after &amp;gt;24 months (“prevention boost”) is effective. Methods In the IPP trial patients were recruited during hospitalization for acute MI and randomly assigned to IPP versus usual care (UC) one month after discharge (after 3-week rehabilitation). IPP was coordinated by non-physician prevention assistants and included intensive group education sessions, telephone calls, telemetric and clinical control of risk factors. Primary study endpoint was the IPP Prevention Score, a sum score evaluating six major risk factors. The score ranges from 0 to 15 points, with a score of 15 points indicating best risk factor control. In the present study the effects of IPP were investigated after 24 months – one year after termination of the program. Thereafter, patients of the IPP study arm with at least one insufficiently controlled risk factor were randomly assigned to a 2-months reintervention (“prevention boost”) vs. no reintervention. Results At long-term follow-up after 24 months, 129 patients of the IPP study arm were compared to 136 patients of the UC study arm. IPP was associated with a significantly better risk factor control compared to UC at 24 months (IPP Prevention Score 10.9±2.3 points in the IPP group vs. 9.4±2.3 points in the UC group, p&amp;lt;0.01). However, in the IPP group a decrease of risk factor control was observed at the 24-months visit compared to the 12-months visit at the end of the prevention program (IPP Prevention Score 10.9±2.3 points at 24 months vs. 11.6±2.2 points at 12 months, p&amp;lt;0.05, Figure 1). A 2-months reintervention (“prevention boost”) was effective to improve risk factor control during long-term course: IPP Prevention Score increased from 10.5±2.1 points to 10.7±1.9 points in the reintervention group, while it decreased from 10.5±2.1 points to 9.7±2.1 points in the group without reintervention (p&amp;lt;0.05 between the groups, Figure 1). Conclusions IPP was associated with a better risk factor control compared to UC during 24 months; however, a deterioration of risk factors after termination of IPP suggests that even a 12-months prevention program is not long enough. The effects of a short reintervention after &amp;gt;24 months (“prevention boost”) indicate the need for prevention concepts that are based on repetitive personal contacts during long-term course after coronary events. Figure 1 Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Stiftung Bremer Herzen (Bremen Heart Foundation)

Does reintervention improve survival in recurrent glioblastoma? Facing a temporal bias in the literature.

Glioblastoma (GBM) is the most frequent intraaxial malignant brain tumour, in which recurrence management is a frequent and demanding issue. Recently, reintervention has emerged as a useful tool for treatment. However, some new evidence has shown that most of the articles published could have overestimated its effects. We aimed to analyse the effect on survival of reintervention considering it as a time-dependent variable and to compare it with classic statistical analysis. We performed a retrospective study with GBM patients between 2007 and 2017. We compared the overall survival (OS) between reintervention and non-reintervention groups with time-dependent statistical methods (Simon-Makuch and landmarking methods and time-dependent multivariable Cox analysis) and compared them with those obtained with non-dependent time variable analysis. A total of 183 patients were included in the analysis and 44 of them were reoperated. The standard analysis with Kaplan-Meier and multivariable Cox regression of the cohort showed an OS of 22.2months (95% CI 12.56-16.06) in the reintervention group and 11.8months (95% CI 9.87-13.67) in the non-reintervention group (p< .001); and an HR 0.649 (95% CI 0.434-0.97 p= .035) for reintervention, demonstrating an increase in OS. However, time-dependent analysis with the Simon-Makuch test and the landmarking method showed that the relationship was not consistent, as this increase in OS was not significant. Moreover, time-dependent multivariable Cox analysis did not show that reintervention improved OS in our cohort (HR 0.997 95% CI 0.976-1.018 p= 0.75). There has been a temporal bias in the literature that has led to an overestimation of the positive effect of reintervention in recurrent GBM. However, reintervention could still be useful in some selected patients, who should be individualized according to prognostic factors related to the patient, biology of the tumour, and characteristics of surgical procedure.

