Transradial approach for carotid artery stenting: a feasibility study.

BACKGROUND: Carotid artery stenting (CAS) has become accepted as an alternative to carotid endarterectomy for revascularization of the internal carotid artery (ICA) among high risk patients. CAS from the femoral approach can be problematic due to access site complications as well as technical difficulties related to peripheral vascular disease (PVD) and/or anatomical variations of the aortic arch. The purpose of the present study is to evaluate the feasibility of the radial artery as an alternative approach for CAS. METHODS: Forty-two patients (mean age 71 +/- 1, 26 male) underwent CAS. All had a CA stenosis greater than 80% and comorbid conditions increasing the risk of carotid endarterectomy. The target common carotid artery (CCA) was initially cannulated via the radial artery using a 5F Simmons 1 diagnostic catheter which was then advanced to the external CA (ECA) over an extra support 0.014" coronary guidewire. After removing the coronary guidewire, a 0.035" guidewire was advanced into the ECA, and the Simmons 1 was exchanged for a 5F or 6F shuttle sheath and positioned in the distal CCA. In four patients with a bovine aortic arch, the left CCA was accessed with a 5F Amplatz R2 catheter which was then exchanged for a shuttle sheath over a 0.035" guidewire. CAS was performed using standard techniques with weight-based bivalirudin for anticoagulation. RESULTS: CAS was successful in 35/42 (83%) patients, including 28/29 (97%) right CA, 4/5 (80%) bovine left CA, 7/13 (54%) left CA. Mean interventional time was 30 +/- 3 minutes. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a stroke 24 hrs after the procedure with complete resolution of symptoms (Mean NIH stroke scale 2.0 +/- 0.3 before, 1.9 +/- 0.3 after). Median hospital stay was 2 +/- 0.6 days. Inadequate catheter support at the origin of the CCA was the technical cause of failure in the seven unsuccessful cases. CONCLUSION: CAS using the transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions and severe PVD or unfavorable arch anatomy, and among patients with a bovine aortic arch.     

A clinico-epidemiological study of rescuer burns

Rescuer burn is a relatively newer terminology introduced to define the burns sustained by a person attempting to rescue a primary burn victim. Few studies have been published thus far on this peculiar type of burns. Due to the general neglect of the rescuer burns victim and discontinuation of treatment in most cases, once the primary victim dies, the rescuer often ends up in badly infected wounds and has a delayed return to work. A prospective study was conducted at the B J Medical College and Civil Hospital, Ahmedabad from January 2009 to December 2012 on the rescuer burns patients treated in its burns and plastic surgery department. 3074 patients of burns received treatment during the period of study. Of these, 48 patients gave the history of sustaining burns while trying to rescue a burns victim. Male to female ratio of rescuers was approximately 7:1. It was significantly higher as compared to the ratio of 1:0.8 of females to male burn victims observed at our centre (p ≤ 0.01). Average age of the rescuers was higher in males as compared to females but the difference was not significant (p ≥ 0.05). Of the 45 cases of female primary burns victims, male rescuer was husband of the primary victim in 41/45 cases (91.1%), mother was rescuer in three cases (6.6% cases) and sister was rescuer in one case. Though multiple people came to rescue a burns victim, in all cases, it was seen that it was the first rescuer who sustained burns himself or herself. None of the rescuers had any knowledge of the techniques and precautions to be taken while performing a rescue operation irrespective of their education status, indirectly pointing to the lack of any teaching on burns rescue in the school education curriculum.     

Double Filtration During Carotid Artery Stenting Using a Novel Post-Dilation Balloon With Integrated Embolic Protection

Objectives

This study evaluated the safety and performance of the Paladin System, a novel angioplasty balloon with an integrated embolic protection filter designed to increase embolic protection during post-dilation.

Influence of body mass index and weight lifting on bicep brachii muscle and distal bicep tendon stiffness evaluated using ultrasound elastography

Background

There is an increased interest in quantifying and characterizing epicardial fat which has been linked to various cardiovascular diseases such as coronary artery disease and atrial fibrillation. Recently, three-dimensional single-phase Dixon techniques have been used to depict the heart and to quantify the surrounding fat. The purpose of this study was to investigate the merits of a new high-resolution cine 3D Dixon technique for quantification of epicardial adipose tissue and compare it to single-phase 3D Dixon in patients with cardiovascular disease.

Methods

Fifteen patients referred for clinical CMR examination of known or suspected heart disease were scanned on a 1.5 T scanner using single-phase Dixon and cine Dixon. Epicardial fat was segmented by three readers and intra- and inter-observer variability was calculated per slice. Cine Dixon segmentation was performed in the same cardiac phase as single-phase Dixon. Subjective image quality assessment of water and fat images were performed by three readers using a 4-point Likert scale (1 = severe; 2 = significant; 3 = mild; 4 = no blurring of cardiac structures).

