Valid Alternative Option Research Articles

Popliteal access for iliofemoral occlusive disease in the office-based catheter laboratory

ObjectivePopliteal access as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study was to evaluate the safety and efficacy of popliteal access for the endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. MethodsFrom October 2018 to October 2023, a total of 1408 interventions for peripheral artery disease were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micropuncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent grafts, aortobifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured perioperatively and at 90 days. Patency was determined clinically, by arterial duplex examination, and by need for reintervention for ≤2 years. ResultsWe performed 27 popliteal access procedures in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in nine. Indications for popliteal access were existing aortoiliac stent graft in 11, aortobifemiliac bypass in 4, noncrossable iliac occlusions in 3, failed antegrade femoral access in 4, flush superficial femoral artery occlusion in 3, and bilateral common femoral artery disease precluding access in 2. Trans-Atlantic Inter-Society Consensus classification preoperatively was B, 4; C, 4; and D, 19. Treatments included atherectomy/balloon angioplasty and stent in 12, balloon angioplasty and stenting in 4, atherectomy/balloon angioplasty in 5, and balloon angioplasty alone in 6. Successful opening of occlusions occurred in 25 of 27 patients (92.5%). No complications or major adverse cardiac events occurred, except one asymptomatic small popliteal arteriovenous fistula. Of the 25 successful procedures, the duplex patency at 3, 6, and 12 months was 19/20 (95%), 11/15 (69.3%), and 11/13 (61%). Rutherford Classification improved from a preoperative value of >4 in 24 of 27 (89%) to a postoperative value of <2 at 1 month in 23 of 23 (100%), at 3 months in 19 of 20 (95%), at 6 months in 11 of 15 (69.3%), and at 12 months in 11 of 13 (61%). Freedom from reintervention at 3 months occurred in 19 of 20 (95%), at 6 months in 13 of 15 (86%), and at 12 months in 12 of 13 (79%). ConclusionsPopliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.

Bilateral Simultaneous Magnetic Resonance-Guided Focused Ultrasound Pallidotomy for Life-Threatening Status Dystonicus.

Invasive treatments like radiofrequency stereotactic lesioning or deep brain stimulation of the globus pallidus internus can resolve drug-resistant status dystonicus (SD). However, these open procedures are not always feasible in patients with SD. The aim was to report the safety and efficacy of simultaneous asleep bilateral transcranial magnetic resonance-guided focused ultrasound (MRgFUS) pallidotomy for life-threatening SD. We performed bilateral simultaneous MRgFUS pallidotomy under general anesthesia in 2 young patients with pantothenate kinase-associated neurodegeneration and GNAO1 encephalopathy. Both patients had medically refractory SD and severe comorbidities contraindicating open surgery. SD resolved at 4 and 12 days after MRgFUS, respectively. Adverse events (intraoperative hypothermia and postoperative facial paralysis) were mild and transient. Bilateral simultaneous MRgFUS pallidotomy under general anesthesia is safe and may be a valid alternative therapeutic option for fragile patients. Further studies are needed to assess long-term efficacy of the procedure.

ARCANGELO: an observational, prospective study with acute coronary syndrome patients undergoing percutaneous coronary intervention who receive cangrelor transitioning to oral P2Y12 inhibitors

