Sac Size Research Articles

Exploring the mechanisms of graphene oxide behavioral and morphological changes in zebrafish.

The presence of natural organic matter such as humic acid (HA) can influence the behavior of graphene oxide (GO) in the aquatic environment. In this study, zebrafish embryos were analyzed after 5 and 7 days of exposure to GO (100 mg L-1) and HA (20 mg L-1) alone or together. The results indicated that, regardless of the presence of HA, larvae exposed to GO for 5 days showed an increase in locomotor activity, reduction in the yolk sac size, and total length and inhibition of AChE activity, but there was no difference in enzyme expression. The statistical analysis indicated that the reductions in total larval length, yolk sac size, and AChE activity in larvae exposed to GO persisted in relation to the control group, but there was a recovery of these parameters in groups also exposed to HA. Larvae exposed to GO for 7 days did not show significant differences in locomotor activity, but the RT-PCR gene expression analysis evidenced an increase in the AChE expression. Since the embryos exposed to GO showed a reduction in overall length, they were submitted to confocal microscopy and their muscle tissue configuration investigated. No changes were observed in the muscle tissue. The results indicated that HA is associated with the toxicity risk modulation by GO and that some compensatory homeostasis mechanisms may be involved in the developmental effects observed in zebrafish.

Type II Endoleak With an Enlarging Aortic Sac Predisposes to Development of Type IA Endoleak

The most common endoleak after endovascular aneurysm repair is type II. Whereas type II endoleaks (T2ELs) are generally considered benign, there have been reports that they can lead to aortic rupture. In this report, we reviewed the effect of T2EL on sac size changes to determine whether sac expansion due to a T2EL could result in the development of a type IA endoleak. Following Institutional Review Board approval, all aortoiliac endovascular aneurysm repairs performed at a single institution between June 2006 and June 2012 were retrospectively reviewed. Demographics, comorbidities, aneurysm diameter, graft type, need for reintervention, and complications were collected. Patients with T2EL diagnosed on follow-up imaging were categorized as those who underwent intervention for the T2EL and those who did not. Outcomes were tabulated with attention to sac size change, development of type IA endoleak, rupture, and survival. During the study period, 627 patients underwent aortoiliac stent graft placement at our institution. Patients with an operative indication other than nonruptured infrarenal abdominal aortic aneurysm and those who did not have a preoperative computed tomography angiography image available or follow-up data were excluded. The total number of patients included was 389, with an average follow-up of 68.8 months (range, 0-194 months). Follow-up imaging diagnosed 122 patients with T2EL (31%). Patients with T2EL were significantly more likely to have a smoking history (P = .01), hypertension (P < .05), and older age (P < .0001). Patients with T2EL had a significantly larger sac size increase than patients without T2EL (9.50 vs −0.78 mm; P < .0001). Patients with T2EL were significantly more likely to develop a type IA endoleak than patients who did not have T2EL (14% vs 6%; P = .02), but the rate of rupture was not significantly different (4% vs 2%; P = .33). Those patients in the T2EL group who underwent intervention for T2EL survived significantly longer than patients who did not undergo intervention (100.5 vs 75 months; P = .004). Our data suggest that there is an increased incidence of late type IA endoleak in patients with T2EL and an enlarging aortic sac. Our study also demonstrates an increased overall survival in T2EL patients who underwent intervention. Future studies are necessary to better define the association between T2EL with enlarging sac and the development of type IA endoleak.

The chest pain in neurological practice. Non deesset...

Chest pain can be a “mask” of a life-threatening condition, which the practitioner must remember. One of such life-threatening condition is aortic aneurysm, which diagnosis presents significant difficulties in routine clinical practice. Clinical manifestations of thoracic aortic aneurysms are extremely variable and non-specific and are mainly depends on the size of the aneurysmal sac, its localization and extent, as well as the etiology of the disease. Here we present a clinical case report of a 48 y.o. patient who died because of the acute cardiac tamponade as a complication of dissecting thoracic aorta aneurysm. The lack of symptoms and clinical instrumental data, initially suggesting the presence of life-threatening disease did not allow the physician to suspect aortic aneurysm and urgently take action regarding it.

