Retrograde Approach Research Articles

Emergency laparoscopic surgery during COVID-19: What can we do and how to do it safely.

Emergency laparoscopic surgery during COVID-19: What can we do and how to do it safely.

Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access.

The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.

Retrograde Versus Antegrade Approach for the Endovascular Treatment of Symptomatic Femoropopliteal Disease: Results of the 2-Year Follow Up.

To compare the antegrade and retrograde approaches, in terms of access site complications and long-term patency in subjects undergoing EVT for symptomatic SFA or popliteal artery stenosis or occlusions. All consecutive patients who underwent retrograde recanalization for partial stenosis or chronic total occlusion of the SFA or PA at 2 centers were enrolled in this retrospective analysis. Subjects were divided into 2 groups, according to the approach selected for EVT as antegrade approach group or retrograde approach group. The rate of primary patency, which was defined as the lack of restenosis at the target lesion, was the primary outcome measure, during the follow-up evaluations. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were secondary outcome measures. A significant improvement occurred in ABI, following the intervention in both the antegrade approach group [0.7 (0.3 - 1.1) versus 0.85 (0.4 - 1.3), P < 0.001] and retrograde approach group [0.5 (0.3 - 1.1) versus 0.8 (0.3 - 1.3), P < .001]. The primary patency rate at the 1st, 6th, 12th and 24th months of the intervention in the antegrade approach group were 94.85%, 83.82%, 74.26%, and 66.91%, respectively. The primary patency rate at the 1st, 6th, 12th, and 24th months of the intervention in the retrograde approach group were 93.33%, 86.67%, 84.44%, and 71.11%, respectively. The groups were similar with respect to the primary patency rates. The rate of complications, including hematoma, bleeding, and distal embolization was similar in the 2 groups. Antegrade approach and retrograde approach provide a similar safety profile in the EVT of SFA and popliteal artery stenosis and occlusion. The primary patency rates at the 1st, 6th, 12th, and 24th months of follow up also were similar in the 2 groups. However, the significant difference in the lesion characteristics of the subjects undergoing retrograde or antegrade approach complicates the ability to reach a clear conclusion, regarding the superiority of one technique over the other.

The Comparative Analysis of Antegrade Versus Retrograde Approach for a Failed Porous Tantalum Rod Removal During Conversion to Total Hip Arthroplasty.

BackgroundThe failure of porous tantalum rods applied to patients with osteonecrosis of the femoral head (ONFH) has been increasingly reported during the last few years. Very few studies have reported methods for implant removal. This study aimed at comparing 2 procedures used for the removal of a failed tantalum rod during conversion to total hip arthroplasty (THA).Material/MethodsA total of 65 patients (65 hips), who underwent THA after failed implantation of a tantalum rod between June 2007 and December 2016, were retrospectively evaluated. These patients were classified into 2 groups depending on whether the antegrade approach (removal of the tantalum rod from the tip to the butt at the lateral femoral cortex, n=27) or retrograde approach (removal of the tantalum rod from the butt at the lateral femoral cortex to the proximal tip, n=38) was used for rod extraction. These 2 groups were compared for incision length, operation time, blood loss, fracture, tantalum debris, Harris hip scores, and the presence of osteolysis and/or radiolucency.ResultsThese 2 groups did not present any significant differences in terms of Harris hip score and incision length. However, the operation time (P=0.000), blood loss (P=0.000), amount of tantalum debris (P=0.000), and presence of radiolucency (P=0.046) were greater for the retrograde approach than for the antegrade approach.ConclusionsThe risk of conversion to THA following failed tantalum rod implantation is high. In such cases, the antegrade procedure was found to be a simple and efficient method for removing the trabecular metal rod with the use of a trephine.

Two-Year Follow-Up After Endovascular Therapy of Superficial Femoral Arteries with Retrograde Popliteal Approach: Single-Center Experience.