Abstract Background The use of oral platelet P2Y12 receptor inhibitors, to reduce the risk of thrombotic complications related to Percutaneous Coronary Intervention (PCI), have some limitations in the acute phase, e.g., the delayed onset of action and lack of bioavailability in critical patients. Cangrelor is the only intravenous P2Y12 inhibitor, which based on its quick onset and offset of action is a valid alternative option for antiplatelet therapy, particularly for patients who are unable to take oral medications or for whom oral administration is not adequate. Notably, during the clinical development program of cangrelor, ticagrelor and prasugrel were not marketed and, therefore, the pivotal studies were conducted only with transitioning to clopidogrel. The aim of ARCANGELO study was the evaluation of the safety and effectiveness of cangrelor when administered to patients with Acute Coronary Syndrome (ACS) undergoing PCI in a real-world setting, including patients who received cangrelor transitioning to either clopidogrel, prasugrel, or ticagrelor. Methods Adult patients eligible to PCI for ACS who received cangrelor and who consented to take part in the study in 28 Italian centers, were followed in the 30 days after PCI. Bleedings, major adverse cardiac events (MACEs), and adverse events were recorded. The primary outcome was the incidence of any bleedings, according to BARC (Bleeding Academic Research Consortium) criteria, at 30 days post-PCI. Results A total of 1,004 patients were enrolled and 995 (99.2%) patients were eligible for analysis. Median (IQR) age was 65 (56-73) years, and 771 (77.5%) patients were males. 597 (59.9%) patients had ST-segment Elevation Myocardial Infarction; 509 (51.2%) patients had multi-vessel vessel coronary artery disease. A radial artery access was used in 926 (93.1%) patients and drug-eluting stents were implanted in almost all patients (n=972, 97.7%). All 995 patients included in the analysis received 30 micrograms/kg by intravenous bolus and 4 micrograms/kg/min by intravenous infusion. 730 patients (73.4%) were then transitioned to ticagrelor, 127 (12.8%) to prasugrel, and 138 (13.9%) to clopidogrel. 52 (5.2%) (95% CI 3.9% - 6.8%) patients experienced at least one bleeding event up to 30 days post-PCI. Five patients (0.5%) experienced at least one BARC type 3-5 (moderate-severe) bleeding (all type 3). Fourteen (1.4%) patients presented with at least one MACEs during observation (6 [0.6%] death, 7 [0.7%] myocardial infarction, 2 [0.2%] stent thrombosis). Six (0.6%) patients experienced at least one Treatment-Emergent Adverse Events related to cangrelor. Conclusions The results of this large real-world evidence study confirm that the use of cangrelor in patients with ACS undergoing PCI and transition strategy to the currently used P2Y12 oral inhibitors is safe and effective in daily practice.

Technical tips and clinical experience with the Nexus Endospan arch branch stent-graft

Aortic arch pathologies are commonly treated by open surgery which is still the gold standard. Patients that are unfit for surgery can be effectively treated mini-invasively with novel endovascular endograft specifically designed for the arch. Endovascular technology has remarkably improved in recent years and is a valid alternative option for the treatment of aortic arch. Available endografts on the market include fenestrated and branched (single, double, or triple). Most endograft designed for the aortic arch are custom-made and production time could be limiting. The aim of this study is to report our experience with the only single branch bi-modular off-the shelf device available on the market specifically designed for aortic arch aneurysms and dissections. We perform endovascular treatment of the arch in a multidisciplinary team together with dedicated anesthesiologist team, interventional cardiologists, and cardiac surgeons. Prior to the implantation of the endograft, a debranching procedure must be made to redirect the blood from brachiocephalic trunk (BCT) to the left common carotid artery and left subclavian artery. A through and through system from the right axillary artery to the femoral artery is required to deploy the main module. The ascending module is delivered over an extra stiff guidewire placed in the left ventricle. Molding of the endografts is performed with kissing balloon in rapid pacing. We performed 8 cases. Six of them came to our attention for residual dissection and has already been treated with ascending aorta replacement. Mean aortic diameter was 63 mm. All patients required complete debranching of the supra-aortic vessel and received a right common carotid -left subclavian artery bypass with reimplantation of the left common carotid artery on the graft. Timing of the debranching was a few days before the endovascular procedure in 76% of cases. Technical success of the endovascular intervention occurred in 100% of cases. In 2 cases the target supra-aortic trunk for the deployment of the main module BCT branch was the left subclavian artery with no adverse event related to this variation. No intraoperative adjunctive maneuvers have been registered, left subclavian artery have been embolized during the procedure in 5 cases. No access complications have been reported. We experienced 1 case of major stroke with permanent neurological impairments that lead to worsening of clinical condition and death at 6 months. No cardiological adverse event have been registered. Two cases of type 2 endoleak have been reported and required reintervention with embolization of the LSA. At 1 year follow-up no aorta-related adverse event has been reported. The use of this off-the-shelf device for the treatment of aortic arch pathologies requiring total debranching of the supra-aortic vessels seems to be safe and effective. Preliminary results are promising despite available data are insufficient and further data collection is mandatory.

