Urgent Setting Research Articles

Assessing myocardial tissue in the acute setting with Photon-Counting CT (PCCT) in comparison with Cardiac Magnetic Resonance (CMR)

Abstract Background Cardiac magnetic resonance (CMR) characterization of myocardial tissue is routinely used in clinical practice. Compared to traditional CT, Photon counting CT (PCCT) uses photon-counting detectors offering higher spatial resolution, elimination of electronic noise and improved contrast-to-noise ratio. A comparison between CMR and PCCT for myocardial characterizazion in an urgent setting, however, has not yet been explored. Purpose The aim of this study was to compare the ability to characterize myocardial tissue between PCCT and CMR in patients presenting with acute chest pain in the emergency department (ED). Methods This single-center prospective study enrolled all consecutive patients presenting to the ED of our hospital from November 2023 to January 2024 with chest pain, ECG alterations and troponin rise consistent with myocardial injury. Patients needing urgent coronary angiography according to guidelines were excluded. PCCT was performed urgently for triple rule-out, but also for tissue characterization through post-iodine-contrast administration images. Within 24 hours, all patients underwent a CMR protocol including T2-weighted and late gadolinium enhancement (LGE) images for tissue characterization. Results Six male patients with a mean age of 20 ± 10 years were enrolled. All clinical, PCCT, and CMR parameters are presented in Table 1. All patients presented with diffuse ST-segment elevation and exhibited T2-weighted images (for edema detection) and LGE distribution (subepicardial and intramyocardial) consistent with acute myocarditis. Mean radiation exposure for PCCT was 0.8±0.1 mSv. A strong linear correlation emerged between PCCT-derived delayed enhancement (DE) volume and CMR-derived late gadolinium enhancement (LGE) volume (r = 0.970; p value 0.001) (Table 1). Similar results were achieved when comparing the number of DE and LGE myocardial segments (r = 0.871; p value 0.026). Significant correlations also emerged between DE, LGE, and high-sensitive troponin (hsTN) at presentation (respectively: PCCT-DE vs hsTN r = 0.951, p value 0.004; CMR-LGE vs hsTN r = 0.918, p value 0.010). CMR showed a much higher signal-to-noise ratio (SNR) for the delayed enhanced myocardium and contrast-to-noise (CNR) ratio between the delayed enhanced and normal myocardium with respect to PCCT in post-contrast images (respectively 7.4 ± 3.9 vs 27.2 ± 17.7, p value 0.024 and 5.5 ± 3.7 vs 38.8 ± 30.2, p value 0.023). In T2-weighted images both SNR for the hyperintense myocardium (30.3 [20.4-122.4]) and CNR between the hyperintense and normal myocardium (26.7 [13.3-60.2]) resulted to be higher compared to PCCT (p value 0.027 and 0.045, respectively) (Table 1). Conclusions PCCT appears to be reliable when compared to CMR for detecting myocardial edema through the acquisition of post-contrast images in the acute setting with an acceptable CNR.

Decoding Acute Scrotum: Diagnostic Accuracy of Ultrasound in Urgent Clinical Settings

Decoding Acute Scrotum: Diagnostic Accuracy of Ultrasound in Urgent Clinical Settings

Early and Mid-Term Results of Endovascular Aneurysm Repair with the Cordis Incraft Ultra-Low Profile Endograft: A High-Volume Center Experience.

Background/Objectives: In recent years, manufacturers have developed new low-profile stent grafts to allow endovascular treatment of abdominal aortic aneurysms (AAA) in patients with small access vessels. We evaluated the early and mid-term outcomes of the Incraft (Cordis Corp, Bridgewater, NJ, USA) ultra-low profile endograft implantation in a high-volume single center. Methods: Between 2014 and 2023, 133 consecutive endovascular aneurysm repair (EVAR) procedures performed using the Incraft endograft were recorded in a prospective database. Indications included infrarenal aortic aneurysms, common iliac aneurysms, and infrarenal penetrating aortic ulcers. Mid-term results were analyzed using the Kaplan-Meier method. Results: During the study period, 133 patients were treated with the Cordis Incraft endograft, in both elective and urgent settings. The Incraft graft was the first choice for patients with hostile iliac accesses, a feature characterizing at least one side in 90.2% of the patients in the study cohort. The immediate technical success rate was 78.2%. The intraoperative endoleak rate was 51.9% (20.3% type 1 A, 0.8% type 1 B, and 30.8% type 2 endoleak). Within 30 days, technical and clinical success rates were both 99.3%; all type 1A and 1B endoleaks were resolved at the 30-day follow-up CT-angiogram. After a mean follow-up of 35.4 months, the actuarial freedom from the re-intervention rate was 96.0%, 91.1%, and 84.0% at 1, 3, and 5 years, respectively. The iliac leg patency rate was 97.1%, 94.1%, and 93.1% at 1, 3, and 5 years, respectively. No statistically significant differences were observed between hostile and non-hostile access groups, nor between the groups with grade 1, grade 2, and grade 3 access hostility. Conclusions: The ultra-low profile Cordis Incraft endograft represents a valid option for the endovascular treatment of AAA in patients with hostile iliac accesses. The procedure can be performed with high rates of technical and clinical success at 30 days and the rates of iliac branch occlusion observed during the follow-up period appear acceptable in patients with poor aorto-iliac outflow.