Imaging characteristics of patients with large vestibular aqueduct syndrome and its relationship with the acoustically evoked short latency negative response

Objective: To explore the imaging characteristics of large vestibular aqueduct syndrome (LVAS) patients and their relationship with the acoustically evoked short latency negative response (ANSR), so as to provide reference for the diagnosis of LVAS. Methods: Clinical data of 174 patients(334 ears) with LVAS diagnosed and treated by the Department of Otorhinolaryngology Head and Neck Surgery of the First Affiliated Hospital of Guangxi Medical University, from October 2009 to December 2017 were retrospectively analyzed, including 117 males and 57 females, aged from 5 months to 47 years old, with the median age of 4 years and 4 months. ABR and imaging data of patients were collected. Midpoint diameter and the outlet diameter of the vestibular aqueduct were measured on CT images, the midpoint diameter of the intraosseous parts and the extraosseous parts of enlarged endolymphatic sac(EES) were measured on MRI images. The correlation between the above measurements was analyzed by Pearson test using SPSS 17.0. According to whether ASNR was detected in ABR, the above data were divided into two groups, and the differences of the above imaging measurements were compared by the Independent-Sample Test. Results: The average midpoint diameter of the vestibular aqueduct was (1.87±0.58) mm (x±s, the following was the same), and the outlet diameter was (3.07±0.99) mm on CT; the average midpoint diameter of the intraosseous parts in enlarged endolymphatic sac(EES) was (2.39±1.37) mm, and the extraosseous parts was (2.50±2.18) mm on MRI. There was a correlation between the four measurements (P<0.05), among which the midpoint diameter of vestibular aqueduct was strongly positively correlated with the outlet diameter (r=0.760), and the remaining pairs were weakly correlated. ASNR was detected in 241 ears (72.16%,241/334) and undetected in 93 ears (27.84%, 93/334) of the 334 ears with LVAS. Midpoint diameter and the outlet diameter of the vestibular aqueduct in no ASNR group were smaller than the ASNR group, and the difference was statistically significant (t value was 2.814 and 2.754, P<0.05). There was no significant difference in the midpoint diameter of the intraosseous parts and the extraosseous parts of enlarged endolymphatic sac between the two groups, and the difference was no statistically significant(t value was 0.101 and 0.683, P>0.05). Conclusions: There is a strong positive correlation between the midpoint diameter of vestibular aqueduct and the outlet diameter in LVAS patients. There is a certain correlation between the size of vestibular aqueduct and the size of endolymphatic sac. The smaller the diameter of vestibular aqueduct, the lower the occurrence rate of ASNR.

Developmental effects in fish embryos exposed to oil dispersions – The impact of crude oil micro-droplets

During accidental crude oil spills and permitted discharges of produced water into the marine environment, a large fraction of naturally occurring oil components will be contained in micron-sized oil droplets. Toxicity is assumed to be associated with the dissolved fraction of oil components, however the potential contribution of oil droplets to toxicity is currently not well known. In the present work we wanted to evaluate the contribution of oil droplets to effects on normal development of Atlantic cod (Gadus morhua) through exposing embryos for 96 h to un-filtered (dispersions containing droplets) and filtered (water soluble fractions) dispersions in a flow-through system at dispersion concentrations ranging from 0.14 to 4.34 mg oil/L. After exposure, the embryos were kept in clean seawater until hatch when survival, development and morphology were assessed. The experiment was performed at two different stages of embryonic development to cover two potentially sensitive stages (gastrulation and organogenesis). Exposure of cod embryos to crude oil dispersions caused acute and delayed toxicity, including manifestation of morphological deformations in hatched larvae. Oil droplets appear to contribute to some of the observed effects including mortality, larvae condition (standard length, body surface, and yolk sac size), spinal deformations as well as alterations in craniofacial and jaw development. The timing of exposure may be essential for the development of effects as higher acute mortality was observed when embryos were exposed from the start of gastrulation (Experiment 1) than when exposed during organogenesis (Experiment 2). Even though low mortality was observed when exposed during organogenesis, concentration-dependent mortality was observed during recovery.