The Role of Extra-Operative Cortical Stimulation and Mapping in the Surgical Management of Intracranial Gliomas.

Aggressive resection without compromising the patient's neurological status remains a significant challenge in treating intracranial gliomas. Our current study aims to evaluate the efficacy and safety of extra-operative stimulation and mapping via implanted subdural electrodes with or without depth (EOCSM), offering an alternative approach when awake mapping is contraindicated. Fifty-one patients undergoing EOCSM for glioma resection in our institution formed the sample study of our current retrospective study. We assessed the effectiveness and safety of our approach by measuring the extent of resection and recording the periprocedural complications, respectively. The mean age of our participants was 58 years (±9.4 years). The lesion was usually located on the left side (80.4%) and affected the frontal lobe (51.0%). EOCSM was successful in 94.1% of patients. The stimulation and electrode implantation procedures lasted for a median of 2.0 h and 75 h, respectively. Stimulation-induced seizures and CSF leakage occurred in 13.7% and 5.9% of our cases. The mean extent of resection was 91.6%, whereas transient dysphasia occurred in 21.6% and transient hemiparesis in 5.9% of our patients, respectively. Extraoperative stimulation and mapping constitute a valid alternative mapping option in glioma patients who cannot undergo an awake craniotomy.

Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer in Childbearing Age Women.

Total hysterectomy and bilateral adnexectomy is the standard treatment for atypical endometrial hyperplasia and early-stage endometrial cancer. However, the recommended surgical treatment precludes future pregnancy when these conditions are diagnosed in women in their fertile age. In these patients, fertility-sparing treatment may be feasible if the desire for childbearing is consistent and specific conditions are present. This review summarizes the available evidence on fertility-sparing management for atypical endometrial hyperplasia and early-stage endometrial cancer. Historically, oral progestins have been the mainstay of conservative management for atypical endometrial hyperplasia and stage IA endometrioid endometrial cancer with no myometrial invasion, although there is no consensus on dosage and treatment length. Intrauterine progestin therapy has proved a valid alternative option when oral progestins are not tolerated. GnRH analogs, metformin, and hysteroscopic resection in combination with progestins appear to increase the overall efficacy of the treatment. After a complete response, conception is recommended; alternatively, maintenance therapy with strict follow-up has been proposed to decrease recurrence. The risk of disease progression is not negligible, and clinicians should not overlook the risk of hereditary forms of the disease in young patients, in particular, Lynch syndrome. Hysterectomy is performed once the desire for childbearing desire has been established. The conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer is feasible, provided a strong desire for childbearing and permitting clinical–pathological conditions. However, patients must be aware of the need for a strict follow-up and the risk of progression with a possible consequent worsening of the prognosis. More homogenous and well-designed studies are necessary to standardize and identify the best treatment and follow-up protocols.

Efficacy and Safety of High energy ThuVAP (Thulium laser Vaporization of Prostatic Adenoma) at 200W

BPH is a common condition afflicting the aging male. The aim of our study is to highlight the safety and efficacy of high power (200 Watt) ThuVAP as a valid alternative treatment option for BPH unresponsive to medical therapy and associated with LUTS.

New formulation of the two-dimensional steep-slope shallow water equations. Part I: Theory and analysis