Retrograde open mesenteric stenting and outcomes for acute mesenteric ischemia.

Data regarding retrograde open mesenteric stenting (ROMS) for urgent mesenteric ischemia is limited to small single center and case series, with variable utilization across patient populations and ill-defined outcomes. We aimed to evaluate characteristics and outcomes of patients with acute mesenteric ischemia requiring urgent surgical intervention. Retrospective cohort study of patients with mesenteric ischemia requiring urgent surgical intervention from 2018 to 2020 was queried from the National Inpatient Sample (NIS) database. Study groups were defined as those requiring an open bypass (BYPASS), an open superior mesenteric artery embolectomy (OPEN), or ROMS. Descriptive statistics were used to report variables. Comparisons were mad using t test, chi-squares tests, and multivariate regression reported as odds ratio (OR), 95% confidence interval (CI) where appropriate. 898 patients with mesenteric ischemia requiring urgent surgical intervention were included: Bypass: 284, OPEN: 363, ROMS: 251. There was no difference in gender or race between groups. Patients requiring ROMS were more likely to be older 70.2 + 11.3versus Bypass 66.81 + 11.6 and OPEN 67.17 + 14.5, p = 0.0035. ROMS patients had the highest Charlson Comorbidity Index (CCI) 2.9 versus 2.5 Bypass and 2.6 OPEN, p = 0.0292 with the most frequent comorbidities: Diabetes 37% (p = 0.01), renal disease 24.3% (p = 0.5), and previous preoperative myocardial infarction 9.2%, p = 0.05; however, the lowest mortality rate was seen within this Group 15.9% versus bypass 19.7%, OPEN 34.5%, p < 0.0001. Patients requiring bypass were more likely to have chronic pulmonary disease 34.5% versus OPEN 24.2% and ROMS 31.5%, p = 0.013, peripheral vascular disease (PVD) 38% versus OPEN 16%, and ROMS 29.9%, p < 0.0001. On multivariate regression, ROMS was associated with 50% decreased incidence of mortality (OR 0.45, 95% CI 0.27-0.75). Open SMA embolectomy was associated with nearly 2x mortality rate compared to bypass procedures OR 2.0, 95% CI 1.3-3.0, p < 0.001. Previous MI was also associated with nearly 2x incidence of mortality (OR 1.9, 95% CI 1.01-3.6), while pre-existing PVD conferred a protective effect (OR 0.56, 95% CI 0.36-0.89). Higher CCI and age were associated with slightly increased risk for mortality OR 1.2 and 1.03, p < 0.05 for both. In patients with acute mesenteric ischemia, ROMS demonstrated a significant mortality benefit compared to traditional open procedures. Advanced age, history of MI, and open SMA embolectomy were associated with increased mortality. Little data exists regarding ROMS in a real-world population evaluating ROMS, which is a newer technique. These data suggest that ROMS may be a superior alternative to restore mesenteric flow in the acute setting and further prospective studies evaluating ROMS to other procedural types in urgent and elective settings are needed.

Urgent or Emergent Endovascular Aortic Repair of Infective Aortitis.

