Safety of elective percutaneous peripheral revascularization in outpatients: A 10-year single-center experience

PurposeTo evaluate the safety and feasibility of peripheral percutaneous endovascular procedures in a large group of outpatients with peripheral arterial disease (PAD).Materials and methodsWe retrospectively evaluated all consecutive patients who underwent peripheral transluminal angioplasty (PTA) for PAD of the lower extremities as “Out-Patient Admission Protocol” (OPAP) from January 2005 until December 2015. A total of 498 consecutive patients (305 men and 193 women) with mean age of 66 ± 10 (SD) years (range: 37–90 years) were evaluated. By protocol, patients were expected to be discharged 6 hours after the procedure. Clinical profile, procedure details and technical success were reviewed. Complications, conversion rate, readmission rate and long-term follow-up were evaluated.ResultsNinety one percent of patients (454/498) suffered from claudication. Unilateral femoral access was performed in 75.4% (493/654) of procedures with a 6-French sheath in 80.7% (528/654) of procedures. Balloon PTA alone was performed in 17.3% (148/857) and stent placement in 82.7% (709/857) of treated segments. Technical success of lesion treatment was 98.2% (857/873). Closure devices were used in 55.4% (362/654) of procedures. Conversion and readmission rates were 1.8% (12/654) and 0.6% (4/654), respectively. Long-term follow-up was obtained in 386 target lesions, 5-year restenosis of lesion was 20.5% (79/386).ConclusionAs designed, the OPAP was feasible, safe and effective with very low conversion and complications rates. These results strongly support a larger use of such approaches as routine practice.     

The perineal midsagittal view in male fetuses — pivotal for assessing genitourinary disorders

A wide range of genitourinary pathologies can be diagnosed in utero, from a simple vesicoureteral reflux to a more complex disorder of sexual differentiation. The prognosis and neonatal management of these conditions differ significantly. Evaluation of the fetal perineal anatomy is paramount to making the right diagnosis. The aim of this pictorial essay is to show sonographers how to acquire a perineal midsagittal view in a male fetus, and to demonstrate how this specific view allows assessment of the urethra and penis, to differentiate various genitourinary pathologies.

     

Amniotic fluid beta-endorphin: a prognostic marker for gastroschisis?

Purpose: The aim of this work was to study amniotic fluid [beta ]-endorphin as a potential predictor for postnatal morbidity in gastroschisis. Methods: Beta-endorphin was assayed in 43 amniotic fluid samples from 13 pregnant women with fetal gastroschisis undergoing diagnostic amniocentesis or therapeutic amnioinfusion and compared with 33 controls. Within the gastroschisis group, the authors investigated the relationship between postnatal morbidity and the peak value of amniotic fluid [beta ]-endorphin (AFBE). Results: Ten AFBE values in 6 cases of gastroschisis were above the upper limit of the 95% confidence interval derived from controls. Postnatal morbidity was significantly higher when peak AFBE exceeded 10 [mu ]g/L (n = 4 pregnancies) compared with below 5 [mu ]g/L (n = 9 pregnancies), as shown by mean duration of mechanical ventilation (15.2 v 3 days; P = .01), of parenteral feeding (77 v. 18.7 days; P = .04), and of hospitalization (84 v 32.2 days; P = .04). There was no statistically significant association between postnatal morbidity markers and prenatal dilation of fetal bowel. Conclusions: The most severe cases of gastroschisis are associated with high levels of AFBE. The authors speculate that this fetal hormonal response could result from stress or pain caused by prenatal bowel damage.     