Two-dimensional (2D) depth-averaged shallow water equations (SWE) are widely used to model unsteady free surface flows, such as flooding processes, including those due to dam-break or levee breach. However, the basic hypothesis of small bottom slopes may be far from satisfied in certain practical circumstances, both locally at geometric singularities and even in wide portions of the floodable area, such as in mountain regions. In these cases, the classic 2D SWE might provide inaccurate results, and the steep-slope shallow water equations (SSSWE), in which the restriction of small bottom slopes is relaxed, are a valid alternative modeling option. However, different 2D formulations of this set of equations can be found in the geophysical flow literature, in both global horizontally-oriented and local bottom-oriented coordinate systems. In this paper, a new SSSWE model is presented in which water depth is defined along the vertical direction and flow velocity is assumed parallel to the bottom surface. This choice of the dependent variables combines the advantages of considering the flow velocity parallel to the bottom, as can be expected in gradually varied shallow flow, and handling vertical water depths consistent with elevation data, usually available as digital terrain models. The pressure distribution is assumed linear along the vertical direction and flow curvature effects are neglected. A new formulation of the 2D depth-averaged SSSWE is derived, in which the two dynamic equations represent momentum balances along two spatial directions parallel to the bottom, whose horizontal projections are parallel to two fixed orthogonal coordinate directions. The analysis of the mathematical properties of the new SSSWE equations shows that they are strictly hyperbolic for wet bed conditions and reduce to the conventional 2D SWE when bottom slopes are small. Finally, it is shown that the SSSWE predict a slower flow compared with the conventional SWE in the theoretical case of a 1D dam-break on a frictionless channel with fixed slope. The capabilities of the proposed model are demonstrated in a companion paper on the basis of numerical and experimental tests.

Kentos: Socio-ecologies of care

What is the relation of humanity to the ‘rest of nature’? Situated in the epoch of the Anthropocene and as concerns about climate emergency dramatically rise, the paper looks beyond the human/nature ontological separation and narratives of domination, in order to investigate the possibility of alternative worldviews and practices, instrumental for socio-ecological repair. Kentos, deriving from the greek verb kentaw (embroider or sting), describes the harvest practice of mastiha tree, which grows solely on Chios island. In the precision of the manual labour and the rituality of Kentos, one can read beyond pure production, a relationship of mutuality and a socio-ecological bond unfolding between human bodies, trees and their environment. The paper revisits the mastiha landscapes of Chios island, at North Aegean in Greece and narrates the story of relations that have occurred between humans and a tree native to the island, the Pistacia lentiscus var. Chia. It unpacks this socio-ecological bond and its various social, political and economic extensions, investigating how this interspecies relation has operated in history as a productive force and how it has survived in the present time, entangled in capitalist flows, climatic and urban pressures. The aim is to explore knowledge latent in interspecies relations that occurre in territories entangled in capitalist processes of extended urbanisation. Gathering this knowledge aims at informing alternative concepts and strategies for dealing with the contemporary socio-ecological challenges. The paper employs a methodology of relational thinking: it problematises and retracts strict ontological boundaries between human and ‘the rest of Nature’. By doing so it reveals a whole new space of relations between species and sets for an exploration of the relations that we encounter there. This space is examined and conceptualised through qualitative ethnographic work, analysis of documentary sources, oral history and secondary sources that have captured intentionally or unintentionally facets of the socio-ecological bond. Concluding, the paper identifies a socio-ecology of care nested in interspecies relations. It reveales care as a latent interspecies practice, as situated knowledge, as a more-than-human collective, and as an intrinsic value of reciprocity between forms of life, within and beyond capitalism, generating alternative socio-political formations and alternative vision. The paper ends with a proposition: care is a choice, a valid alternative option for design space, strategy and practice to re-engage productively with the ‘rest of nature’, material and living world.

Numerical Weather Predictions and Re-Analysis as Input for Lidar Inversions: Assessment of the Impact on Optical Products