Popliteal artery puncture, which makes possible the use of lower profile sheaths and devices, has gained popularity as an alternative to the antegrade approach, due to the reduction in vascular complications at the access site. The present study aimed to analyze the safety of the procedure and long-term patency of the superficial femoral artery (SFA) and popliteal artery (PA) and in subjects undergoing recanalization with the popliteal retrograde approach. Forty-three subjects, who underwent endovascular therapy (EVT) of the SFA or PA with retrograde popliteal approach, were enrolled in this retrospective study. The decision for the retrograde approach was made according to pre-intervention CT angiography results (severe calcification and relatively long CTO segment) in 20 of the subjects. The remaining 23 subjects underwent SFA or PA recanalization with the retrograde approach, due to failed antegrade recanalization attempt. All patients underwent color duplex ultrasound at the first, sixth, 12th, and 24th months to determine patency. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were recorded for all subjects. Technical success was achieved in all cases. Access site complications, including hematoma and bleeding, were observed in 2 subjects (4.66%). Transfusion or surgical treatments were not required in any cases with access site complications. The acute success rate was defined as the recovery of good blood flow evaluated by angiography after EVT was 100%. Distal embolization, which did not cause any limitations in distal flow, occurred in 1 subject (2.33%). Ankle-brachial index (ABI) calculated at 1 month post-intervention was significantly higher than pre-intervention ABI [0.9 (0.59 - 1.3) versus 0.7 (0.4 - 1.1), P < .001]. Patency rates, as determined by ultrasonographic assessment at post-interventional first, sixth, 12th, and 24th months, were 100%, 95.34%, 88.37%, and 86.04%, respectively. Our findings demonstrate that retrograde popliteal artery puncture can be used as a safe and effective technique for recanalization of SFA and PA stenosis and occlusions. The retrograde popliteal approach provides excellent long-term primary patency rates.

Tratamiento percutáneo de oclusiones coronarias crónicas aorto-ostiales: resultados y consideraciones técnicas de un registro multicéntrico

Introduction and objectivesPercutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry. MethodsPatients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed. ResultsA total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P <.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization. ConclusionsAorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.

Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Intervention.

The retrograde approach has increased the success rate of chronic total occlusion percutaneous coronary intervention but has also been associated with a higher risk of complications. The retrograde approach is usually performed in complex lesions, in which the antegrade approach is not feasible or has failed previously. Using a systematic 10-step approach can maximize the likelihood of success and minimize the risks of retrograde chronic total occlusion interventions.

Endovascular Treatment of Chronic Total Occlusion in the Subclavian Artery: A Review of 23 Cases.

Objectives and Background: To review technical details and long-term outcomes of endovascular treatment of chronic total occlusion (CTO) of the subclavian artery.Methods: From January 2010 to May 2017, 23 patients (17 male; median age, 65 years) underwent endovascular treatment for CTO of the subclavian artery. All lesions had been diagnosed by duplex scanning or computed tomography angiography before treatment. Sixteen (70.0%) patients had symptoms of vertebrobasilar insufficiency, 6 (26.1%) patients had symptoms of arm ischemia, and 2 (8.7%) patients were asymptomatic. Duplex scanning revealed that 16 patients had grade 3 and 7 patients had grade 2 steal blood flow. After recanalization, lesions were treated by stenting. Patients were followed up at 1, 3, 6, and 12 months after endovascular treatment, and annually thereafter.Results: The overall technical success rate was 91.3% (21/23). The successful recanalization rate of antegrade and retrograde approaches were 68.2% (15/22) and 75.0% (6/8), respectively. The rate of clinical symptom remission was 95.2% (20/21) after treatment. No perioperative death or permanent neurological deficits were observed. One patient had arterial dissection treated by covered stent. The estimate cumulative primary and secondary patency rates at 5 years were 74.6 and 78.8%, respectively.Conclusion: Endovascular treatment is a feasible and safe treatment for CTO lesions of the subclavian artery.

Transpedal Approach in Failed Antegrade Attempt of Lower Limb Peripheral Arterial Disease-A Review with Different Treatment Strategies.

Transpedal access is an evolving technique primarily used in patients after failed femoral antegrade approach to revascularize complex tibiopedal lesions. In patients who are at high risk for surgery the transpedal access may be the only option in failed antegrade femoral access to avoid amputation of the limbs. In recent years transpedal access is used routinely to revascularize supra-popliteal lesions due to more success and less complications over femoral artery approach. Retrograde approach parse will not give success in all cases and importantly success depends on techniques used. There are different techniques that need to be used depending on lesion characteristics, comorbidities, and hardware available to improve success with less complications. This review provides different strategies for successful treatment of iliac and femoral artery lesions by transpedal approach after failed antegrade femoral attempt.

Catheter ablation of the parahisian accessory pathways from the aortic cusps-Experience of 20 cases-Improving the mapping strategy for better results.

