Direct discharge of patients with simple stable musculoskeletal injuries as an alternative to routine follow-up: a systematic review of the current literature.

PURPOSE: There is growing evidence that patients with certain simple stable musculoskeletal injuries can be discharged directly from the Emergency Department (ED), without compromising patient outcome and experience. This study aims to review the literature on the effects of direct discharge (DD) of simple stable musculoskeletal injuries, regarding healthcare utilization, costs, patient outcome and experience. METHODS: A systematic review was performed in Medline, Embase, CINAHL, Cochrane Library and Web of Science using PRISMA guidelines. Comparative and non-comparative studies on DD of simple stable musculoskeletal injuries from the ED in an adult/paediatric/mixed population were included if reporting ≥ 1 of: (1) logistic outcomes: DD rate (proportion of patients discharged directly); number of follow-up appointments; DD return rate; (2) costs; (3) patient outcomes/experiences: functional outcome; treatment satisfaction; adverse outcomes; other. RESULTS: Twenty-six studies were included (92% conducted in the UK). Seven studies (27%) assessed functional outcome, nine (35%) treatment satisfaction, and ten (38%) adverse outcomes. A large proportion of studies defined DD eligibility criteria as injuries being minor/simple/stable, without further detail. ED DD rate was 26.7-59.5%. Mean number of follow-up appointments was 1.00-2.08 pre-DD, vs. 0.00-0.33 post-DD. Return rate was 0.0-19.4%. Costs per patient were reduced by €69-€210 (ranging from - 38.0 to - 96.6%) post-DD. Functional outcome and treatment satisfaction levels were 'equal' or 'better' (comparative studies), and 'high' (non-comparative studies), post-DD. Adverse outcomes were low and comparable. CONCLUSIONS: This systematic review supports the idea that DD of simple stable musculoskeletal injuries from the ED provides an opportunity to reduce healthcare utilization and costs without compromising patient outcomes/experiences. To improve comparability and facilitate implementation/external validation of DD, future studies should provide detailed DD eligibility criteria, and use a standard set of outcomes. Systematic review registration number: 120779, date of first registration: 12/02/2019.

High sensitivity 10Gb/s Si photonic receiver based on a low-voltage waveguide-coupled Ge avalanche photodetector.

We demonstrate low-voltage germanium waveguide avalanche photodetectors (APDs) with a gain × bandwidth product above 100GHz. A photonic receiver based on such a Ge APD, including a 0.13µm SiGe BiCMOS low-noise trans-impedance amplifier and a limiting amplifier, is realized. A 5.8dB sensitivity improvement is demonstrated at -5.9V bias at an avalanche gain of 6 through bit error ratio measurements. The absolute sensitivity in avalanche mode is -23.4dBm and -24.4dBm at a bit error ratio of 1 × 10(-12) and 1 × 10(-9) respectively.

Clinical and epidemiological assessment concerning hybrid revascularization techniques in the treatment of multilevel arterial occlusive disease.

UNLABELLED: Aim of the study was to report a novel hybrid technique for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the combined (hybrid) treatment, consisting of endovascular intervention and classical surgical intervention on the same vascular axis seems to be the most indicated treatment in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: We have performed a non-randomized study during a 44-month period (January 2010 - September 2013) in a number of 94 patients treated by hybrid revascularization techniques. All the patients included in the study have been post-surgically surveyed at well established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT or MR Angiography. RESULTS: The 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 58.69%, 68.42%, and 62.06%, respectively; the 12 months primary patency was 45.65%, 57.89%, and 34.48%, respectively. Clinical improvement has been noticed in 83 patients (88.29%). There have been registered 19 amputations (20.21% of the cases): 11 majors (thigh and below the knee), representing 11.7% of the total number of cases and 8 minors (toe or transmetatarsal), representing 8.51% of the total number of cases. The amputation-free survival period ranged between 7 days and 24 months, with an average of 7.66 months. CONCLUSIONS: The hybrid techniques are a feasible option for the multilevel arterial disease, with favorable patency and limb salvage rates.

Which is currently the best strategy for treatment of SFA in-stent restenosis?