The atmospheric molecular number density can be obtained from atmospheric temperature and pressure profiles and is a significant input parameter for the inversion of lidar measurements. When measurements of vertical profiles of temperature and pressure are not available, atmospheric models are typically considered a valid alternative option. This paper investigates the influence of different atmospheric models (forecast and reanalysis) on the retrieval of aerosol optical properties (extinction and backscatter coefficients) by applying Raman and elastic-only methods to lidar measurements, to assess their use in lidar data processing. In general, reanalyzes are more accurate than forecasts, but, typically, they are not delivered in time for allowing near-real-time lidar data analysis. However, near-real-time observation is crucial for real-time monitoring of the environment and meteorological studies. The forecast models used in the paper are provided by the Integrated Forecasting System operated by the European Centre for Medium-Range Weather Forecasts (IFS_ECMWF) and the Global Data Assimilation System (GDAS), whereas the reanalysis model is obtained from the fifth-generation European Centre for Medium-Range Weather Forecasts ReAnalysis v5 (ERA5). The lidar dataset consists of measurements collected from four European Aerosol Research Lidar Network (EARLINET) stations during two intensive measurement campaigns and includes more than 200 cases at wavelengths of 355 nm, 532 nm, and 1064 nm. We present and discuss the results and influence of the forecast and reanalysis models in terms of deviations of the derived aerosol optical properties. The results show that the mean relative deviation in molecular number density is always below ±3%, while larger deviations are shown in the derived aerosol optical properties, and the size of the deviation depends on the retrieval method together with the different wavelengths. In general, the aerosol extinction coefficient retrieval is more dependent on the model used than the aerosol backscatter retrievals are. The larger influence on the extinction retrieval is mainly related to the deviation in the gradient of the temperature profile provided by forecast and reanalysis models rather than the absolute deviation of the molecular number density. We found that deviations in extinction were within ±5%, with a probability of 83% at 355 nm and 60% at 532 nm. Moreover, for aerosol backscatter coefficient retrievals, different models can have a larger impact when the backscatter coefficient is retrieved with the elastic method than when the backscatter coefficient is calculated using the Raman method at both 355 nm and 532 nm. In addition, the atmospheric aerosol load can also influence the deviations in the aerosol extinction and backscatter coefficients, showing a larger impact under low aerosol loading scenarios.

Current Evidence in Migraine Surgery: A Systematic Review.

Migraine headache is a widespread neurovascular disorder with an enormous social and economic impact. A subgroup of patients cannot be managed with pharmacological therapy. Although surgical decompression of extracranial sensory nerves has been proposed as a valid alternative treatment option, the medical community remains reluctant to accept it. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. An electronic search was performed in September 2020 on PubMed, ScienceDirect, CENTRAL, and Google Scholar databases for original articles reporting outcomes on migraine surgery. The search strategy revealed a total of 922 studies, of which 52 were included in the review. Significant improvement was reported in 58.3% to 100% and complete elimination in 8.3% to 86.8% of patients across studies. No major complications were reported. This systematic review demonstrates that migraine surgery is an effective and safe procedure, with a positive impact in patients' quality of life and a reduction in long-term costs. There is considerable scientific evidence suggesting extracranial migraine surgery is an effective and safe procedure. This surgery should be considered in properly selected migraineurs refractory to medical treatment.

Immunoglobulin therapy in chronic inflammatory demyelinating polyneuropathy: Intravenous versus subcutaneous administration

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired sensory-motor neuropathy with autoimmune pathogenesis. First line treatments include corticosteroids, plasmapheresis, and immunoglobulin therapy. The classic form of immunoglobulin administration is intravenous, however subcutaneous immunoglobulin (SCIG) therapy became a valid alternative option especially for maintenance therapy. Cross-sectional study to compare long-term response to intravenous immunoglobulin (IVIG) and SCIG.

Personalized External Aortic Root Support (PEARS) for Aortic Root Aneurysm

The Personalized External Aortic Root Support (PEARS) procedure offers a novel alternative to traditional surgical options for aortic root aneurysms in patients with connective tissue disorders and neo-aortic root dilatation following the arterial switch or Ross procedures. It has a lower biological insult than conventional surgical management with shorter operating times and avoidance of cardiopulmonary bypass and cardioplegic arrest in most cases. The patient's own valve, root architecture, and blood to vessel wall interface are maintained. Avoidance of mechanical valve replacement negates the requirement for anticoagulation which is especially beneficial in young patients. This article aims to describe the key principles and operative steps for implanting the PEARS device. We describe the technical steps applicable to all PEARS implants and have included our tips and tricks at each stage. We consider PEARS to be a valid alternative therapeutic option for surgical teams managing patients with aortopathies.