Catheter ablation of the parahisian accessory pathways (PHAP) has been established as the definitive therapy for this type of arrhythmia. However, the PHAP proximity to the normal atrioventricular conduction system makes the procedure technically challenging. Here, we have reported a case series of 20 patients with PHAP who underwent aortic access ablation to evaluate the safety and efficacy of this approach in the PHAP ablation. The ablation through the aortic cusps was the successful approach in 13 of 20 (65%) of the cases. In 11 patients, the aortic approach was the initial strategy for ablation, and the accessory pathway was eliminated in seven (63.6%) of them. The aortic approach followed a failed right-sided attempt in nine patients. In six (66.7%) patients, the ablation was successful with the aortic approach. The only independent predictor for the successful ablation with each approach was the earliest ventricular activation before delta wave (predelta time) and a right-sided earliest ventricular activation of more than 23 ms had high sensitivity and specificity for right-sided success. Systematically using the two strategies (right and left approaches), the ablation of the PHAP was successful in 18 (90%) patients. The aortic approach seems to be a safe and effective strategy for the ablation of PHAP. It can be used when the right-sided approach fails or even considered as an initial strategy when the predelta time is less than 23 ms in the right septal region. When combining the right- and left-sided approaches, the success rate is high. We believe that the retrograde aortic approach remains a key tool for this challenging ablation.

Stabilization of a steerable sheath during retrograde access to antegrade-oriented branches in complex endovascular aortic aneurysm repair.

During branched endovascular aneurysm repair, cannulation of the visceral target vessels through antegrade branches and insertion of bridging stents are frequently done from an upper extremity access. A retrograde femoral approach is a challenging alternative when an antegrade approach is not preferred. Herein, we describe a technique to increase stability of a steerable sheath, using a single suture, for bridging antegrade-facing branches from a retrograde access. This technique secures the sheath's deflected tip and provides more pushability to the steerable sheath.

A snare-assisted pure NOTES retrograde cholecystectomy using a single channel flexible endoscope: a pilot experiment in a porcine model.

Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy is an emerging technology. Interest is ongoing and developments have been rapid but NOTES cholecystectomy has failed to gain traction. Here, we share our experience of snare-assisted pure NOTES retrograde cholecystectomy using porcine models. Under general anesthesia, an incision was created on the posterior vagina wall and an endoscope with a snare attached to the transparent cap was introduced into the pelvic cavity and then upward into peritoneal cavity. After locating the liver and gallbladder, the fundic wall of gallbladder was grasped using a biopsy forceps and the snare was released to ligate the fundus. The gallbladder was then carefully dissected from the gallbladder bed using hook/IT knives with the assistance of the snare. The cystic duct and cystic artery were identified, clipped twice and isolated from the gallbladder using the hook knife to cut between the clips. The specimen was then removed through the vagina using the snare. This procedure was successfully performed in 8 consecutive pigs. The average procedure time was 53min (range 40-60min). No severe bleeding or other complication was observed either during or after the procedure. Normal diets were given on the same day of the procedure. All animals recovered uneventfully. We successfully performed snare-assisted pure NOTES retrograde cholecystectomy in pigs using standard endoscopic instruments. In our experience, pure NOTES cholecystectomy using the retrograde approach performed with a single channel flexible endoscope proved safe and feasible with a short procedure time and quick recovery. The translation of this technique to human subjects seems straight forward and provides a new fitting path to pure NOTES.

Transforaminal Epidural Balloon Adhesiolysis via a Contralateral Interlaminar Retrograde Foraminal Approach: A Retrospective Analysis and Technical Considerations.

Several treatment modalities have been proposed for foraminal stenosis, but the treatment options remain unsatisfactory. Previous studies have shown that transforaminal balloon adhesiolysis may be effective in patients with refractory lumbar foraminal stenosis. However, in patients with a high iliac crest, balloon catheter insertion may be difficult via a conventional transforaminal approach (particularly targeting the L5–S1 foramen). It has been reported that an epidural catheter can be placed easily by a contralateral interlaminar retrograde foraminal approach. Therefore, we applied this approach to L5–S1 transforaminal balloon adhesiolysis in patients with a high iliac crest. We retrospectively analyzed data from 22 patients who underwent combined epidural adhesiolysis and balloon decompression (balloon adhesiolysis) using the novel foraminal balloon catheter via a contralateral interlaminar retrograde foraminal approach. The pain intensity significantly decreased over the three-month period after balloon adhesiolysis (p < 0.001). There were no complications associated with the balloon procedure. The present study suggests that balloon adhesiolysis for L5-S1 foramen via a contralateral interlaminar retrograde foraminal approach may be an effective alternative for patients with a high iliac crest and refractory lumbar radicular pain due to lumbar foraminal stenosis. In addition, detailed procedural aspects are described here.