Long-term Stent Outcomes for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a disease process that has significant morbidity and mortality. Stent placement for treatment of mesenteric occlusive disease had offered a minimally invasive alternative to open surgery. The objectives of this study were to identify long-term outcomes for mesenteric stenting in the setting of chronic mesenteric ischemia. A single vascular group’s database was retrospectively reviewed for all patients who underwent mesenteric artery stenting for chronic mesenteric ischemia between 2000 and 2019. Demographics, indications, operative details, and long-term results were recorded and compared. Standard statistics using life tables and t-tests were used. There were 275 patients who had stents placed: 186 superior mesenteric artery (SMA) stents, 61 celiac stents, and 28 both SMA and celiac stents. Average age was 71 years (range, 30-91 years). Demographic characteristics were as follows: hypertension, 39% (106/275); hyperlipidemia, 26% (70/275); tobacco, 20% (56/275); coronary disease, 21% (57/275); chronic obstructive pulmonary disease, 10% (28/275); and diabetes, 15% (41/275). Median follow-up was 60 months (range, 1-120 months). Celiac stent patency was 100%, 98%, 97%, 93%, and 87% at 1 month, 3 months, 6 months, 12 months, and 24 months, respectively. SMA stent patency was 97%, 96%, 93%, 90%, and 83% at 1 month, 3 months, 6 months, 12 months, and 24 months. Reintervention was required in 28% (77/275), of which 66% (51/77) was repeated angioplasty and 34% (26/77) was stent graft placement. The SMA stent length was 34.4 mm, and the celiac stent length was 33.7 mm. In the reintervention group, stent length was 33.7 mm; in the nonreintervention group, stent length was 42.3 mm (P = .001). Twenty-two patients crossed over to open mesenteric bypass (14 SMA, 8 celiac). Of the crossover patients, all 22 had reinterventions before converting to open repair (9 repeated stent placements as a reintervention before failure and 13 angioplasty procedures). Stenting for treatment of chronic mesenteric ischemia offers excellent patency and freedom from open bypass surgery. Very few stents fail and require open surgery. Shorter stent lengths appear to require statistically more reinterventions to maintain patency.

Reinterventions after Endovascular Revascularization in Elderly Patients with Critical Limb Ischemia: An Observational Study

Endovascular-first strategy for critical limb ischemia is widely accepted, especially in elderly patients, because of the increasing patency rates and minimally invasive character. Nonetheless, the impact of reinterventions because of endovascular treatment failure in this population is not well known. The aim of this study was to evaluate the reintervention rate and outcomes following reinterventions. Patients aged >70years with critical limb ischemia as a result of aortoiliac, femoropopliteal, and/or crural disease, treated by "endovascular-first strategy" between 2006 and 2013, were retrospectively analyzed. Follow-up was until 31 December 2014. Primary end point was freedom from reintervention or major amputation. Secondary outcome measures were limb salvage and mortality after reintervention. Reintervention was defined as endovascular or surgical re-revascularization and categorized into early reintervention (<3months) and late reintervention (>3months). In total, 263 patients were treated by endovascular revascularization. The majority (60%) of the treated lesion was located in the femoropopliteal segment. In total, a reintervention was performed in 32%, with 48% performed within 3 months. Freedom from reintervention or major amputation at 1 and 3years was 0.71±0.03 and 0.61±0.03, respectively. The 1-year Kaplan-Meier estimate amputation-free survival was 0.35±0.06 in the early reintervention group, compared with 0.73±0.06 in the late reintervention group and 0.71±0.04 in the no reintervention group (P<0.001; log rank). The 1-year mortality in the early reintervention group was 0.35±0.06, compared with 0.14±0.05 in the late reintervention group and 0.29±0.04 in the group who did not require reintervention (P=0.047; log rank). Endovascular revascularization first strategy for critical limb ischemia results in high reintervention rates in elderly patients. Failure of the endovascular revascularization requiring early reintervention is associated with lower amputation-free survival.

Outcomes of reintervention for recurrent symptomatic disease after tibial endovascular intervention

ObjectiveTibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remain barriers to durability after intervention. The aim of this study was to examine the patient-centered outcomes of open and endovascular reintervention for symptomatic recurrent disease after a primary isolated tibial endovascular intervention. MethodsA database of patients undergoing isolated primary lower extremity tibial endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with recurrent critical ischemia (Rutherford 4 and 5) were identified. Outcomes in this cohort were analyzed, and three groups were defined: endovascular reintervention (ie, a repeated tibial or pedal endovascular intervention), bypass (bypass to a tibial or pedal vessel), and primary amputation (ie, above- or below-knee amputation) on the ipsilateral leg. Patient-oriented outcomes of clinical efficacy (absence of recurrent signs or symptoms of critical ischemia, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention, such as new bypass graft or jump or interposition graft revision) were evaluated after the reintervention. ResultsThere were 1134 patients (56% male; average age, 59 years) who underwent primary tibial intervention for critical ischemia, and 54% presented with symptomatic restenosis and occlusion. Of the 513 patients with recurrent disease, 58% presented with rest pain and the remainder with ulceration. A repeated tibial endovascular intervention was performed in 64%, open bypass in 19%, and below-knee amputation in 17%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Patient-centered outcomes were better in the bypass group compared with the reintervention group (amputation-free survival, 45% ± 9% vs 27% ± 9% [P < .01]; major adverse limb events, 50% ± 9% vs 31% ± 9% [P < .05]; clinical efficacy, 60% ± 7% vs 30% ± 9% [P < .01], mean ± standard error of the mean at 5 years). ConclusionsTibial interventions for critical ischemia are associated with a high rate of reintervention. In patients with good target vessel, venous conduit, and good pedal runoff, bypass appears more durable than repeated tibial endovascular intervention.

Optimal Timing for Elective Early Primary Repair of Tetralogy of Fallot: Analysis of Intermediate Term Outcomes

We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention. Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS. A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p= 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention. Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.

Effects of a 1-year randomised controlled trial of resistance training on blood lipid profile and chylomicron concentration in older men.

Resistance exercise is promoted in older adults for its ability to improve muscle mass, strength and, hence, in reducing falls. However, its effects on blood lipids and CVD risk are less well established, particularly in this age group. This study aimed to investigate whether a 1-year resistance exercise program improves lipid profile and chylomicron concentration in older men. Participants were randomised to either three, 1h resistance training sessions per week (RE) or an active control group [asked to undertake three 30min walking sessions per week (AC)]. Fasting blood samples were collected at 0, 6, and 12months for determination of lipid profile and glycaemic control. Diet, morphological and activity data were also collected at these time points. Following 12months, the RE intervention group had greater improvements in cholesterol profile; LDL-cholesterol concentration significantly decreased by 0.2 (0.2)mM [mean (SEM)] compared to control (P<0.05). The RE group also exhibited a significant increase in lean body mass of 0.9 (1.3)kg after 12months compared to the AC group (P<0.05). There was no treatment or time effect on other anthropometric measures or fasting triacylglycerol, glucose, insulin or chylomicron concentrations. The observed improvements in lean body mass and cholesterol profile promote the implementation of a resistance exercise intervention in this population.

Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos)

Uncovered self-expandable metal stents (USEMSs) are used to treat unresectable malignant hilar biliary obstructions (MHBOs). However, ingrowth is not prevented, and reintervention is often troublesome. A novel 6-mm threaded fully covered self-expandable metal stent (T-FCSEMS) is available that may mitigate these issues. We aimed to clarify the safety and efficacy of T-FCSEMS placement for MHBO. Thirty patients underwent T-FCSEMS placements for MHBOs between 2014 and 2015. T-FCSEMSs were used for initial stenting in 17 patients (initial group) and for reinterventions for USEMS occlusions caused by ingrowth in 13 patients (reintervention group). The technical success rates, times to recurrent biliary obstruction, and the reintervention success rates were evaluated. The technical success rates were 94% (16/17) and 92% (12/13) in the initial group and reintervention group, respectively. Intrahepatic bile duct occlusions caused liver abscesses 8 days and 22 days after T-FCSEMS placements in 2 cases (7%) in the initial group, in which T-FCSEMSs were placed across the intrahepatic bile duct bifurcation. The median times to recurrent biliary obstruction were 210 days in the initial group after bilateral placement and 112 days and 152 days in the reintervention group after bilateral and unilateral placements, respectively. During reintervention, T-FCSEMS removal was successful in all patients in whom it was attempted, and the success rate of endoscopic reintervention was 100% in both groups. T-FCSEMS placement is a promising option for both initial stenting and reintervention for MHBO. However, we should consider the possibility of intrahepatic bile duct occlusion.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis

ABSTRACTPurpose: Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA. Material and Methods: The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions. Results: Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001). Conclusions: Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

Medium‐term CT evaluation of stent geometry, integrity, and valve function of the Edwards SAPIEN transcatheter heart valve in the pulmonary position