Noninvasive assessment of fetal pulmonary blood flow in experimental pulmonary hypertension in the fetal lamb

The aim of this study was to assess pulmonary arterial blood flow changes induced by the creation of a systemic arteriovenous fistula (120 d gestation) in the fetal lamb using Doppler technique. Doppler echocardiographic assessment of the pulmonary artery blood flow performed 1, 6, and 14 d after surgery showed that mean pulmonary arterial blood flow in the left or right pulmonary artery was 224 +/- 58 mL/min at day 1 in the fistula group, significantly higher than in the control group (113 +/- 22 mL/min; p < 0.01, ANOVA test) whether no difference was found at days 6 and 14. The mean inner diameter of the left pulmonary artery measured on postmortem lung arteriograms compared favorably to the one measured on day 14 at the same level on ultrasound. The mean left pulmonary arterial blood flow, measured at birth on day 14 after surgery, using ultrasonic flow transducer, was not statistically different from the one measured by Doppler on day 14. Our data demonstrate that echocardiography allows accurate assessment of pulmonary arterial blood flow in utero, providing evidence suggesting transient high pulmonary blood flow that did not last >6 d after the creation of a systemic fistula.     

An update on the fetal circulation

The fetal circulation has been an exciting area of study for centuries. The principles which grew from the period of hypotheses have been demonstrated in several animal models. These experiments have shaped the major concept of fetal circulation. More recently, the improvement in ultrasound technology has allowed a non invasive study of the fetal circulation in humans. Although the general schema of the fetal circulation has been confirmed in humans, in some aspects some substantial differences have been demonstrated. They may not only reflect some inter-species differences, but also underscore the limitation of chronically instrumented animal studies.     

Middle cerebral artery Doppler in fetuses with transposition of the great arteries.

OBJECTIVE: A previous anthropometric study has shown that neonates with transposition of the great arteries have a smaller head circumference and intracranial volume, which may be related to a lower oxygen content of blood delivered to the head and upper extremities. The aim of this study was to compare Doppler blood flow velocity waveforms in fetuses with transposition of the great arteries with those in healthy fetuses. METHODS: Doppler blood flow velocimetry was performed in the middle cerebral artery, the umbilical artery, the aorta and the ductus venosus in a consecutive series of 23 fetuses with transposition of the great arteries between 36 and 38 weeks' gestation. The control group consisted of 40 healthy fetuses matched for gestational age. RESULTS: There was no significant difference in pulsatility indices in the umbilical artery, the aorta and the ductus venosus between fetuses with transposition of the great arteries and controls. The median middle cerebral artery pulsatility index in the group with transposition of the great arteries was 1.37 (range, 1.10-2.02) and was significantly lower than that in the control group (median, 1.68; range, 1.46-2.04) (P < 0.001, Mann-Whitney test). CONCLUSIONS: The lower pulsatility indices observed in the middle cerebral artery of fetuses with transposition of the great arteries may reflect a trend towards cerebral vasodilation. This phenomenon could be an indicator of hypoxemia and/or hypercapnia restricted to areas perfused by the preisthmus aorta and be related to the characteristics of the circulation in fetuses with transposition of the great arteries.     

Contribution of three-dimensional volume contrast imaging to the sonographic assessment of the fetal uterus.

OBJECTIVE: To investigate the contribution of volume contrast imaging (VCI) in assessing the fetal uterus in normally developed female fetuses. METHODS: The pelvis of 38 normal female fetuses was examined at 20-22 and 32-34 weeks' gestation using both conventional two-dimensional (2D) ultrasound and VCI on the same transverse or oblique longitudinal view of the fetal pelvis. Two experienced sonographers evaluated the ability of both techniques to image the fetal uterus. Results were compared by kappa index to evaluate the interobserver variability. RESULTS: A clear picture of the fetal uterus was obtained in 50% and 82-87% of the cases at 20-22 weeks' gestation and in 80-85% and 95-100% of the cases at 32-34 weeks' gestation using conventional 2D ultrasound and VCI, respectively. There was moderate to good agreement of uterus visualization between the two observers, with kappa values ranging from 0.43 to 0.65. The lower level of agreement was obtained for conventional 2D ultrasound during the second trimester. CONCLUSIONS: Our results suggest that VCI may be successfully applied to prenatal ultrasonography of the fetal pelvis anatomy. By enhancing the contrast between the intrapelvic organs, VCI provides a clearer picture of the fetal uterus.