Evaluation of a brain angiotensinergic circuit in fear‐related behavior

BackgroundThe renin‐angiotensin system (RAS) has been implicated in post‐traumatic stress disorder (PTSD), however the mechanisms responsible for this connection and the therapeutic potential of targeting the RAS in PTSD remains unknown. Combining neuroanatomical, genetic knockdown and behavioral approaches, we examined components of the brain RAS, in particular the origin of brain angiotensinogen (AGT), angiotensin II type 1 receptor (AT1R) and their functional role in fear‐related behavior.MethodsRNA Scope combined with immunohistochemistry (IHC) were used to examine the expression pattern and cellular localization of brain AGT in C57BL/6J mice. Dual IHC was used to characterize AT1R‐eGFP+ cells in the amygdala of the AT1R‐eGFP‐BAC reporter mouse. Pavlovian fear conditioning and cre‐expressing lentivirus (LV) injection were used to demonstrate the effects of AT1R deletion on fear memory in male AT1R‐floxed mice.ResultsAGT mRNA was primarily expressed in the diencephalon, midbrain and hindbrain, including the parabrachial complex (PB) which sends strong neuropeptide projections to the amygdala. Some AGT positive cells in PB were determined to be of neuronal origin as they co‐localized with neuronal marker NeuN (FIG 1A). In the amygdala, AGT mRNA was highly expressed in the medial division of the central amygdala (CeM) and the medial amygdala (MeA), but not in the lateral division of the central amygdala (CeL) or basolateral amygdala (BLA) (FIG 1B). Different from AGT, the AT1R‐eGFP+ neurons in the amygdala were predominantly expressed in CeL, with little AT1R‐eGFP expression in BLA, MeA or CeM (FIG 1C). Characterization of AT1R‐eGFP+ neurons in the CeL demonstrated that the AT1R neurons are GABAergic (98.6%) and the majority were co‐located with fear off neuronal marker protein kinase C‐δ (65.7%) as opposed to the fear on neuronal marker somatostatin (9.4%). Next, using cre‐expressing lentivirus, AT1R was deleted from the central amygdala (CeA) of AT1R‐floxed mice. CeA AT1R deletion did not affect fear acquisition, but enhanced the extinction of fear as determined by a reduction in percent freezing during extinction training (57.04% ± 3.9 LV‐GFP v.s. 42.6% ± 4.1 LV‐Cre group, p&lt;0.05, n=9) and retention tests (53.5% ± 5.3 LV‐GFP v.s. 34.4% ± 5.3 LV‐Cre group, p&lt;0.05, n=9) (FIG 2).ConclusionsThese findings provide neuroanatomical and behavioral evidence for brain RAS pre‐cursor AGT and the AT1R in the extinction of fear memory. We speculate that AGT modulates the PB‐CeA circuit during threat responding in fear learning and memory. To further understand the neuroanatomy and function of this circuit, future studies are needed to apply retrograde tracing approaches combined with AGT RNA Scope and region specific deletion of the AGT positive neurons.Distribution of AGT and AT1R in PB and Amygdala Subdivisions(A) AGT mRNA was found in PB (left) and co‐localized with NeuN (right). (B) AGT mRNA was mainly expressed in CeM and MeA. (C) AT1R‐GFP+ neurons were predominately found in CeL.Figure 1Enhanced fear extinction following CeA AT1R deletion.(A) Auditory fear conditioning protocol. (B) AT1R deletion from the CeA did not affect fear acquisition (left) but enhanced the extinction of fear as shown by reduced percent freezing during extinction training (middle) and extinction retention test (right).Figure 2

The Safety and Feasibility of a New Through-the-scope Balloon-assisted Enteroscopy in Children.