Predictive value of ultrasound-related scoring system on embryo development in early pregnancy after IVF/ICSI: An observation of embryonic quality

ObjectiveThis study aims to evaluate the value of the ultrasound-related scoring system on pregnant patients receiving assisted reproductive technology (IVF/ICSI) and early pregnancy outcome. Materials and methodsThis prospective study included 208 pregnant women receiving assisted reproductive technology (IVF/ICSI). The following ultrasound parameters were measured: gestational sac size, the proportion of the embryo and gestational sac (embryo/gestational sac), yolk sac size, and fetal cardiac activity. The above data were assigned according to the ongoing pregnancy rate (up to 14 weeks), and the score increased parallel to the pregnancy rate. All patients were grouped according to their scores. ResultsPatients with a score of 4–5 had a low ongoing pregnancy rate of 14.29%, while patients with a score of 6–7 had an ongoing pregnancy rate of 55.56%. Surprisingly, patients with a score of 8–9 had an ongoing pregnancy rate of 97.22%. In addition, it was found that the ongoing pregnancy rate was 100% (36/36) in patients with a score of 9. Conversely, there was no ongoing pregnancy in patients with a score of 4. ConclusionFirst, this scoring system is strongly associated with an ongoing pregnancy of over 14 weeks. Second, some reassurance can be given to patients with favorable ultrasound parameters, regardless of maternal age or previous pregnancy loss. Third, it would be meaningless to continue the pregnancy in patients with a score of 4, according to the scoring system. Fourth, patients without cardiac activity and embryos at days 33–35 after embryo transfer should discontinue the pregnancy, while patients with embryos should proceed with the pregnancy.

Factors associated with pseudoaneurysm development and necessity for reintervention: a single centre study.

Evaluate the factors associated with pseudoaneurysm development and morphology. Measure ultrasound-guided thrombin injection (UGTI) and surgical treatment outcomes for pseudoaneurysms, and the necessity for post-primary intervention (reintervention). Retrospective analysis of ultrasound scans and CT angiography of peripheral pseudoaneurysm interventions from February 2011 to April 2017. 99 patients (61.6% female) were identified; median age 72 years (range 12-89). Multivariate analysis of patient demographics, including pre-intervention anticoagulant and antiplatelet medication was performed. Primary intervention for peripheral pseudoaneurysms (62.6% common femoral artery) included 93 UGTI and 6 surgical repairs; with 12 reinterventions (9 UGTI and 3 surgical). Pseudoaneurysm incidence for vascular interventional radiology (VIR) was 0.48% (31/6451) and cardiology was 0.24% (60/25,229). Rates for primary success, immediate complications, 30-day mortality and reintervention were measured respectively for UGTI (98.9%, 3.0%, 2.0%, and 11.8%) and surgical repair (100%, 0.0%, 22.2% and 16.7%). Reintervention risk factors included pre-intervention thrombocytopaenia (<150 × 109/L) ( p = 0.025) and pseudoaneurysms following vascular surgery (p = 0.033). Other positive associations for reintervention (non-significant) included use of a sheath size > 6 Fr ( p = 0.108) or arterial closure device ( p = 0.111) during the pseudoaneurysm causative procedure. The pre-intervention warfarin subgroup developed a larger mean pseudoaneurysm sac size (4.21 cm, range 0.9-7.6), compared to no treatment (p = 0.003), aspirin (p = 0.005) and clopidogrel (p = 0.026) subgroups. UGTI dosage for thrombosis had a positive correlation with incremental sac size increase (p < 0.001). The main reintervention risk factor was pre-intervention thrombocytopaenia, with additional positive associations including pseudoaneurysms caused by surgery, increased sheath size and arterial closure devices. Warfarinized patients developed larger sac-sized pseudoaneurysms compared with other pre-intervention regimens, with positive correlation of higher UGTI dosage required for thrombosis. Patients with pre-intervention thrombocytopaenia and pseudoaneurysms attributed to vascular surgery are subgroups that may benefit from post-intervention imaging surveillance due to significant reintervention risk.

Yolk sac size and embryonic heart rate as prognostic factors of first trimester pregnancy outcome

Yolk sac size and embryonic heart rate as prognostic factors of first trimester pregnancy outcome

Predictors of poor first trimester outcome in asymptomatic women : the value of embryonic heart rate , mid sac diameter / yolk sac ratio &amp; mid sac diameter / crown rump length

Background: Ultrasound provides a powerful tool for assessing early pregnancy and detecting pregnancy failure at first trimester and promoting rapid effective management. Several criteria have been established to predict the pregnancy outcome particularly in symptomatic women .&#x0D; Aim: To evaluate asymptomatic women at the first trimester of pregnancy , to assess the efficacy of certain ratios as mid sac diameter (MSD) / yolk sac ratio &amp; crown rump length (CRL)/mid sac diameter (as indicator of early first trimester oligohydramnios) in predicting poor 1st trimester outcome&#x0D; Type of the study: A cross-sectional study.&#x0D; Patients &amp; Methods: A sixty three asymptomatic women were enrolled in this prospective study . Transvaginal sonography was performed for confirmation of pregnancy viability &amp; exclusion of multiple pregnancies 6-8 weeks of gestation &amp; follow up ultrasound repeated at the beginning of second trimester to confirm the continuation of pregnancy and viability of fetus. Several parameters assessed and tested against each others as embryonic heart rate , the size and morphologic criteria of gestational sac , yolk sac and the crown rump length &#x0D; Results: The women were classified into two groups: group A are those with successful outcome at the first trimester and group B are those with poor outcome of the 1st trimester . Decrease embryonic heart rate below 100 beat per minute and low mid sac diameter/ yolk sac size ratio of &lt; 1.9 , were found to be significant predictors of poor outcome however mid sac diameter/crown rump length ratio was not found to have a similar significance &#x0D; Conclusion: In addition to the classical parameters assessed by trans-vaginal ultrasound, other important parameters need to be routinely applied as the embryonic heart rate that predict poor outcome when less than 100 bpm . In addition to the ratio of mid sac diameter to the yolk sac diameter which , if less than 1.9 , may point to abnormal first trimester fate.

TREO Aortic Endograft Demonstrates Significant Aneurysmal Sac Shrinkage

BackgroundAneurysmal sac shrinkage is associated with successful aneurysm repair after endovascular aortic repair (EVAR). There are a variety of approved aortic endografts, with a recent study demonstrating increased sac shrinkage in certain endografts compared with others. The TREO endograft (Terumo Aortic Ltd, Renfrewshire, Scotland, UK) is being evaluated for use in EVAR, with preliminary data demonstrating high rates of success. The objective of this study is to evaluate sac shrinkage of the TREO endograft. MethodsThis is a retrospective analysis of EVARs at a single institution by a high-volume surgeon over a 1-year period in which the TREO graft was used. The change in sac size and rate of sac shrinkage (mm/mo) were evaluated between TREO and non-TREO grafts. All TREO grafts were included in the analysis. Non-TREO grafts were matched a priori for TREO indications for use anatomic specifications. Non-TREO grafts were also excluded for traumatic or emergent cases. The primary outcome was sac shrinkage, and secondary outcomes were composite complication profile within 30 d of operation. ResultsSix TREO grafts and 16 non-TREO grafts were included for analysis. The groups were similar in age, gender, and race. The groups were also similar in aortic anatomy before EVAR. The aneurysm sac shrinkage rate (mm/mo) is significantly greater in the TREO group than in the non-TREO group (0.484 ± 0.107 versus 0.018 ± 0.112, P = 0.033). The total average size of sac shrinkage was also greater for the TREO group (−0.688 ± 2.262 versus 12.00 ± 2.78, P < 0.001). The composite complication profile of stroke, myocardial infarction, death, and respiratory complications was not different between groups. ConclusionsTREO aortic endografts for aneurysm repair are being used in Europe. However, their application in the United States is limited. Our data demonstrate the significant advantage the TREO graft has with increased sac shrinkage and minimal complications, compared with other grafts. This study adds to the growing body of literature supporting TREO graft use for EVAR.

