Uterine arteriovenous malformation: a case report with proposal for pathogenesis.

Uterine arteriovenous malformation (UAM) is a rare medical condition. Even though UAM can cause abnormal and life-threatening uterine hemorrhage, there is no consensus on the clinical guideline on its treatments, most likely due to its low incidence, unknown etiology, and distinct fertility demands by different patients. Here, we present one elderly woman with uncommon UAM. We first discuss our experience regarding the diagnoses and treatments of UAM and then propose a hypothesis for the pathogenesis of UAM.

Embolize, supercharge, resect: Embolization to enhance hepatic vascularization prior to en-bloc pancreas and arterial resection.

INTRODUCTION: Embolization could increase the resectability of pancreatic tumors by supercharging visceral arterial perfusion prior to pancreatic surgery with arterial en-bloc resection. Its indications, however, are controversial. METHODS: We retrospectively analyzed the results of a single-center database of patients undergoing pancreatic surgery with arterial resection (AR) after preoperative arterial embolization (PAE) to increase hepatic vascular flow and spare arterial reconstruction. RESULTS: PAE was planned in 15 patients with arterial involvement due to pancreatic tumors. Three patients were excluded due to the finding of irresectable disease during surgery. Twelve cases were resected because of pancreatic cancer (10), distal cholangiocarcinoma (1), and pancreatic neuroendocrine tumor (1). Arterial involvement in these cases required embolization of the substitute right hepatic artery (RHA) (5), left hepatic artery (1), and common hepatic artery (CHA) (6) to enhance liver vascularization. Two patients presented migration of the vascular plug after PAE. Six pancreatoduodenectomies and 6 distal pancreatectomies were performed, the latter associated with en-bloc celiac trunk and CHA resection. R0 was achieved in 7 out of 12 patients, and pathological vascular involvement was confirmed in 8. Postoperative complications included one patient who developed gastric ischemia and underwent gastrectomy, and one patient who underwent reoperation for acute cholecystitis with liver abscesses. CONCLUSION: Preoperative arterial embolization before pancreatic surgery with hepatic arterial resection enables surgeons to precondition hepatic vascularization and prevent hepatic ischemia. In addition, this avoids having to perform arterial anastomosis in the presence of pancreatic suture.

Cost Comparison of Prostatic Artery Embolization Between In-Hospital and Outpatient-Based Lab Settings.

Purpose This study aimed to determine the costs associated with prostatic artery embolization (PAE) performed in hospital and outpatient-based lab (OBL) settings. Methods Procedures were performed in similarly equipped procedure suites located within a tertiary hospital or OBL. Time-driven activity-based costing (TDABC) was utilized to calculate procedural costs incurred by the institution. Process maps were created describing personnel, space, equipment, and materials. The time duration of each procedural step was recorded independently by a nurse caring for the patient at the time of the procedure, and mean values were included in our model. Using institutional and publicly available financial data, costs, and capacity cost rates were determined. Results Thirty-seven PAE procedures met inclusion criteria with a mean patient age of 70.4 (+/- 6.7) years and a mean prostate gland size of 129.7 (+/-56.4) cc. Twenty-six procedures were performed within the hospital setting, and 11 procedures were performed within the OBL. Reduction in International Prostate Symptom Score (IPSS) was not significantly different following hospital and OBL procedures (57.2% vs. 82.4%, P = 0.0796). Mean procedural time was not significantly different between the hospital and OBL settings (136.6 vs. 147.3 minutes, P = 0.1893). However, the duration between admission and discharge was significantly longer for procedures performed in a hospital (468.8 vs. 325.4 minutes, P <0.0001). Total costs for hospital-based procedures were marginally higher ($3,858.28 vs. $3,642.67). Conclusion Total PAE cost was similar between the hospital and OBL settings. However, longer periprocedural times for hospital-based procedures and differences in reimbursement may favor the performance of PAE in an OBL setting.

Giant Dissecting Aneurysm of the Internal Carotid Artery in a 35-Year-Old Patient: A Case Report.