Concentrated Growth Factors vs. Leukocyte-and-Platelet-Rich Fibrin for Enhancing Postextraction Socket Healing. A Longitudinal Comparative Study

Platelet concentrates (PCs) have been used for over 20 years in dentistry, as an adjunct to oral surgery procedures, to improve hard and soft tissue healing and control postoperative symptoms. Among various PCs, Leukocyte and Platelet-Rich Fibrin (L-PRF) has become very popular due to its excellent cost-effectiveness ratio, and to the simple preparation protocol, but comparative clinical studies with other PCs are lacking. The aim of this split-mouth cohort study was to evaluate the effect of Concentrated Growth Factors (CGF), a recently introduced PC, as compared to L-PRF for enhancing post-extraction socket healing. Methods: Patients in need of bilateral tooth extractions were included. Each side was treated with either CGF or L-PRF. Pain, socket closure and healing index were the main outcomes. Results: Forty-five patients (24 women), aged 60.52 ± 11.75 years (range 37–87 years) were treated. No significant difference in outcomes was found, except for Pain at day 1 (p &lt; 0.001) and socket closure in the vestibulo-palatal/lingual dimension at day 7 post-extraction (p = 0.04), both in favor of CGF. Conclusions: based on the present results, CGF proved to be as effective and safe as L-PRF, representing a valid alternative option for improving alveolar socket healing and reducing postoperative discomfort.

SURG-09. EXTRAOPERATIVE CORTICAL MAPPING VIA IMPLANTED SUBDURAL AND DEPTH ELECTRODES FOR MAXIMIZING ELOQUENT AREA GLIOMA RESECTION

Abstract OBJECTIVE Aggressive, even supramarginal, resection without compromising the neurological status of the patient remains a great challenge in the management of glioma cases. Accurate cortical and subcortical functional mapping allows more radical glioma resection. Numerous imaging, electrophysiological, and hybrid methodologies have been employed in the cortical mapping of patients with gliomas in eloquent areas. Despite the recent advances of these non-invasive modalities, direct electrical cortical and subcortical stimulation and mapping through an awake craniotomy remains the gold standard for maximal glioma resection and preservation of eloquent cortex functions. Extraoperative stimulation and mapping via implanted subdural and/or depth electrodes may be a valid alternative mapping method in these cases that an awake procedure is not feasible. The role of this mapping method is examined in our current study. MATERIAL &amp; METHODS In a retrospective study, 51 patients undergoing extraoperative stimulation and mapping for glioma resection were included. The demographic data, the clinical characteristics, the stimulation parameters and complications, the extent of resection, the perioperative complications, and the tumor histological grade were analyzed. Shapiro-Wilk test, as well as uni- and multi-variate regression analysis was used for our statistical analysis. RESULTS The mean age of our participants was 58 (SD: 9.4) years. The location of the glioma was on the left side in 80.4%, while the frontal lobe was affected in 51.0%. Extraoperative cortical and subcortical stimulation and mapping was successful in 94.1%. The median stimulation procedure was 2.0 hours, while the median implantation time was 72 hours. Stimulation-induced seizures occurred in 13.7%, while CSF leakage in 5.9% of our cases. The mean extent of resection was 91.6%, while transient dysphasia occurred in 21.6%, and transient hemiparesis in 5.9% of our cases. CONCLUSIONS Extraoperative stimulation and mapping constitutes a valid alternative mapping option in glioma patients, who cannot undergo an awake craniotomy.

Outcome of peripheral blood allogeneic hematopoietic stem cell transplantation as a treatment option in patients with severe aplastic anemia between 40 and 50 years

The frontline treatment for patients younger than 40 years with severe aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen-identical sibling donor. However, in patients with severe AA who are older than 40 years, allogeneic HSCT has been found to be associated with increased treatment-related mortality and toxicity, even when matched sibling donors are used. We report our institutional experience with allogeneic HSCT in patients with severe AA between 40 and 50 years. A total of 19 patients with severe AA were included in the study. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan–Meier method. The mean age of patients at the time of transplant was 43.79 years, and 57.9% were male. The mortality rate was 36.8%, attributed to infection (10.5%), relapse (15.8%), and renal failure (5.3%) in all cases. Acute graft-versus-host disease (GVHD) occurred in five patients (26.3%), and chronic GVHD occurred in two patients (10.5%). The 5-year OS was 62% and the 5-year DFS was 52%. We found that the patient's age, platelet level prior to transplantation, and the number of CD3 cells infused for each transplant were independent prognostic factors for OS, and the age and sex of the patient, graft rejection, and platelet level prior to transplantation were significant prognostic factors associated with DFS. We recommend that immunosuppressive therapy be considered as a first-line treatment in patients with severe AA who are older than 40 years. Allogeneic HSCT can be considered a valid alternative option in patients whose suppression therapy fails.