Background: Aortitis is a rare inflammation of the aorta. It can be classified as infective, non-infective, or idiopathic. Infective aortitis can debut as an acute aortic syndrome that needs urgent or emergent treatment. Historically, these kinds of patients have been preferably treated by open surgery, with subsequent lack of information about the endovascular repair. The aim of the present study is to report the results of our experience with the urgent or emergent endovascular repair of infective aortitis with acute presentation. Methods: All consecutive urgent or emergent endovascular repairs, performed between January 2019 and January 2024 for the treatment of infective aortitis, were included. The inclusion criteria were clinical, laboratory, and radiological findings recognized as aortitis risk factors. Patients with graft or endograft infection, aortic fistulae, and mycotic aneurysm were excluded. Primary endpoints were technical success and 30-day and follow-up survival. Early and late major adverse events, any changes in lesion morphology over time, and need for re-intervention were also assessed. Results: A total of 15 patients (14 males and 1 female) with a mean age of 74.2 ± 8.3 were included. All the subjects were treated by endovascular means in an urgent or emergent setting because of a rapidly growing aneurysm, symptomatic lesion, or contained or free aortic rupture. The diagnosis of infective aortitis was confirmed postoperatively by positive blood cultures in all the patients. A rapidly growing or symptomatic lesion was noted in all 15 subjects. Among these there were six (40%) contained and two (13%) free aneurysm ruptures. The endovascular techniques performed were as follows: four thoracic-EVAR (TEVAR), three off-the-shelf branched-EVAR (BEVAR), one Chimney-EVAR (Ch-EVAR), six EVAR with bifurcated graft, and one EVAR with straight tube graft. Technical success was achieved in 100% of the patients. Two patients (13%) died within 30 days after the index procedure. No case of early aortic-related mortality was registered. During a mean follow-up of 31.6 ± 23.1 months (range 1-71), no further death or major adverse event was registered among the remaining 13 alive patients. Re-interventions were performed in three cases (20%). Aneurysm's shrinkage > 5 mm or stability was noted in 10 of the 13 patients who survived the early period after repair. Conclusions: Despite the relative reluctance to use an endograft in an infected area, in our experience the endovascular approach resulted to be feasible, safe, and effective in the treatment of infective aortitis with acute presentation, with acceptable peri-operative and mid-term follow-up outcomes. Further studies are needed to confirm our results.

Physician-Modified Reversed Iliac Branch Device to Prevent Spinal Cord Ischemia in an Urgent Branched Endovascular Aortic Repair.

Repair of pararenal aneurysms poses a challenge, especially in an urgent setting. Despite the minimally invasive nature of the fenestrated/branched endovascular aortic repair, the technique may require extensive coverage of the aorta, increasing the risk of spinal cord ischemia. A 68-year-old man was admitted with a rapid enlargement of an asymptomatic juxtarenal aortic aneurysm. A minimally invasive treatment with an off-the-shelf branched endovascular graft was planned. Before completing the aneurysm exclusion, an angiography highlighted a large lumbar artery, potentially significant for the perfusion of the spinal cord collateral network. Owing to this finding and an unsuccessful placement of the cerebrospinal fluid drainage, the procedure was staged and completed 5 days later using a physician-modified iliac branch device (IBD) for the segmental artery. The device was shortened and reversely loaded to obtain a cranially-oriented branch. A balloon-expandable covered stent was used to connect the retrograde branch (8 mm) to the lumbar artery (4 mm). Pre-discharge computed tomography (CT)-angiography confirmed the vessel patency. No neurological symptoms occurred. The use of a reversely-loaded IBD for segmental artery preservation appears feasible and safe. Intraoperative modification of an iliac branch device during an urgent branched endovascular aortic repair enabled preservation of a potentially critical segmental artery, thus reducing the risk of spinal cord ischemia. This adaptive interventional technique may also offer a strategy for preserving other anatomically significant vessels, such as accessory renal arteries, during complex aortic reconstructions in urgent settings.

Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft

ObjectiveThe aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). MethodsData from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. ResultsOf 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. ConclusionsThe E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.

Is implementation of robotic-assisted procedures in acute care general surgery cost-effective?

Over the past 2 decades, the use and importance of robotic surgery in minimally invasive surgery has increased. Across various surgical specialties, robotic technology has gained popularity through its use of 3D visualization, optimal ergonomic positioning, and precise instrument manipulation. This growing interest has also been seen in acute care surgery, where laparoscopic procedures are used more frequently. Despite the growing popularity of robotic surgery in the acute care surgical realm, there is very little research on the utility of robotics regarding its effects on health outcomes and cost-effectiveness. The current literature indicates some value in utilizing robotic technology in specific urgent procedures, such as cholecystectomies and incarcerated hernia repairs; however, the high cost of robotic surgery was found to be a potential barrier to its widespread use in acute care surgery. This narrative literature review aims to determine the cost-effectiveness of robotic-assisted surgery (RAS) in surgical procedures that are often done in urgent settings: cholecystectomies, inguinal hernia repair, ventral hernia repair, and appendectomies.