Giant dissecting aneurysms of the internal carotid artery are extremely uncommon, particularly in young adults. In this report, we provide a case of a 35-year-old male patient who experienced severe headaches, double vision, paralysis of the left abducens nerve, trigeminal neuralgia, nausea, and vomiting. The cerebral MRI showed an intensely gadolinophilic lesion following the left internal carotid artery route from the petrous canal; it also caused an internal deviation of the cavernous route of the internal carotid artery with a fluid heterogeneous area that pushed the cavernous dura mater (including the Gasser ganglion) on the free cisternal route of the trigeminal nerve. Furthermore, the cerebral angiography revealed a giant dissecting aneurysm at the C2-C4 junction of ICA, anteriorly oriented with perilesional stenoses. The interdisciplinary medical team determined that the most optimal therapeutic strategy would involve coil embolization, and the giant left ICA aneurysm was occluded along with the left ICA, with 15 giant platinum coils. Following the successful intervention, the patient experienced a remarkable clinical outcome, characterized by an immediate reversal of the majority of the symptoms. Although we were not certain of the alleviation of symptoms after the endovascular treatment, fortunately, the results were beyond expectations.

Uterine Arteriovenous Malformations.

Uterine arteriovenous malformations (AVMs) are an abnormal presence of shunts between myometrial arteries and veins within the myometrium that usually occurs after a traumatic event on the uterus and it is often diagnosed after a miscarriage. In this case report, we propone the case of a woman, gravida 3 para 2, admitted at the emergency department presenting deep vaginal bleeding and suspicion of incomplete miscarriage at 11 weeks of pregnancy. The suspect of AVM was made with noninvasive procedure; transvaginal ultrasound examination with the advantage of color Doppler showed a myometrial hypervascular lesion of the posterior wall. Pulsed Doppler permitted the waveform analysis of uterine arteries and three-dimensional sonography with color Doppler and reconstructions clearly showed dilated ad tortuous blood vessels within the contest of the myometrium. Magnetic resonance angiography showed multiple tubular structures with tortuous appearance that confirmed the suspicion of AVM. Uterine artery embolization was performed of the right uterine artery. One month after uterine embolization, the ultrasound control confirmed the complete resolution of the AVM.

Robotic right lower lobectomy for a persistent large pulmonary arteriovenous malformation following repeated coil embolization.

Pulmonary arteriovenous malformations create continuous shunting of unoxygenated blood through the lungs into the systemic circulation. These malformations are asymptomatic if small, but cause serious symptoms as they grow in size. Treatment primarily consists of endovascular embolization; lobectomy is preserved for recurring or endovascularly untreatable cases. We describe a case of a 24-year-old man who was first treated with coil embolization 10 years previously, with complete symptom resolution. However, more recently he noted recurrent exercise intolerance, with shortness of breath and hypoxemia. After repeat re-embolization, a computed tomography scan noted some persistent flow. Given the patient's young age, we considered resection as a definite therapy. The patient underwent an uncomplicated robot-assisted right lower lobectomy. Afterward, his symptoms resolved completely. In selected cases, robotic lobectomy for pulmonary arteriovenous malformation is feasible and safe.

Trash Feet and Mesenteric Ischemia as a Rare Manifestation of a Complicated Abdominal Aortic Aneurysm: A Case Report.

BACKGROUND: Abdominal aortic aneurysms and atheromatous plaques are well-established potential culprits in the development of cholesterol embolization. This embolic phenomenon can result in the occlusion of peripheral arteries in the forefoot or toes, commonly referred to as "trash foot". CASE: A 61-year old patient exhibited severe symptoms and signs of lower limb and mesenteric ischemia, represented clinically by abdominal pain, hematochezia, and bilateral plantar necrotic lesions, attributed to embolization from a previously unknown large infrarenal abdominal aortic aneurysm. Diagnosis was confirmed by performing angio-CT of the abdomen, an angiologic examination, as well as colonoscopy. The patient underwent open surgical repair of the aortic aneurysm and received intravenous prostanoids, resulting in a successful outcome with resolution of bowel ischemia and complete recovery of bilateral foot lesions with no tissue loss. CONCLUSION: Cholesterol embolization syndrome seldom manifests with its complete clinical spectrum. Identifying and addressing the underlying cause is crucial, with a focus on potential abdominal aortic aneurysms. A combined approach involving surgical repair and prostanoid therapy may offer a viable option for patients experiencing severe manifestations.