Prognostic Factors of Ultrasonography of Yolk Sac Size and Embryonic Heart Rate in First Trimester Pregnancy Outcome

Prognostic Factors of Ultrasonography of Yolk Sac Size and Embryonic Heart Rate in First Trimester Pregnancy Outcome

Efficacy and Safety of Transvenous Embolization of Type II Renal Arteriovenous Malformations with Coils

PurposeTo evaluate the efficacy and safety of transvenous coil embolization of the venous sac for type II renal arteriovenous malformation (AVM). Materials and MethodsA retrospective review was conducted of 8 patients (5 women and 3 men; mean age, 57 years; age range, 41–69 years) who underwent transvenous coil embolization for type II congenital renal AVM at 5 different hospitals between 2012 and 2018. Additional intra-arterial ethanol injection was performed if shunt flow persisted after venous sac coiling. Technical success was defined as complete occlusion of shunt flow with coil embolization. Clinical success was defined as no symptom recurrence during the follow-up period. The renal parenchymal infarction rate was measured on computed tomography (CT), and procedure-related complications were reviewed. ResultsNine sessions of embolization were performed for 8 patients. The mean venous sac size was 24 mm (range, 10–39 mm), and a mean of 14 micro and/or micro-detachable coils (range, 3–50) were used. The technical success rate was 88% (7 of 8) using coil embolization. One patient (12%) required additional ethanol injection to complete occlusion of the shunt flow and had a less than 10% parenchymal infarction on follow-up CT. No procedure-related complications or recurrences occurred during a mean clinical follow-up period of 20.8 months (range, 4.7–76.6 months). ConclusionsTransvenous coil embolization of type II renal AVM showed an 88% technical success rate. One patient (12%) showed less than 10% renal parenchymal infarction after additional ethanol injection. No additional complications or recurrences occurred during the follow-up period.

Explant of aortic stent grafts following endovascular aneurysm repair.

Background Failure of endovascular aneurysm repair may require explant of the stent graft in a subset of patients. We sought to assess outcomes in a cohort of patients undergoing explant of endovascular aneurysm repair in both emergency and elective settings. Methods Patients undergoing explant of endovascular aneurysm repair were identified from a prospectively maintained database, with additional information obtained through retrospective analysis of medical records. Results Over a 21-year period, 1997–2018 (May), there were 597 endovascular aneurysm repair procedures performed in our institution for abdominal aortic aneurysm. There were 19 endovascular aneurysm repair explants; five of these were referrals from other vascular centres. The median age was 73 years (range 46–81). The median length of time from insertion to explant was 39.2 months (range 0–153). Indications for elective explant were type Ia endoleak (n = 4), type 1b endoleak (n = 1), type II endoleak with increasing sac size (n = 1), type I/III endoleak (n = 1), type IV endoleak (n = 1), and increasing sac size without evident endoleak (type V, n = 2). The remaining nine cases were emergency procedures, with four patients presenting with rupture post endovascular aneurysm repair, four patients presenting with acute stent thrombosis, of which one also had a type 1a endoleak and one aorto-enteric fistula. There were no mortalities in the elective group and three mortalities in the emergency group (0 vs 33.3%, p = 0.087). Overall 30-day mortality was 15.8% Conclusion Explant of aortic stent grafts can be associated with high mortality and morbidity rates, especially in the emergent setting. Patient and device selection and post-operative surveillance remain vitally important to optimise outcomes post endovascular aneurysm repair.