Partial Deployment to Save Space for Vessel Cannulation When Treating Complex Aortic Aneurysms with Narrow Paravisceral Lumen Is Also Feasible Using Inner-Branched Pre-Cannulated Endografts.

Introduction: The aim of this paper is to propose a sequential deployment technique for the E-nside off-the-shelf endograft that could potentially enhance target visceral vessel (TVV) cannulation and overstenting in narrow aortic anatomies. Methods: All data regarding patients consecutively treated in two aortic centers with the E-nside graft employing the partial deployment technique were included in the study cohort and analyzed. To execute the procedure with partial endograft deployment, the device should be prepared before insertion by advancing, under fluoroscopy, all four dedicated 400 cm long 0.018″ non-hydrophilic guidewires until their proximal ends reach the cranial graft's edge. Anticipating this guidewire placement prevents the inability to do so once the endograft is partially released, avoiding potentially increased friction inside the constricted pre-loaded microchannels. The endograft is then advanced and deployed in the standard fashion, stopping just after the inner branch outlets are fully expanded. Tip capture is released, and the proximal end of the device is opened. Visceral vessel bridging is completed from an upper access in the desired sequence, and the graft is fully released after revascularizing one or more arteries. Preventing the distal edge of the graft from fully expanding improves visceral vessel cannulation and bridging component advancement, especially when dealing with restricted lumina. Results: A total of 26 patients were treated during the period December 2019-March 2024 with the described approach. Procedure was performed in urgent settings in 14/26 cases. The available lumen was narrower than 24 mm at the origin of at least one target vessel in 11 out of 26 cases performed (42.3%). Technical success was obtained in 24 out of 26 cases (92.3%), with failures being due to TVVs loss. No intraoperative death or surgical conversion was recorded, and no early reintervention was needed in the perioperative period. Clinical success at 30 days was therefore 80.7%. Conclusions: The described technique could be considered effective in saving space outside of the graft, allowing for safe navigation and target vessel cannulation in narrow visceral aortas, similar to what has already been reported for outer-branched endografts.

Complementary Thoracic Endovascular Aortic Repair (TEVAR) after Frozen Elephant Trunk for Residual Type A Aortic Dissection: Perioperative and Mid-Term Outcomes.

Objectives: The aim of this retrospective study was to evaluate the results of complementary TEVAR following the frozen elephant trunk (FET) procedure for patients with residual type A aortic dissection (rTAAD) in terms of technical feasibility, safety and mid-term outcomes. Methods: This was a retrospective single-centre analysis of patients who received TEVAR after FET for rTAAD from January 2012 up to December 2021. The primary endpoint was technical success. Safety parameters included 30-day/in-hospital morbidity and mortality. Furthermore, mid-term clinical and morphological outcomes were evaluated. Results: Among 587 TEVAR procedures, 60 patients (11 with connective tissue disorders) who received TEVAR after FET for rTAAD were identified. The median interval between FET and TEVAR was 28.5 months. Indications for TEVAR after FET were true lumen collapse distal to FET prosthesis (n = 7), dSINE (n = 2), planned completion (n = 13) and aortic diameter progression (n = 38). In forty-seven patients, TEVAR was performed in an elective setting; eight and six patients were operated on in an urgent or emergency setting, respectively. All TEVAR procedures were successfully completed. The 30-day mortality and spinal cord ischemia rates were 1.7%. During a median follow-up of 37 months, two further patients died. Nine patients had to undergo a further aortic intervention: fenestrated stent-graft (n = 3) or open repair of the infrarenal abdominal aorta (n = 6). Conclusions: Complementary TEVAR following FET for rTAAD showed excellent technical success and low perioperative risk, supporting the feasibility and safety of this strategy. Despite the favourable mid-term survival, certain patients might require a further aortic procedure.

Management of inflammatory bowel disease in the emergency setting: the MIBODI international survey and evidence-based practices.