Stents have been created to prevent vessel recoil after percutaneous transluminal angioplasty (PTA). Despite the evolution in stent design, intimal hyperplasia and stent fractures and the resulting in-stent restenosis (ISR) still occur. Different strategies to treat ISR have been described with variable results in patency rates in the short and the long-term. PTA only in the treatment of ISR showed high procedural success, but the mid and long-term patency rates were very disappointing. Atherectomy devices have showed same insufficient results. If stent fracture is the cause of the ISR, the fracture has to be overstent. The best two options are covered stents and drug eluting stents (DES). Drug eluting devices like DES and drug eluting balloons (DEBs) showed promising results, with patency rates up to over 90% after one year. DEBs have the advantage of leaving nothing behind. Combined treatment of ISR with atherectomy and DEB has a similar good result. Endovascular brachytherapy showed high patency rates after one year but this technique is limited due to the time-consuming nature of the procedure, complex radiation safety measurements, and staffing requirements. Overall drug-eluting devices are emerging as the best treatment of SFA ISR with patency rates over 90% after 2 years.

Popliteal artery aneurysm: when open, when endo?

The purpose of this article was to obtain a more clear view in the management of popliteal artery aneurysms (PAAs). When do we need to treat it and how is it best treated? After going through multiple review articles and case reports concerning this matter, we came to the following conclusions. Repair of a PAA is indicated when it reaches a postero-anterior diameter of 3 cm (at higher risk for thrombosis) or becomes symptomatic (mild claudication or severe ischemic symptoms). Whether the repair is then performed in an endovascular (Endovascular repair) or open way (Open repair), depends on the personal experience and clinical evaluation of the surgeon.

Spontaneous rupture of an aneurysm of the right subclavian artery as a first presentation of Ehlers Danlos syndrome in a 15-year old boy.

We report a case of a spontaneous rupture of a right subclavian aneurysm in a 15 year-old patient. This ruptured aneurysm was successfully treated in an endovascular manner by placing a covered stent-graft in the right subclavian artery via right brachial access. Subsequent work-up by skin biopsy and fibroblast culture and by DNA-screening revealed the diagnosis of Ehlers Danlos type IV. Meanwhile, the patient developed twice a spontaneous pneumothorax, treated with thoracoscopic pleurodesis. This article provides a clear overview of the clinical and genetic characteristics of a case of Ehlers Danlos type IV and illustrates the importance of avoiding surgery in patients with connective tissue disease because of the high risk of perioperative complications.

New devices for a better endovascular approach.

The endovascular approach has known a great evolution in terms of vessel patency and treatment possibilities. Longer and more complex lesions with a difficult anatomy can be addressed by a range of endovascular tools. However, to maintain the patency of the treated lesion is the true challenge. In order to fulfill these long-term expectations, newer devices have been developed. The drug-coated balloon combines local drug uptake with no residual material after treatment. To maintain patency and prevent recoil of the arterial wall, the drug-eluting stent has been created to offer stent support with an antiproliferative drug. The main drawbacks of the drug-coated balloon and the drug-eluting stent are being addressed by the drug-eluting absorbable scaffold. The initial scaffolding support in combination with the drug release during a prolonged period, poses the same advantages while the scaffold is being metabolized over time. This continuing evolution in endovascular tools paves the way to an endovascular treatment for the majority of peripheral artery diseases.

Drug-eluting technologies in femoral artery lesions.

The treatment of femoropopliteal lesions has known an important evolution in the last years. An important limitation of current endovascular therapy remains the occurrence of restenosis. In order to minimize restenosis rates, drug eluting technologies are evolving. The use of drug-eluting stents (DES) in coronary arteries shows beneficial results, leading to investigation of DES in femoropopliteal arteries. In this article, we give an overview of current available data on treatment with drug eluting technologies in the superficial femoral artery (SFA). This paper summarizes also the current available data of the use of drug-coated balloons (DCB) in the femoropopliteal tract. Currently, no data are available on the use of DCB in long lesions. A drug eluting bioresorbable scaffold seems to be very promising in coronary arteries. The transfer to the peripheral area is nowadays ongoing. Which technique and device for which lesion and patient requires further investigation to build up a real evidence based SFA treatment strategy.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Refining stent technologies for femoral interventions.