Fate or independency: is batch-specific larval performance determined by egg traits? A case study in farmed pikeperch (Sander lucioperca)

Fish embryos and larvae undoubtedly depend on maternal provisioning of essential egg components, such as fatty acids (FA), during early ontogeny. But which aspects and stages of batch-specific larval development are modulated by these inherent oocyte traits? This question is of major importance from an ecological, as well as from an aquacultural perspective. We examined the effects of batch-specific non-nuclear-genetic egg traits (fatty acid (FA) profiles, egg size, mtDNA fragmentation, cortisol content) already in unfertilized oocytes of pikeperch (Sander lucioperca) and studied their influence on survival (15 dph) and larval performance (length at hatch, stress resistance, first feeding, swim bladder inflation rate, yolk sac and lipid droplet size, growth in weight and length) after hatching under stable laboratory conditions (n = 12 batches). While larval survival and performance were independent of mtDNA fragmentation and cortisol levels, FA profiles affected specific larval traits. Especially, FA of the neutral fraction were positively correlated with larval size and growth (16:0, 18:0, 22:1n-9, total saturated FA), swim bladder inflation (arachidonic acid 20:4n-6, total FA), and early first feeding (16:0, 18:0, total saturated FA). Important FA of the polar fraction included 15:0 and 16:1n-7, which showed alternate effects on larval survival, first feeding, and growth (length). Furthermore, larval length at hatch was positively correlated with egg diameter. Other larval parameters (yolk sac and lipid droplet size and stress response) were not or only marginally affected by egg traits. Consequently, high oocyte FA deposition fuels fast rates of growth and development during early ontogeny. On the other hand, larvae develop independently of assumed disadvantageous properties (cortisol content, mtDNA damage). Knowledge of this relation allows for the improvement of aquaculture practice, as well as predicting recruitment success in the wild.

Aneurysm Characteristics, Study Population, and Endovascular Techniques for the Treatment of Intracranial Aneurysms in a Large, Prospective, Multicenter Cohort: Results of the Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm Study.

The Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) prospective study aims to determine factors predicting recurrence after endovascular treatment for intracranial aneurysms. In this publication, we review endovascular techniques and present the study population. Characteristics of treated and untreated unruptured aneurysms were analyzed. Sixteen neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured intracranial aneurysms between December 2013 and May 2015. Patient demographics, aneurysm characteristics, and endovascular techniques were recorded. A total of 1289 patients with 1761 intracranial aneurysms, 835 (47.4%) ruptured, were enrolled. Of these, 1359 intracranial aneurysms were treated by endovascular means. Ruptured intracranial aneurysms were treated by coiling and balloon-assisted coiling in 97.8% of cases. In unruptured intracranial aneurysms, the rates of flow diversion, flow disruption, and stent-assisted coiling were 11.6%, 6.9%, and 7.8%, respectively. Rupture status and aneurysm location, neck diameter, and sac size significantly influenced the chosen technique. Treated unruptured intracranial aneurysms, compared with untreated counterparts, had larger aneurysm sacs (7.6 ± 4.0 versus 3.4 ± 2.0 mm; P < 0.001) and neck dimensions (4.1 ± 2.2 versus 2.4 ± 1.3 mm; P < 0.001) and more frequently an irregular form (84.6% versus 44.4%; P < 0.001). Also, its location influenced whether an unruptured intracranial aneurysm was treated. Our study provides an overview of current neurointerventional practice in the ARETA cohort. The technique choice was influenced by aneurysm morphology, location, and rupture status. Flow diversion, flow disruption, and stent-assisted coiling were commonly used in unruptured intracranial aneurysms, while most ruptured intracranial aneurysms were treated with coiling and balloon-assisted coiling.