Distortion of transcatheter heart valve (THV) stent shape and morphology has been shown to impact on THV function. This study sought to evaluate the relationship between geometrical CT follow-up data and consequent valve function in patients undergoing transcatheter pulmonary valve replacement with the Edwards SAPIEN THV. All patients were enrolled in the COMPASSION trial. Multidetector computed tomography (MDCT) was performed as part of the study protocol at 6 months and yearly thereafter following valve implantation. Prosthesis eccentricity indices, circularity ratios, and expansion ratios (ER) were calculated. Valve function and reintervention rates were correlated with MDCT findings. Twenty consecutive patients undergoing 58 CT scans were included. Maximum Doppler gradients across the right ventricular outflow tract (RVOT) were significantly reduced following valve implantation (P < 0.001). Geometrical indices and maximum RVOT gradients were compared between the reintervention group (n = 4) and the nonreintervention group (n = 16). Although there was no difference in eccentricity index between the groups, ER [6 months: 90 +/- 12% vs. 69 ± 9%; P = 0.014; at 12 months: 89 ± 14 vs. 69 ± 10%; P = 0.018; at 24 months: 87 ± 14% vs. 70 ± 11%; P = 0.056] and valve area [6 months: 3.98 ± 0.54 vs. 2.86 ± 0.38 P = 0.005; at 12 months: 3.93 ± 0.56 vs. 2.86 ± 0.39 P = 0.006; 24 months: 3.78 ± 0.50 vs. 2.90 ± 0.45 P = 0.019] were lower in the reintervention group compared with the nonreintervention group at all time periods. Geometrical THV measurements as assessed by CT may predict the need for reintervention in patients undergoing transcatheter pulmonary valve replacement with the SAPIEN valve. Valve symmetry is maintained, however under-expansion and smaller valve area are strongly associated with the need for reintervention.

Aortic remodeling after thoracic endovascular aortic repair for intramural hematoma

Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection comprise a spectrum of acute aortic pathologies. Although thoracic endovascular aortic repair (TEVAR) has increasingly been applied to aortic dissection, there is a paucity of data on the anatomic effect of TEVAR for IMH. Our goal was to investigate the extent of aortic remodeling after TEVAR. A retrospective chart review from 2006 to 2012 was conducted on patients who underwent TEVAR for IMH. Data were collected from the electronic medical record. Radiology images were reviewed and primary data points included diameter (TLD) and volume measurements for aortic true lumen and total aortic diameter (TAD) and volume at the site of maximal pathology. Aortic remodeling was evidenced by a TAD/TLD ratio closest to 1.0. Patients with no imaging beyond 30 days postoperatively were excluded. During the 6-year period, 44 patients underwent TEVAR for IMH. Twenty-five patients had an IMH with concomitant PAU. There were 25 (57%) female patients. Mean age was 71 ± 11 years, and 40 (91%) patients had hypertension. Operative indications included intractable pain in 31 (70%), rapidly progressing IMH or conversion to dissection in 13 (30%), rupture in 10 (23%), and uncontrolled hypertension in 6 (14%). Technically successful TEVAR was performed in all patients with 42 (95%) reporting complete relief of symptoms. The 30-day mortality rate was 5% with a 5% rate of permanent paraplegia or paraparesis. At a mean follow-up of 26 months, there were no additional aortic-related deaths and overall survival was 80% with a reintervention rate of 11%. For our imaging analysis, 10 patients were excluded because of lack of follow-up imaging beyond 30 days. At a mean follow-up of 13 months, all measured data points were statistically improved from before to after TEVAR: thickness of IMH (12 mm vs. 4 mm; P = .01), mean TLD (35 mm vs. 37 mm; P = .04), mean TAD (47 mm vs 42 mm; P = .02), TAD/TLD ratio (1.35 vs. 1.14; P < .01), and IMH volume (103 cm3 vs. 14 cm3; P < .01). The mean Δ in TAD/TLD ratio from before to after TEVAR for the reintervention group was Δ0.14, and the mean Δ in TAD/TLD ratio for the nonreintervention group was Δ0.29 (P = .05). Analysis of patients with isolated IMH and those with concomitant PAU revealed no statistical differences. TEVAR is safe and effective in treating IMH and based on longitudinal computed tomography scan analysis, aortic remodeling is evidenced by normalization of all measured indices.