Small bowel involvement in Crohn disease (CD) is clinically important for diagnosis and treatment. Single and double-balloon enteroscopy have already become important diagnostic tools in such cases. The on-demand NaviAid AB device enables deep advancement into the small bowel, using an anterograde or retrograde approach. In adults, this procedure is feasible, safe, and rapid. This work aimed to assess the safety and feasibility of NaviAid AB enteroscopy in pediatric patients. Single-center, prospective study using the through-the-scope balloon-assisted-enteroscopy (TTS-BAE) NaviAid AB device for the evaluation of the small bowel in children with suspected or known inflammatory bowel disease (IBD). The system consists of a single-use balloon catheter inserted through the instrument channel of a standard colonoscope. It consists of an inflation/deflation system (NaviAid SPARK), which is inflated to anchoring pressure. The repetitive push-pull technique enables the advancement of the colonoscope along the small intestine. Fifty analyzed endoscopic procedures (30 retrograde, 20 anterograde) were performed in 34 children (52.9% boys, mean age 13.7 years). Average maximal depth of insertion (MDI), advancement depth using the NaviAid AB and average total procedure time were 138 cm (range 100-190 cm), 81 cm (range 40-120 cm), and 12.8 minutes (range 7.3-19.0 minutes), respectively, for the anterograde approach and 143 cm (range 100-170 cm), 64 cm (range 20-95 cm), and 21.9 minutes (range 13.9-32.0 minutes), respectively, for the retrograde approach. No serious or device-related adverse events were reported. NaviAid AB enteroscopy in children is safe, feasible, and enables assessment of the small intestine in a short period of time.

Percutaneous coronary intervention in aorto-ostial coronary chronic total occlusion: outcomes and technical considerations in a multicenter registry

Introduction and objectivesPercutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry. MethodsPatients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed. ResultsA total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P <.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization. ConclusionsAorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.

Mortality and chronic obstructive pulmonary disease in patients treated with endovascular revascularization of the infra-inguinal lower limb arteries from retrograde access.

BackgroundIn this trial, our objective was to evaluate the relationship between long-term clinical outcomes in patients with peripheral arterial disease (PAD) treated with retrograde endovascular recanalization (ER) of chronic total occlusions (CTOs) regarding the infra-inguinal lower limb arteries and chronic obstructive pulmonary disease (COPD).MethodsA total of 834 consecutive subjects were enrolled in the study. The mean age was 67.8±10.6 years (62.6% males). COPD was diagnosed in 98 patients (11.7%). The infra-inguinal location included the deep, superficial and common femoral artery, popliteal artery or below the knee arteries. During follow-up, we evaluated major adverse cardiac and cerebrovascular events (MACCE) and major adverse limb events (MALE). MACCE was considered as death, stroke/transient ischemic attack, myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting operation, while MALE regarded amputation, target lesion re-intervention, target vessel re-intervention and surgical action.ResultsThe mean follow-up was 1,144.9±664.3 days and the interquartile range was 1,110.5 (504.5–1,734.7). Data were collected between 2006 and 2016. We noticed significant differences in death rates among the COPD and non-COPD groups. The cumulative number of events (deaths) was 12.2%, 17.3%, 18.4%, 22.4%, 23.5%, 23.5% and 23.5% in the COPD group and 6.1%, 7.5%, 10.5%, 11.3%, 11.4% 11.5% and 11.5% in the non-COPD group after 1, 2, 3, 4, 5, 6 and 7 years of follow-up, and was notably greater for COPD (P=0.0007).ConclusionsPatients with COPD and PAD treated with the ER and retrograde approach due to CTOs are related to higher mortality than non-COPD patients.

Use of Lifetech™ Konar-MF, a device for both perimembranous and muscular ventricular septal defects: A multicentre study

BackgroundThe objective of this study was to evaluate the safety and efficacy of transcatheter closure of ventricular septal defects (VSD) using the LifeTech™ multifunctional occluder device (MF-Konar). MethodsClinical features and demographic characteristics and follow-up findings were evaluated retrospectively from three centers. ResultsMF-Konar was used in 98 patients. The median age and weight of the patients were 3.8 years (range 5.4 months–50 years) and 15.3 kg (range 5.5–80 kg), respectively. The mean fluoroscopy time was 13.7 ± 8.2 min (range 3.4–42.6 min). Procedural success was obtained for 96 out of 98 patients (98%). In 54 out of 98 patients, closure was performed via the antegrade route. Major complications occurred in four patients (embolization in two, complete heart block in one, and device dislocation needing surgical treatment in one). All of the complications were treated successfully, and there was no mortality. Mild residual flow in eight patients (8%), new onset tricuspid valve insufficiency in one (moderate), and new onset aortic valve insufficiency in one (mild) were observed during a mean follow-up duration of 224 ± 149 (10–515) days. Minor rhythm disturbances were observed in eight patients. ConclusionsTranscatheter closure of VSDs in selected patients using the LifeTech MF-Konar device seems effective. Its advantages are softer design, use of both an antegrade and retrograde approach, and an advanced smaller delivery system. Increasing the number of usage and the experience will provide more accurate data and low complication rates.