Efficacy and Safety of AMPLATZER Vascular Plug Type IV for Embolization of Pulmonary Arteriovenous Malformations

PurposeTo assess the efficacy and safety of the AMPLATZER Vascular Plug type IV for pulmonary arteriovenous malformation (PAVM) treatment. Materials and MethodsBetween June 2013 and January 2018, 13 patients with 26 PAVMs were treated with the type IV AVP. Patients without follow-up computed tomography (CT) were excluded. Technical success was defined as flow occlusion on angiography. Plug-to-sac distance was measured on angiographic images. Feeding artery and venous sac diameter changes were measured on preprocedural and follow-up CT. Successful embolization was defined as > 70% sac size regression. Procedure time, device migration, and complications were evaluated. ResultsNine female patients (mean age, 49 y; range, 40–71 y) with 19 PAVMs were enrolled. Four patients with 7 PAVMs were lost to follow-up. Nineteen PAVMs were treated in 11 sessions, and the mean procedure time was 29 min. The technical success rate was 100%. Mean feeding artery diameter was 3.1 mm ± 0.7 (range, 2.1–4.9 mm). Mean plug-to-sac distance was 5.4 mm ± 4.9 (range, 0–13.3 mm). The mean CT follow-up period was 14 months ± 7 (range, 6–30 mo). Sixteen of 19 PAVMs (84%) were successfully embolized. Minor complications (tachycardia and chest discomfort) arose in 2 of 11 sessions. No device migrations or major complications occurred. ConclusionsThe type IV AVP showed an 84% treatment success rate based on 70% sac size regression criteria in small PAVMs. There were no device migrations or major complications.

Abdominal Aortic Disease: A Multicase Review

Abdominal aortic disease affects more than 3 million people per year. For vascular sonographers, imaging aortic disease can become routine. Therefore, it is necessary to expand the knowledge that we have of aortic disease, diagnosis, and treatment. We present 4 cases with new or worsening conditions diagnosed by duplex ultrasound (DUS). Our first case is a 79-year-old woman returning for surveillance of an endovascular aneurysm repair (EVAR). The DUS findings reveal an increasing abdominal aortic aneurysm (AAA) sac, with evidence of flow originating from an incomplete seal at the attachment suggesting type I endoleak. Next, is a 56-year-old man returning 1 month after type A dissection repair, now presenting with unilateral claudication. The DUS findings of the left lower extremity demonstrated an early systolic deceleration waveform, suggesting more proximal disease. Upon further imaging, an abdominal aortic dissection was identified terminating into the left internal iliac artery, causing the true lumen to be compressed. The third case was a 75-year-old man returning for follow-up of an EVAR and iliac repair. The DUS findings show an increase in iliac artery sac size and anechoic area that was filled with color Doppler flow. These findings are suggestive of type I endoleak involving the distal attachment. The last case is a 56-year-old man returning for EVAR and iliac artery repair surveillance. The common iliac artery aneurysm sac had increased in diameter and length. The distal attachment of the left iliac extension cuff terminated within the aneurysm sac, causing a type I endoleak. Accurate DUS diagnosis of aortic disease is crucial for patient care. Meticulous analysis of the vessels and surrounding structures can make a difference in diagnostic outcomes. Vascular sonographers should continually review and revise vascular laboratory protocols to increase their diagnostic accuracy and improve patient care. It is important to extend the vascular laboratory protocols when complex cases arise to better demonstrate complicated diagnoses and challenging anatomy.

Independent risk factors for contralateral patent processus vaginalis undetected by pre-operative ultrasonography in boys with unilateral inguinal hernia.

Many trials have been done to make sure probability of metachronous contralateral side hernia (MCH) and contralateral patent processus vaginalis (CPPV). But the necessity of contralateral side exploration is still on debate. The aim is to investigate the risk factors for the consideration of contralateral examination on operation. The study was designed as retrospectively. Patients with unilateral inguinal hernia from January 2010 to May 2015 were enrolled. Pre-operative ultrasonography was done in all patients. Patients with obvious contralateral side hernia on pre-operative US were excluded. The presence of CPPV was evaluated by transinguinal laparoscopy during the operation. In univariate analysis, hernial sac size only shows difference (P value: 0.001). The others, location of the hernia, age at surgery, gestational age (preterm), low birth weight and parent's age, did not show statistically significant differences. Multivariate analysis also demonstrates CPPV is more common in patients with large hernial sac (Odds ratio: 2.727, 95% confidence interval 1.495-4.974, P value: 0.001). We propose that surgeons should consider contralateral evaluation during operation in case with large ipsilateral hernial sac, although CPPV was not detected by pre-operative US.