Results

Intra-observer variability was excellent for cine Dixon images (ICC = 0.96), and higher than single-phase Dixon (ICC = 0.92). Inter-observer variability was good for cine Dixon (ICC = 0.76) and moderate for single-phase Dixon (ICC = 0.63). The intra-observer measurement error (mean ± standard deviation) per slice for cine was − 0.02 ± 0.51 ml (− 0.08 ± 0.4%), and for single-phase 0.39 ± 0.72 ml (0.18 ± 0.41%). Inter-observer measurement error for cine was 0.46 ± 0.98 ml (0.11 ± 0.46%) and for single-phase 0.42 ± 1.53 ml (0.17 ± 0.47%). Visual scoring of the water image yielded median of 2 (interquartile range = [Q3-Q1] 2–2) for cine and median of 3 (interquartile range = 3–2) for single-phase (P < 0.05) while no significant difference was found for the fat images, both techniques yielding a median of 3 and interquartile range of 3–2.

Conclusion

Cine Dixon can be used to quantify epicardial fat with lower intra- and inter-observer variability compared to standard single-phase Dixon. The time-resolved information provided by the cine acquisition appears to support the delineation of the epicardial adipose tissue depot.

     

1-Year Results From the RANGER II SFA Randomized Trial of the Ranger Drug-Coated Balloon

ObjectivesThis study sought to evaluate the safety and effectiveness of the Ranger drug-coated balloon (DCB) (paclitaxel dose density 2 μg/mm²) for treating superficial femoral artery or proximal popliteal artery lesions.BackgroundPaclitaxel-coated balloon treatment prevents reinterventions, but dose and coating characteristics differ among balloons and necessitate discrete confirmation of safety and effectiveness.MethodsPatients with symptomatic lower limb ischemia (Rutherford classification 2 to 4) were randomized 3:1 to treatment with the Ranger DCB or standard percutaneous transluminal angioplasty (PTA). Twelve-month primary target lesion patency, freedom from major adverse events (i.e., target lesion revascularization, major amputations, death within 1 month of the index procedure), and patient outcomes were analyzed.ResultsMean lesion length was 82.5 ± 48.9 mm for the Ranger DCB group (n = 278) and 79.9 ± 49.3 mm for the control group (n = 98). Ranger DCB was superior to PTA (82.9% [n = 194 of 234] vs. 66.3% [n = 57 of 86]) with observed 12-month primary patency rates yielding a difference of 16.6% (95% confidence interval: 5.5% to 27.7%; p = 0.0013). Noninferior freedom from major adverse events (94.1% [n = 241 of 256] vs. 83.5% [n = 76 of 91]) was demonstrated with a difference of 10.6% (95% confidence interval: 2.5% to 18.8%; noninferiority p < 0.0001). Primary patency rate curves showed significant separation by Kaplan-Meier analysis (log-rank p = 0.0005), with rates of 89.8% and 74.0% estimated at day 365 for the Ranger DCB and PTA cohorts, respectively.ConclusionsThe low-dose Ranger DCB demonstrated significantly better effectiveness than standard PTA through 1 year and a good safety profile. (Ranger? Paclitaxel Coated Balloon vs Standard Balloon Angioplasty [RANGER II SFA]; NCT03064126)     

Oestrogen hormone receptors in focal nodular hyperplasia

Background

The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results.

Objective

The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material).

Methods

Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score.

Results

Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34–66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples.

Conclusions

By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.     

Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars

Purpose

In this study we assessed the clinical efficacy of sub-mucosal injection of ketamine at sub-anesthetic dose of 0.5 mg/kg on post-operative pain, swelling and trismus following surgical extraction of impacted mandibular third molars.

Methods

Forty bilaterally symmetrical impacted mandibular third molars in 20 patients who required surgical removal were included in the study. Within the same individual, one of the sites received a test medication whereas the other site was used as control. All patients received nerve blocks with local anesthetic (2 % lignocaine hydrochloride with 1:80,000 adrenaline); the Test group received sub-mucosal infiltration of 0.5 mg/kg of ketamine hydrochloride (without preservative) around the impacted mandibular third molar and along the incision line, while the Placebo group received normal saline infiltration, 10 min before placement of the incision.

Results

The pain scores on VAS at 30 min, 1, 4, 12 h and 1 day post-operatively was significantly lower in the Test group than in the Placebo group (p < .05). With respect to facial swelling and mouth opening the Test group and Placebo group showed overall no statistically significant difference (p > .05) on the 1st, 3rd and 7th post-operative days.

Conclusion

The sub-mucosal injection of 0.5 mg/kg ketamine administered before surgical removal of impacted mandibular third molars was found to be effective in significantly reducing post-operative pain for the first 24 h.

     

Symptomatic patients have similar outcomes compared with asymptomatic patients after carotid artery stenting with emboli protection

In a single-center cohort of 174 consecutive patients, we sought to evaluate whether the use of emboli protection devices (EPDs) results in equivalent rates of adverse events in symptomatic and asymptomatic patients after carotid artery stenting (CAS) with EPDs. Death or stroke occurred in 3.3% in the symptomatic group and in 3.5% of the asymptomatic group at 30 days (p = NS). At 6 months, there was also no significant difference in the rate of stroke or death between the groups. Unlike surgical revascularization, symptomatic patients did not have a greater risk for stroke and death compared with asymptomatic patients after CAS with EPDs.