3:00 PM Abstract No. 364 Clinical outcomes of patients with acute gastrointestinal tract bleeding treated with N-butyl-2-cyanoacrylate glue embolization

To assess clinical outcomes of patients with acute arterial gastrointestinal (GI) tract bleeding treated with N-butyl-2-cyanoacrylate (NBCA) We reviewed procedural and clinical information in 106 patients who underwent GI embolization between September 2016 and June 2019 at a single center. Embolization with exclusively NBCA was performed in 41 patients (17 female, mean age, 67.8 years) with acute upper GI (n = 22), lower GI (n = 17), rectal (n = 2) bleeding. The most common etiology of bleed was diverticular (n = 9), ulcer (n = 7), angiodysplasia (n = 7), and GI anastomosis (n = 4). Embolization was performed using 1:3 to 1:5 mixtures of NBCA and iodized oil. Four patients had empirically treated bleeding, without active contrast extravasation see on angiogram. Coagulopathy (defined as platelet count <80, INR >1.5, or PTT >45 seconds) was present in 39% (16/41) of patients. Technical success (defined as the disappearance of angiographic findings of hemorrhage on completion), early recurrent bleeding (defined as clinical signs of rebleeding requiring medical, radiologic, endoscopic, or surgical treatment at the treated focus within 30 days of embolization) and complications were recorded. The technical success rate was 97.5%. In 1/41 patients there was persistent contrast extravasation after embolization of a third order branch of the right colic artery, thought to be likely arising from a collateral, that was unable to be accessed from a retrograde approach. Early recurrent rebleeding occurred in 4/41 (9.7%) patients, of which 2 patients had empirically treated bleeds. 3/41 (7.3%) patients presented with clinical signs/symptoms of bowel ischemia postprocedurally; two patients had complete resolution with medical management, and one patient had bowel ischemia complicated by intestinal perforation. Surgical management was recommended, but patient declined. Findings in this large cohort adds to the growing body of evidence that NBCA is a durable agent for GI tract embolization with low recurrent bleed rates.

The evaluation of technical outcome and wire manipulation time within 30min in patients with poor distal vessel quality on percutaneous coronary intervention for chronic total occlusion.

The technical outcome of poor distal vessel quality (PDV) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is yet to be clearly elucidated. PDV has not been evaluated in scoring systems. We examined 193 consecutive CTO-PCIs performed in January 2013-December 2017. The endpoint, including the technical outcomes in these patients between with and without PDV, was analyzed. Moreover, we re-evaluated the predictors for CTO-PCI difficulty according to Japan-CTO score. Out of 193 CTO-PCIs, 181 (93.8%) achieved technical success [including 101 (55.8%) with and 80 (44.2%) without PDV]. In patients with and without PDV, the success rates of guidewire crossing using only the antegrade technique were 46.5% vs. 83.8%, respectively (p < 0.0001) and using the retrograde approach were 53.5% vs. 16.3%, respectively (p < 0.0001). Moreover, there were 56 non-interventional collateral channels in 181 patients. The successful rate of primary antegrade approach was significantly lower and the rate of a rescue retrograde approach was significantly higher with PDV (37.2% vs. 62.8%, 76.9% vs. 23.1%, respectively; p < 0.0119). Significant predictors associated with successful guidewire crossings of ≤ 30min included blunt stump, calcification, bending, occlusion length ≥ 20mm, retry lesion following Japan-CTO score, and PDV (p < 0.05, all). Multivariate analyses demonstrated that blunt stump, calcification, bending, retry lesion, and PDV were independent predictors of unsuccessful guidewire crossing of ≤ 30min (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.71, p = 0.0039; OR 0.34, 95% CI 0.16-0.71, p = 0.0035; OR 0.17, 95% CI 0.05-0.60, p = 0.0034; OR 0.18, 95% CI 0.06-0.54, p = 0.0008; and OR 0.19, 95% CI 0.09-0.41, p < 0.0001, respectively). PDV could affect the technical outcome of CTO-PCI.