Microbiological analysis of autologous bone particles obtained by low-speed drilling and treated with different decontamination agents

The aim of this study was to compare the effectiveness of three agents – two antibiotics (amoxicillin and clindamycin) and an antiseptic (chlorhexidine) – to decontaminate bone grafts obtained by low-speed drilling. The study included 248 bone tissue samples harvested from 62 patients by low-speed drilling before dental implant placement. Each of four samples obtained from every patient was dropped, using a sterile instrument, into a sterile tube containing a 500-μl solution of 400μg/mL amoxicillin, 150μg/mL clindamycin, 0.12% chlorhexidine, or physiological saline for 1min. The number of colony-forming units (CFU) was determined at 48h of culture. The use of clindamycin, amoxicillin, or chlorhexidine as decontaminant for 1min significantly reduced the CFU count when compared to physiological saline (control agent). In both anaerobic and CO2-rich atmospheres, significant differences in CFU/mL were found between the control and chlorhexidine groups (P<0.001), control and amoxicillin groups (P<0.001), control and clindamycin groups (P<0.001), chlorhexidine and amoxicillin groups (P<0.0001), and chlorhexidine and clindamycin groups (P<0.0001). In conclusion, clindamycin had the highest decontaminating effect on bone particles obtained by low-speed drilling, followed by chlorhexidine and amoxicillin. Clindamycin may therefore be a valid alternative option for the routine decontamination of intraoral bone grafts.

VMAT partial-breast irradiation: acute toxicity of hypofractionated schedules of 30Gy in five daily fractions.

To report acute toxicities in breast cancer (BC) patients (pts) recruited in a prospective trial and treated with accelerated partial-breast irradiation (APBI) using Volumetric Modulated Arc Therapy (VMAT) delivered with a hypofractionated schedule. From March 2014 to June 2019, pts with early-stage BC (Stage I), who underwent breast conservative surgery (BCS), were recruited in a prospective study started at the National Cancer Institute of Milan. Pts received APBI with a hypofractionated schedule of 30Gy in five daily fractions. Radiotherapy treatment (RT) was delivered using VMAT. Acute toxicity was assessed according to RTOG/EORTC criteria at the end of RT. Between March 2014 and June 2019, 151 pts were enrolled in this study. 79 Pts had right-side and 72 had left-side breast cancer. Median age was 69 (range 43-92). All pts presented with pathological stage IA BC, molecular classification was Luminal A in 128/151 (85%) and Luminal B in 23/151 (15%) cases. Acute toxicity, assessed at the end of RT, consisted of G1 erythema in 37/151 (24. 5%) pts and skin toxicities higher than G1, did not occur. Fibrosis G1 and G2 were reported in 41/151 (27. 1%) pts and in 2/151 pts (1. 3%), respectively. Edema G1 occurred in 8/151 (5. 3%) pts and asthenia G1 occurred in 1/151 (0. 6%) pts. APBI with VMAT proved to be feasible and can be a valid alternative treatment option after BCS in selected early breast cancer pts according to ASTRO guidelines. A longer follow-up is needed to assess late toxicity.

Percutaneous left atrial appendage closure, a safe alternative to anticoagulation for patients with nonvalvular atrial fibrillation and end-stage renal disease on hemodialysis: A single center experience.