Stents were created as a mechanical scaffold to prevent vessel recoil and luminal renarrowing after percutaneous transluminal angioplasty (PTA). In femoropopliteal arteries, indication for stent implantation remains a topic much debated on, especially in long lesion configurations. Ever since the first stents were introduced on the market, in-stent restenosis (ISR) has been an important issue. The evolution in stent design has known a major progression in the last decades from the first generation of stents, plagued with high fracture rates and low primary patency rates, to the design of newer stents to tackle these outcomes. More flexible and longer stents decreased the high fracture rates and drug-eluting stents offered a solution to the restenosis rates by local drug application. The difficult recrossibility of the lesion because of the presence of a permanent vascular scaffold is an obstacle that the drug-coated balloon (DCB) overcomes. Future perspectives in the treatment of femoropopliteal lesions are found in the bioresorbable stent implantation. The bioresorbable stent combines the advantages of a drug-eluting scaffolding stent without the remainder of a foreign object in the long-term. Further investigations in this area will eventually evolve in the creation of a superior endovascular treatment modality with high long-term patency rates and minimal detriments.

Dysphagia lusoria. Indications and surgical approaches for non-aneurysmatic aberrant right subclavian artery.

Non-aneurysmatic aberrant right subclavian artery is a rare cause of dysphagia. We report a case of a 65-year-old female patient having a symptomatic lusorian artery. We reviewed literature as for indications and operative techniques for type I lusorian arteries. Different types of surgical approaches have been reported but there is no consensus to date. We performed a minimally invasive sternotomy with right cervicotomy. This surgical approach maximized our visibility resulting in a safe dissection, resection and reinsertion of the aberrant right subclavian artery. Postoperative morbidity was low.

In lower extremity PTAs intraluminal is better than subintimal.

With subintimal recanalization, a channel is deliberately created by dissecting the vessel wall in order to replace the native occluded lumen. This is opposed to intraluminal recanalization, where passage of an arterial obstructive lesion is performed by central luminal navigation. Both intraluminal and subintimal treatment has its proponents and adversaries. The appreciation of an investigator for a certain technique is commonly related to the training received and the personal experience. Yet, the intraluminal technique uses the clinically preferred route for adjunctive treatment, such as balloon angioplasty or stent deployment. A wide variety of devices designed to obtain intraluminal lesion passage is available and is currently being used in vascular centers worldwide. With intraluminal techniques, success rates of up to 95% have been reported.

Endovascular procedures and new insights in diabetic limb salvage.

Critical limb ischemia (CLI) is affecting an increasing number of patients, mainly due to an ageing population and the growing number of diabetics. Clinically, CLI is characterized by rest pain, non-healing foot wounds and gangrene, due to insufficient arterial blood supply. Limb preservation should be the goal in patients with diabetic foot due to tibial occlusive disease. As surgery is associated with considerable morbidity and mortality rates, endovascular therapy can offer a valuable alternative. Small-diameter below-the-knee arteries that were previously unamenable to surgical methods, can now be reached and treated. Currently, many endovascular techniques are available, from regular PTA and bare metal stents to drug-coated balloons and drug-eluting stents. In our opinion the results of endovascular therapy for below-the-knee vessels will be further improved by the continuous technical evolution and new material developments. In the light of the current evolution towards minimally invasive techniques, an increasing number of experienced centers will be able to treat the vast majority of all below-the-knee arterial pathology by endovascular means.

BRAVISSIMO study: 12-month results from the TASC A/B subgroup.