Initial Experience with the New DERIVO® Mini Embolisation Device for the Treatment of Intracranial Aneurysms.

The aim of this study is to present the outcomes of cerebral aneurysm treatment with the DERIVO® mini Embolisation Device (DMD), which is compatible with microcatheters with 0.021-inch inner diameters. Consecutive patients treated with DMD were identified retrospectively. Patient and aneurysm characteristics, procedural findings, clinical outcomes and follow-up imaging results were evaluated. A total of 44 target aneurysms in 30 patients were treated with DMD. The mean age of the patients was 49.9 (range, 4-77 years). Four patients with five aneurysms presented with acute subarachnoid hemorrhage. The mean aneurysm size was 6.8 mm (range, 1.5-22 mm). In 29 (65.9%) aneurysms, adjunctive devices were used for endovascular treatment. The overall mortality rate was 3.3% and procedure-related mortality was 0%. Overall neurologic morbidity was 6.6% and none of the patients had a permanent sequela secondary to the procedure. The mean clinical follow-up period was 20.9 months (range, 3 days-46 months) and the mean DSA follow-up period was 10.9 months. A total of 37 (84.1%) aneurysms demonstrated total occlusion (Raymond-Roy [RR 1]); 3 (6.8%) aneurysms had a neck remnant or infundibular filling at the origin of the jailed side branch (RR 2), 4 (9.1%) aneurysms had residual aneurysm filling (RR 3). For those aneurysms treated with bare DMD, the total occlusion rate was 73.3% at a mean follow-up of 16.1 months. In this initial clinical single-center experience, DMD had a good safety profile and efficacy comparable with the currently used flow diverters.

Percutaneous preoperative embolization with onyx in the management of a carotid body tumor: A case report.

Carotid body tumors (CBTs) are rare, hypervascular neuroendocrine neoplasms that can lead to significant complications during surgical resection due to the high risk of bleeding. We present the case of a 64-year-old male with a palpable neck mass on the left side, diagnosed as a CBT through imaging studies. Given the tumor's increasing size and rich vascularization, percutaneous preoperative embolization with Onyx under ultrasound and angiographic guide, was performed to minimize intraoperative complications. Forty-eight hours later, the tumor was surgically resected with minimal blood loss and no injury to cranial nerves or the carotid bifurcation.

Preoperative embolization of a solitary bone plasmacytoma of the proximal humerus.

Solitary plasmacytoma of bone (SPB) is a rare plasma cell malignancy that most often presents with localized pain. This case describes a 70-year-old female with a pathologic humeral fracture due to a large, hypervascular SPB. The tumor was assumed to be a metastatic lesion, and preoperative embolization was performed to minimize intraoperative blood loss, followed by tumor debulking and total shoulder arthroplasty. The total estimated blood loss was limited to 100cc, and the patient was returned to baseline functional status with full shoulder range of motion at 6 months postop. Literature on embolization of appendicular plasmacytomas is sparse; however, this case supports its efficacy. We recommend considering preoperative embolization as an adjunctive therapy for all hypervascular bone tumors requiring surgical management, regardless of origin.

Change of skeletal muscle mass in cirrhotic patients with hypersplenism after partial splenic artery embolization.