This study aimed to evaluate the impact of the WSES-AAST guidelines in clinical practice and to investigate the knowledge, attitudes, and practices of emergency surgeons in managing the complications of ulcerative colitis (UC) and Crohn's disease (CD). The MIBODI survey is a cross-sectional study among WSES members designed as an international web-based survey, according to the Checklist for Reporting Results of Internet E-Surveys, to collect data on emergency surgeons' knowledge, attitudes, and practices concerning the management of patients presenting with acute complications of CD and UC. The questionnaire was composed of 30 questions divided into five sections: (1) demographic data, (2) primary evaluation, (3) non-operative management, (4) operative management, and (5) perianal sepsis management. Two hundred and forty-two surgeons from 48 countries agreed to participate in the survey. The response rate was 24.2% (242/1000 members on WSES mail list). Emergency surgeons showed high adherence to recommendations for 6 of the 21 assessed items, with a "correct" response rate greater than or equal to 60%, according to WSES-AAST recommendations. Nine critical issues were highlighted, with correct answers at a rate of less than 50%. Inflammatory bowel disease is a complex disease that requires a multidisciplinary approach with close collaboration between gastroenterologists and surgeons. Emergency surgeons play a crucial role in managing complications related to IBD. One year after publication, the MIBODI study showed significant global implementation of the WSES-AAST guidelines in clinical practice, offering an imperative tool in the improved management of IBD in emergency and urgent settings.

Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm.

Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.

Standardized approach for four-fenestrated physician-modified endograft to treat complex abdominal aortic aneurysms using Valiant Captivia

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

Hereditary hemorrhagic telangiectasia diagnosis: A case report

This case report presents a 13-year-old patient with a lung nodule identified on a chest radiograph in the emergency department during an evaluation of knee and side pain after a fall. The patient had nosebleeds, family history of hereditary hemorrhagic telangiectasia (HHT) and after chest computed tomography with angiography, the nodule was defined as a single pulmonary arteriovenous malformation (PAVM). Neither parent nor patient had been evaluated for HHT, an autosomal dominant disease, despite the family history. This patient satisfied the clinical criteria for the diagnosis and had a confirmatory genetic test, which led to diagnosis in mother also. The patient's PAVMs were treated, decreasing the risk of life threatening complications. Diagnosing HHT in children is often delayed or missed, even in families with HHT, as in this case report. Without any physical signs or clinical symptoms, families and healthcare providers often dismiss the possibility of the diagnosis. Children with HHT are at the same risk for complications of stroke, anemia, hypoxemia, heart failure and increased morbidity as adults. It is essential to recognize the importance of family history when evaluating children in primary care and urgent settings, as this patient's diagnosis was delayed 13 years. Awareness of HHT signs and symptoms are essential to early referral to an HHT specialist, for diagnosis and management.

Timing of CHolecystectomy In Severe PAncreatitis (CHISPA): study protocol for a randomized controlled trial

Acute pancreatitis is the recurrent reason for gastrointestinal admission in a clinical urgent setting, it happens secondary to a wide array of pathologies out of which biliary disease stands as...

Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits

ObjectiveCryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated. MethodsThis study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates. ResultsOf 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications. ConclusionsNon-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

Klinički rezultati perkutanog lečenja stenoze na glavnom stablu leve koronarne arterije u akutnom infarktu miokarda

Introduction: Acute myocardial infarction due to left main coronary artery stenosis is a rare, but life-threatening event often accompanied by sudden cardiac death and/or cardiogenic shock. The optimal revascularization strategy for unprotected left main coronary artery disease is the subject of ongoing debate, especially in urgent settings, where immediate optimal acute angiographic result is required to ensure patient survival and improve prognosis. Aim: This study aims to investigate patient characteristics and procedural and clinical variables associated with favorable outcomes of percutaneous treatment. Material and methods: A number of 40 patients undergoing PCI with acute myocardial infarction due to left main coronary artery stenosis were reviewed retrospectively from 1st January 2019 to 21st December 2022. Results: There was a total of 40 patients with a mean age of 70.83 ± 11.415. Cardiogenic shock occurred in 20 (50%) patients. Two patients (5%) died in the catheterization laboratory and 16 (40%) died during hospitalization. Twenty-two patients survived to be discharged; five patients died during the follow-up period. The overall mortality rate was 23 (57.5%). Factors associated with increased mortality included female gender (p = 0.008), cardiogenic shock (p = 0.025) and inotropes (p = 0.000). Conclusion: Acute myocardial infarction caused by left main coronary artery stenosis is complicated by high incidence of cardiogenic shock and mortality. In univariate analysis, cardio-genic shock, female gender and usage of inotropes correlated with death. Emergency PCI provides an important treatment option in these high-risk patients, but mortality remains high.