AIM: The BRAVISSIMO study is a prospective, non-randomized, multicenter, multinational, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports on the BRAVISSIMO TASC A&B iliac lesion cohort, based on data collected up to the 13-month time point. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without Target Lesion Revascularization (TLR) within 12 months. METHODS: Between July 2009 and February 2010, a total of 190 patients who presented with TASC A or TASC B aorto-iliac lesions were included, of which 140 patients were enrolled in Belgium and 50 in Italy. RESULTS: The demographic data were comparable for the TASC A and TASC B patients groups. The number of occlusions, the average degree of stenosis, the average lesion length was significantly higher in the group of TASC B lesions, which is congruent with the TASC lesions definitions. Similarly, there were significantly more unilateral lesions in the TASC A group, compared to the TASC B group. The 12-month primary patency rate was 94.0% for TASC A lesions and 96.5% for TASC B lesions, which is not statistically significant. The 12-month primary patency rate was 92.9% in lesions treated with the Omnilink Elite stent, 97.1% in lesions treated with the Absolute Pro stent groups, and 100% in lesions treated with both stents. CONCLUSION: Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A/B aortoiliac lesions. Currently, we are collecting the 12-month data for the TASC C/D subgroup in the BRAVISSIMO study. Upon release of the results from this subgroup, we will be able to compare the results from both arms of this large-scale international study.

Drug-eluting stents below the knee.

The fear that early thrombosis and late luminal loss due to intimal hyperplasia formation potentially leads to insufficient long-term patency rates can explain the reluctance on implanting stents in small diameter below-the-knee (BTK) arteries. Drug-eluting stent (DES) technology was developed to prevent early thrombosis and late luminal loss to potentially improve long-term patency rates. Currently, the first level 1 evidence from prospective, randomized, controlled DESTINY and ACHILLES studies indicate that the implantation of DES in short lesion lenghts in the infrapopliteal vasculature leads to favorable outcomes with high primary patency rates. This makes that primary DES placement can be recommended as treatment strategy in short BTK-lesions.

Prevention and treatment of in-stent restenosis.

In-stent restenosis has always been an important issue, since the launch of the first stents on the market. The occurrence of in-stent restenosis (ISR) is due to two main reasons. First, the presence of stent fractures significantly influences restenosis rates. Second, the continuous interaction between the permanently implanted artificial material and the vessel tissue, leads to physical irritation, long-term endothelial dysfunction, or chronic inflammatory reactions. In the Literature only very limited data on ISR treatment in the peripheral arteries are available. There are no peer-reviewed publications or studies with in-depth follow-up on this specific indication. The underlying reason for this probably being that currently available treatments do not yield satisfactory results. However, the continuing search for better solutions and the technological evolution lead to the introduction of the Viabahn with PROPATEN coating, DES and DCB, which may result in the first promising treatment options for ISR.

The role of carotid artery stenting for recent cerebral ischemia.

Patients with cerebral ischemia as a result of acute cervical internal carotid artery occlusion are generally considered to have a poor prognosis. Despite maximal medical treatment, a better treatment for patients with acute ischemic stroke who present with serious neurologic symptoms on admission or continue to deteriorate neurologically due to a total occlusion, a dissection or a high-grade stenosis of the internal carotid artery is required. An effective intervention to improve their neurologic symptoms and clinical outcome has not yet been established and represents a challenging and complex problem. Treatment of acute symptomatic occlusion of the cervical internal carotid artery includes intravenous administration of thrombolytic agent, carotid endarterectomy and an interventional approach (intra-arterial administration of thrombolytic agent, transluminal angioplasty with or without stenting). The endovascular interventional approach is becoming a part of the stroke therapy armamentarium for intracranial occlusion. It may also now be considered in select patients with acute internal carotid artery occlusion. Stenting and angioplasty for acute internal carotid artery occlusion appears to be feasible, safe and may be associated with early neurological improvement. The encouraging preliminary results await confirmation from prospective, randomized studies.

Endovascular management of acute limb ischemia.

Acute limb ischemia (ALI) refers to a rapid worsening of limb perfusion resulting in rest pain, ischemic ulcers or gangrene. With an estimated incidence of 140 million/year, ALI is serious limb-threatening and life-threatening medical emergency demanding prompt action. Three prospective, randomized clinical trials provide data on trombolytic therapy versus surgical intervention in patients with acute lower extremity ischemia. Although they did not give us the final answer, satisfactory results are reported for percutaneous thrombolysis compared with surgery. Moreover, they suggest an important advantage of thrombolysis in acute bypass graft occlusions. Therefore, we believe thrombolytic therapy should be a part of the vascular surgeon's armamentarium to safely and successfully treat ALI patients.