The evidence about the effectiveness and safety of oral anticoagulation in patients on hemodialysis is conflicting and scarce. Percutaneous left atrial appendage occlusion (LAAO) has demonstrated to be a valid alternative therapeutic option for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study is to present the outcomes of percutaneous LAAO in patients with end-stage renal disease (ESRD) on hemodialysis and NVAF in our center. We conducteda retrospective review of clinical records, demographics, LAAO procedure, complications, and outcomes of patients with NVAF and ESRD on hemodialysis who underwent a percutaneous LAAO in our center between January 2017 and January 2019. In the period of the study, eight patients with ESRD on hemodialysis underwent a percutaneous LAAO in our center. The overall mean age was 67.5years (range 56-81; SD±7.2). All patients had permanent NVAF. The total mean dialysis duration was 8.49years (range 0.83-14.8; SD±6.2). The mean CHA2DS2-VASc and HAS-BLED scores were high (4.75 [SD±1.16] and 4.62 [SD±0.91], respectively). All patients had history of a major hemorrhagic event (BARC Score ≥3). Most patients (n=6) showed left ventricular hypertrophy, and the average LVEF was 54% (SD±6.5). All devices were implanted successfully. Postprocedural antithrombotic regimen prescribed was based on antiplatelet therapy. No deaths, cardioembolic events, or major bleeding (according to the BARC scale) were reported during a mean follow-up of 14.24months (SD±9.44). Percutaneous LAAO could be of particular interest in patients with NVAF and CKD in hemodialysis. Further studies will be necessary to confirm this hypothesis.

Safety and Efficacy of Infraclavicular Arterio-arterial Chest Wall Prosthetic Loop Graft for Hemodialysis Access. A Review of 45 Patients

Introduction: Increase the need for hemodialysis (HD) due to concomitant increase incidence of nephropathic disease in association with increase in patients' life expectancy in the last three decades, makes it necessary to establish secondary or tertiary dialysis access to overcome exhausted peripheral veins and central venous occlusion.The increase of patients' life expectancy, with the limited durability of these angioaccesses, increases the demand to repeat fistula construction at different upper extremity levels (wrist, forearm, upper arm) and can ultimately result in exhaustion of autogenous AVF.(3) Methods: We conducted an analysis of prospectively collected data over a 3-year period in between December 2014 and December 2017 for 45 patients (32 men, 13 women) with ESRD who underwent infraclavicular arterio-arterial chest wall prosthetic graft procedures as a permanent vascular access for hemodialysis. After the local hospital’s ethical and scientific committee approved the study protocol, patients were enrolled at Vascular Surgery Unit, Benha University/Department of Surgery, Vascular Surgery Department, Nile Insurance Hospital & Vascular Surgery Department, Helwan University. An IAALG procedure was indicated only for patients who had no suitable superficial cephalic and basilic veins for an AVF and who belonged to one of the following indication:1.Cardiac insufficiency that was refractory to medical therapy confirmed by echocardiography based ejection fraction ≤ 40%.2.The unsuitability of large six deep veins (the subclavian, internal jugular and femoral veins). A vein was considered unsuitable when an occlusion or high-grade long stenosis (<70% in diameter, >4 cm long) of the venous outflow was detected and could not be treated by any interventions.3.Patients with at least one patent central vein that should be preserved as bailout access for an emergency central venous catheter (CVC). Results: The primary patency rates were 100%, 97.7%, 93%, 77.5% and 73.7% at 6, 9, 12, 18, and 24 months, respectively. The secondary patency was 100%, 88.7%, and 66.6% at 6, 9, and 12 months, respectively, after successful thrombectomy in nine patients. There were 20 (44.4%) secondary variable procedures performed during follow-up period Eighteen (40%) patients required 20 secondary procedures due to complications. The most common complication was graft thrombosis; it occurred in 11 patients (24.4%), surgical thrombectomy done in 9 (20%) patients, the other two thrombosed grafts were secondary to late graft infection that necessitate grafts removal. Puncture site aneurysm occurred in 7 cases (15.6%) with no procedure related mortality or limb threatened conditions were documented in our study. Conclusion: our case study reports reasonable mid-term patency and complications associated with this pattern of vascular access show that Infraclavicular arterio-arterial axillary loop grafts are a valid alternative option for complex patients. We advocate the use of this technique in patients with exhausted all vascular access possibilities in both upper extremities with central venous obstruction. We also indicate it in case of patients with cardiac insufficiency that could not tolerate long-term hemodynamic effect of arterio-venous fistula / graft.