Detection of monkeypox virus based on a convenient and sensitive single-step RPA-CRISPR/Cas12a strategy.

The global outbreak of monkeypox virus (MPXV) has highlighted the need for rapid molecular diagnostics techniques. In this study, a single-step recombinase polymerase amplification (RPA)-CRISPR/Cas12a system was developed for rapid and sensitive detection of MPXV. The limit of detection of this assay was 1 copy per μL of extracted nucleic acids. A heating lysis method was integrated to further simplify the sample processing workflow and shorten the assay time to 40 min from sample to result. The reaction mixture can be lyophilized to improve its accessibility in resource-limited settings. The analysis results of the proposed single-step RPA-CRISPR/Cas12a assay for clinical MPXV positive and negative samples were 100% consistent with standard PCR assay. These results demonstrate the feasibility and efficiency of this method for rapid and accurate MPXV detection in real-world settings, showcasing its potential utility in urgent and practical settings.

Staging TEVAR after FET — an exception or the rule?

PurposeFrozen elephant trunk (FET) was born as an ideal one-step procedure to treat complex arch and descending thoracic aorta pathology. It was then proved that it frequently needs reintervention, which can often be performed by thoracic endovascular aortic repair (TEVAR) extension since FET provides a safe proximal landing zone. We hereby describe our experience in TEVAR extension after FET, its main indications, technique, and outcomes.MethodsBetween 2007 and 2022, 371 patients underwent FET at our center. Of these, 119 needed TEVAR extension. Some required more than one TEVAR, with a total of 154 procedures. The preoperative characteristics, indications, and outcomes were analyzed retrospectively.ResultsOf 154 TEVAR procedures, 15 were performed in an urgent setting. Mean time from FET to TEVAR was 22,2 ± 28,73 months. Two patients died in the operating room; no others died during the hospital stay. Survival after 1, 2, 5, and 10 years was 96.2%, 93.9%, 90.1%, and 70.5% respectively. There was no statistically significant difference in the rates of TEVAR extension for patients in which a Thoraflex™ vs E-vita™ graft was used, nor for zone 2 vs zone 3 anastomosis and stent length.ConclusionThough TEVAR extension is often required after FET, it is a safe and effective procedure with excellent post-operative outcomes in the short-, mid-, and long-term and allows successful treatment of complex aortic pathologies. Rigorous and specialized follow-up after FET is central to identify the right moment to intervene.

In-depth biological characterization of two black soldier fly anti-Pseudomonas peptides reveals LPS-binding and immunomodulating effects.

As effector molecules of the innate immune system, antimicrobial peptides (AMPs) have gathered substantial interest as a potential future generation of antibiotics. Here, we demonstrate the anti-Pseudomonas activity and lipopolysaccharide (LPS)-binding ability of HC1 and HC10, two cecropin peptides from the black soldier fly (Hermetia Illucens). Both peptides are active against a wide range of Pseudomonas aeruginosa strains, including drug-resistant clinical isolates. Moreover, HC1 and HC10 can bind to lipid A, the toxic center of LPS and reduce the LPS-induced nitric oxide and cytokine production in murine macrophage cells. This suggests that the peptide-LPS binding can also lower the strong inflammatory response associated with P. aeruginosa infections. As the activity of AMPs is often influenced by the presence of salts, we studied the LPS-binding activity of HC1 and HC10 in physiological salt concentrations, revealing a strong decrease in activity. Our research confirmed the early potential of HC1 and HC10 as starting points for anti-Pseudomonas drugs, as well as the need for structural or formulation optimization before further preclinical development can be considered. IMPORTANCE The high mortality and morbidity associated with Pseudomonas aeruginosa infections remain an ongoing challenge in clinical practice that requires urgent action. P. aeruginosa mostly infects immunocompromised individuals, and its prevalence is especially high in urgent care hospital settings. Lipopolysaccharides (LPSs) are outer membrane structures that are responsible for inducing the innate immune cascade upon infection. P. aeruginosa LPS can cause local excessive inflammation, or spread systemically throughout the body, leading to multi-organ failure and septic shock. As antimicrobial resistance rates in P. aeruginosa infections are rising, the research and development of new antimicrobial agents remain indispensable. Especially, antimicrobials that can both kill the bacteria themselves and neutralize their toxins are of great interest in P. aeruginosa research to develop as the next generation of drugs.