PURPOSE: Partial splenic artery embolization (PSAE) is an effective procedure for cirrhotic patients with hypersplenism. The aim of our study is to evaluate the effect of PSAE on skeletal muscle, and to identify the predictor for an improvement in skeletal muscle index (SMI) in cirrhotic patients with hypersplenism after PSAE. MATERIALS AND METHODS: 466 cirrhotic patients with hypersplenism underwent PASE between Dec 2013 and Mar 2022. Medical records and CT images of enrolled patients were analyzed. RESULTS: 105 cirrhotic patients with hypersplenism were enrolled. Sarcopenia was observed in 60.00 % (63/105) of these patients, 68.25 % (43/63) of male patients, and 31.75 % (20/63) of female patients. In cirrhotic patients, no significant change in the mean SMI at the third lumbar vertebra (L3) level after PSAE. In patients with sarcopenia, the L3 SMI increased from 36.77 cm2/m2 (baseline) to 43.38 cm2/m2 (P < 0.01), the L3 subcutaneous fat area (SFA) increased from 79.16 cm2 (baseline) to 103.52 cm2 (P < 0.01) at 12-month follow-up after PSAE. In patients without sarcopenia, the L3 SMI decreased from 58.38 cm2/m2 (baseline) to 49.44 cm2/m2 (P < 0.05), the L3 SFA increased from 89.63 cm2 (baseline) to 94.77 cm2 (P > 0.05) at 12-month follow-up after PSAE. Univariate and multivariate analysis demonstrated splenic infarction rate (OR: 0.01, P = 0.0032) and SMI (OR: 0.84, P < 0.001) were independent predictors for an improvement in skeletal muscle in patients with sarcopenia. CONCLUSIONS: In cirrhotic patients with sarcopenia, an improvement in skeletal muscle and fat mass was observed after PSAE; splenic infarction rate and the L3 SMI before PSAE predicted an improvement in skeletal muscle index in patients with sarcopenia after PSAE.

Minimally Invasive Therapies for Knee Osteoarthritis.

Knee osteoarthritis (KOA) is a musculoskeletal disorder characterized by articular cartilage degeneration and chronic inflammation, affecting one in five people over 40 years old. The purpose of this study was to provide an overview of traditional and novel minimally invasive treatment options and role of artificial intelligence (AI) to streamline the diagnostic process of KOA. This literature review provides insights into the mechanisms of action, efficacy, complications, technical approaches, and recommendations to intra-articular injections (corticosteroids, hyaluronic acid, and plate rich plasma), genicular artery embolization (GAE), and genicular nerve ablation (GNA). Overall, there is mixed evidence to support the efficacy of the intra-articular injections that were covered in this study with varying degrees of supported recommendations through formal medical societies. While GAE and GNA are more novel therapeutic options, preliminary evidence supports their efficacy as a potential minimally invasive therapy for patients with moderate to severe KOA. Furthermore, there is evidentiary support for the use of AI to assist clinicians in the diagnosis and potential selection of treatment options for patients with KOA. In conclusion, there are many exciting advancements within the diagnostic and treatment space of KOA.

A case of preoperative embolization for a giant hypervascular pancreatic serous cystic neoplasm in pancreaticoduodenectomy.

BACKGROUND: Preoperative vascular embolization is an effective strategy for managing meningiomas, neck paragangliomas, renal cell carcinomas, and bone metastasis by reducing the intraoperative bleeding volume and operation time. Although hypervascular tumors also occur in the pancreas, preoperative embolization for these tumors is not commonly practiced. We herein present a case of a giant serous cystic neoplasm (SCN) of the pancreas with significant arterial vascularity that was managed with preoperative interventional radiology and subsequently resected via pancreaticoduodenectomy. CASE PRESENTATION: A 60-year-old man presented with an 8-cm hypervascular tumor located at the head of the pancreas, identified as an SCN on pathologic examination. The tumor had increased by 13 mm over 5 years, necessitating surgical intervention. Computed tomography revealed a substantial blood supply to the tumor from the dorsal pancreatic artery and gastroduodenal artery, both branches of the superior mesenteric artery. To mitigate the risk of severe intraoperative bleeding from this giant hypervascular tumor, branches of the dorsal pancreatic artery and gastroduodenal artery were embolized using metallic coils and further secured using a gelatin sponge 1 day prior to pancreatectomy. During the laparotomy, the tumor appeared to have decreased in size, likely because of reduced distension and congestion. Despite significant adhesions to surrounding tissues secondary to prolonged compression and inflammation, the pancreaticoduodenectomy was completed successfully in 5 h and 15 min with blood loss of 763 mL. The patient was discharged on postoperative day 15 without complications. CONCLUSIONS: Preoperative arterial embolization for hypervascular pancreatic tumors might control the risk of massive intraoperative bleeding, contributing to a favorable postoperative outcome. Utilizing interventional radiology for preoperative inflow control is one of the beneficial strategies for pancreatectomy in patients with a giant SCN.