Comparison of two preventive dual antiplatelet regimens for unruptured intracranial aneurysm embolization with flow diverter/disrupter: A matched-cohort study comparing clopidogrel with ticagrelor

PurposeStandard dual antiplatelet therapy (DAPT) for complex aneurysms treated with flow diversion and flow disruption is acetylsalicylic acid (ASA) plus clopidogrel. However, clopidogrel resistance frequently occurs and can lead to thromboembolic events. Ticagrelor is an alternative not requiring platelet inhibition testing. We compared two DAPT regimens (ASA with clopidogrel or ticagrelor) on morbi-mortality, safety and efficacy of unruptured aneurysm embolization with flow diverter/disrupter. Materials and methodsThis retrospective analysis of a 1:1 matched cohort compares patients treated with ASA + clopidogrel (March 2013–December 2015) vs. ASA + ticagrelor (January 2016–March 2017). No platelet inhibition testing was conducted. Patients matched for age (±10 years), type of treatment and aneurysm sac size ( ± 2 mm). Primary outcome measures were morbidity and mortality at 1-month; secondary outcomes were thromboembolic and hemorrhagic complications [on angiography and magnetic resonance imaging (MRI)] and groin complications. Outcomes were compared using bivariate analyses. ResultsNinety patients fulfilled inclusion criteria, of which 80 remained after matching (40 per group). There was no statistical difference in 1-month morbidity between the ticagrelor and clopidogrel groups (2.5% vs. 10%, P = 0.36) and no deaths reported. We observed no significant differences between ticagrelor and clopidogrel groups in terms of angiographic thromboembolic complications (5% vs. 12.5%, P = 0.43), territorial infarction on DWI (2.5% vs. 7.5%, P = 0.61), angiographic (0% vs. 0%, P = 1) and MRI (5% vs 5%, P = 1) hemorrhagic complications, new microbleeds (57.5% vs. 40%, P = 0.12) and groin puncture complications (2.5% vs. 0%, P = 1). At three months, there was no delayed territorial infarction or hemorrhage in either group. ConclusionsTicagrelor is safe and effective in replacing clopidogrel as DAPT for unruptured aneurysms.

Aggressive Surveillance Is Needed to Detect Endoleaks and Junctional Separation between Device Components after Zenith Fenestrated Aortic Reconstruction

Junctional separation and resulting type IIIa endoleak is a well-known problem after EVAR (endovascular aneurysm repair). This complication results in sac pressurization, enlargement, and eventual rupture. In this manuscript, we review the incidence of this late finding in our experience with the Cook Zenith fenestrated endoprosthesis (ZFEN, Bloomington, IN). A retrospective review was performed of a prospectively maintained institutional ZFEN fenestrated EVAR database capturing all ZFENs implanted at a large-volume, academic hospital system. Patients who experienced junctional separation between the fenestrated main body and distal bifurcated graft (with or without type IIIa endoleak) at any time after initial endoprosthesis implantation were subject to further evaluation of imaging and medical records to abstract clinical courses. In 110 ZFENs implanted from October 2012 to December 2017 followed for a mean of 1.5years, we observed a 4.5% and 2.7% incidence of clinically significant junctional separation and type IIIa endoleak, respectively. Junctional separation was directly related to concurrent type Ib endoleak in all 5 patients. Three patients presented with sac enlargement. One patient did not demonstrate any evidence of clinically significant endoleak and had a decreasing sac size during follow-up imaging. The mean time to diagnosis of modular separation in these patients was 40months. Junctional separation was captured in surveillance in 2 patients and reintervened upon before manifestation of endoleak. However, the remaining 3 patients completed modular separation resulting in rupture and emergent intervention in 2 and an aortic-related mortality in the other. Junctional separation between the fenestrated main and distal bifurcated body with the potential for type IIIa endoleak is an established complication associated with the ZFEN platform. Therefore, we advocate for maximizing aortic overlap during the index procedure followed by aggressive surveillance and treatment of stent overlap loss captured on imaging.