Transcatheter arterial embolization for small-bowel bleeding: technical and clinical outcomes and risk factors for early recurrent bleeding.

Background: This study evaluated the technical and clinical outcomes of transcatheter arterial embolization (TAE) in patients with acute small-bowel bleeding (SBB) and aimed to identify potential risk factors for early recurrent bleeding after TAE. Methods: Thirty-one patients with SBB managed with TAE between January 2006 and December 2021 were included. Technical and clinical success was defined as angiographic occlusion of the bleeding artery and disappearance of clinical or laboratory signs of persistent bleeding without major complications. Complications were classified according to the Society of Interventional Radiology's guidelines. Kaplan-Meier estimates assessed overall survival, and logistic regression models determined risk factors for clinical success and early rebleeding. Results: Technical and clinical success were achieved in 30/31 (97%) and 19 (61%), respectively. Early recurrent bleeding was present in 9 (29%) patients, and was treated by repeat embolization in 4 patients, conversion to surgery in 4, and comfort therapy in 1 patient. TAE-related small bowel ischemia requiring surgery was found in 2 (6.5%) patients. Thirty-day and in-hospital mortality were 19% (6/31) and 23% (7/31), respectively; overall 5-year estimated survival was 60%. Thrombocytopenia and elevated prothrombin time (PT)/activated partial thromboplastin time (aPTT) levels prior to TAE were identified as risk factors for clinical failure (P=0.0026 and P=0.027, respectively), and for residual or early recurrent bleeding (P<0.001 and P=0.01, respectively). Conclusions: TAE is safe and effective for managing severe SBB; however, early recurrent bleeding was found in nearly one third of patients. Thrombocytopenia and elevated PT/aPTT levels were risk factors for early recurrent bleeding.

Telescoping Flow Diverters for the Treatment of Brain Aneurysms: Indications and Outcome.

OBJECTIVE: Few studies have reported the impact of telescoping flow diverters (FDs) in intracranial aneurysm treatment. Our study compared aneurysms treated using telescoping FDs to those treated with a single FD and identified predictors of telescoping. METHODS: This was a single-center retrospective review of a prospectively maintained database of aneurysms treated with FDs between 2011 and 2023. All patients who were treated with FDs for intracranial aneurysms were included in the study. RESULTS: The study comprised 750 patients with 750 aneurysms treated using 871 FDs. The study cohort was divided into 85 patients requiring telescoping FDs and 655 who did not. Rates of hemorrhage (7.1% vs. 1.8%, P < 0.001), symptomatic stroke (5.9% vs. 2.6, P < 0.001), and asymptomatic stroke (1.2% vs. 0.8%, P < 0.001) were significantly higher in the telescoping cohorts. At final follow-up, the rate of nonocclusion (9.8% vs. 5.1%, P = 0.029) and the rate of complete occlusion (88.5% vs. 81.1%, P = 0.029) were significantly higher in the telescoping cohort. On multivariate analysis, fusiform morphology (odds ratio [OR]: 2.4, 95% confidence interval [CI] 1.0-5.0, P = 0.03), increasing aneurysm height (OR: 1.0, 95% CI 1.0-1.1, P= 0.034), and the use of the Pipeline Embolization Device FD (OR: 2.4, 95% CI 1.3-4.4, P = 0.005) were independent predictors of telescoping. CONCLUSIONS: Aneurysms with fusiform morphology, increasing aneurysm height and those that underwent flow diversion using Pipeline Embolization Device had higher odds for telescoping. Significantly higher rates of angiographic occlusion with the use of telescoping FD add to the literature on its efficacy in treating aneurysms of varying morphology.

Mechanical investigation of a Tandem embolization-visualization system for minimally invasive procedures.

Transcatheter arterial embolization is a minimally invasive intervention process in which the blood supply to a tumor or an abnormal area of tissue is blocked. One of the most commonly used embolic agents in clinics is microsphere (MS). In order to understand the flow behavior of microspheres in arteries, it is essential to study their mechanical properties systematically. In this work, calcium-alginate MSs with varying calcium concentrations were synthesized using a coaxial airflow method. Indocyanine green (ICG) was added as a fluorescent dye. The effect of ICG concentration change on microspheres was investigated by studying morphology, imageability, rheology, and swelling behavior. Then the effect of calcium chloride concentration change on microspheres was studied by conducting rheological tests, atomic force microscopy tests, hemolysis assay, and thrombogenicity assay. Results showed that microspheres with higher ICG concentrations have longer lasting fluorescence and lower storage modulus (G'). Higher concentrations of calcium chloride led to higher G', while the local Young's modulus obtained by AFM test was not significantly affected. The MSs with and without ICG showed good hemocompatibility and thrombogenicity.

Efficacy of transarterial embolization using intermittent flow control for tentorial dural arteriovenous fistula presenting as myelopathy: a technical report.

BACKGROUND: Transarterial embolization (TAE) is generally the endovascular treatment of choice for tentorial dural arteriovenous fistula (dAVF). Although flow control of the feeder vessel has been reported to achieve complete shunt blockade, flow control in the absence of ischemia tolerance of ICA as a feeder has not been reported. we present a case in which treatment by Onyx TAE with intermittent flow control of the meningohypophyseal trunk (MHT) as the feeder was successful for a tentorial dAVF presenting with myelopathy without tolerance of ischemia. METHODS: The intermittent flow control is presented for a tentorial dAVF presenting with myelopathy without tolerance for ischemia. An inflation of the balloon in the internal carotid artery was set for 5 minutes, and the Onyx injection was repeated at intervals of at least 2 minutes. Injections and pauses were repeated to allow Onyx to reach the shunt pouch. RESULTS: The patient underwent successful TAE with intermittent flow control for a tentorial dAVF presenting with myelopathy. The disappearance of the shunt was confirmed with gait disturbance resolution postoperatively. CONCLUSION: Intermittent flow control of the MHT using a balloon may be safe and effective for cases showing no tolerance for ischemia.

Efficacy of Tailored Treatment Strategies for Chronic Subdural Hematoma Based on Hematoma Characteristics and Volume: A Retrospective observational Study.

OBJECTIVE: We assessed the effectiveness of a treatment strategy based on hematoma characteristics and volume. METHODS: From September 2022 to December 2023 (the Study period), a two-center retrospective observational study of initial chronic subdural hematoma (CSDH) was performed. The baseline period was from January 2018 to December 2019. Patients were classified into the high and low retreatment rate groups (Groups H and L, respectively). During the Study period, Group H was treated with drainage and middle meningeal artery embolization (MMAE), while Group L was treated with drainage or MMAE alone. During the Baseline period, all the patients were treated with drainage alone. The primary and secondary endpoints were group retreatment rates and severe procedure-related complications requiring surgical intervention and permanent sequelae, respectively. RESULTS: Fifty-two patients were included during the Study period (31 in Group H and 21 in Group L) and 53 during the Baseline period (32 in Group H and 21 in Group L). Three (5.8%) and nine (17.0%) patients required retreatment in the Study and Baseline periods, respectively (p = 0.12). One (3.2%) and nine (28.1%) patients in Group H required retreatment during the Study and Baseline periods, respectively (p = 0.01). Similarly, two patients (9.5%) and no patient in Group L required retreatment during the Study and Baseline periods, respectively (p = 0.49). No severe complications were reported throughout. CONCLUSIONS: CSDH treatment strategies that consider to hematoma volume and characteristics have the potential to identify and reduce treatment rates in cases with high retreatment rates.

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review.

OBJECTIVE: In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity. DATA SOURCES: We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS: Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations. RESULTS: Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria). CONCLUSIONS: Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.