Minimally Invasive Segmental Artery Coil Embolization (MISACE) Prior to Endovascular Thoracoabdominal Aortic Aneurysm Repair.

PURPOSE: Minimally Invasive Segmental Artery Coil Embolization (MISACE) is a novel approach to reduce paraplegia risk in Thoracoabdominal aortic aneurysm (TAAA) repair with limited data. We report our experience with MISACE as a method of spinal cord pre-conditioning to prevent spinal cord ischemia following endovascular repair of TAAA. MATERIAL AND METHODS: A retrospective analysis of 17 patients who had an attempted MISACE prior to endovascular TAAA repair with mean follow-up of 350 days (2017-2020). Baseline patient and aneurysm characteristics along with procedural technique and outcomes were analyzed. RESULTS: Mean age of 69 years and 76.5% were males. TAAA Crawford classification were II, n = 6 (35.3%), III, n = 4 (23.5%) and IV, n = 5 (29.4%). The mean aortic diameter was 70.6 ± 10.9 mm. Staged repair was performed on 9 patients. Technically successful embolization occurred in 14 patients (82.4%) and was unsuccessful in 3 patients. The median number of embolized arteries was 3 and 71% of the target arteries were between T9 and T12. Mean fluoroscopy time was 51.5 ± 22.5 min and mean contrast volume used was 132.8 ± 56.1 mL. Average number of catheters used was 4.6 and 3.5 wires. No complications related to the procedure. Mean interval between embolization to endovascular TAAA repair was 51.2 days (5-110 days). All patients received spinal drainage at the time of repair. Postoperatively, 2/14 of patients developed paraparesis in the MISACE successful group and 1/3 patients developed paraplegia in the unsuccessful group. CONCLUSIONS: MISACE is a promising strategy to prevent SCI. This data demonstrates the technique is feasible and safe but anatomic challenges remain.

Percutaneous Transluminal Angioplasty for Below-the-Elbow Critical Hand Ischemia: A Systematic Review.

PURPOSE: To perform a systematic review assessing the safety and efficacy of percutaneous transluminal angioplasty (PTA) for treatment of critical hand ischemia (CHI) due to below-the-elbow (BTE) obstructive arterial disease. MATERIALS AND METHODS: MEDLINE and EMBASE systematic searches were performed from inception to December 2020 to identify studies assessing PTA for management of BTE obstructive arterial disease. Three independent reviewers performed abstract selection, data extraction, and quality assessment. The Newcastle-Ottawa Scale was used to assess individual study bias for non-randomized controlled trials. RESULTS: Eight studies comprising 176 patients with obstructive BTE vessel disease were included. All studies had a score >5 on the Newcastle-Ottawa Scale, indicative of high quality. All studies used low-profile balloons (1.5-4 mm) for PTA of stenotic lesions or chronic total occlusions (CTOs). The weighted average technical success and clinical success rates were 89.3% (range = 82%-100%) and 69.9% (range = 19%-100%), respectively, at a mean follow-up of 29.7 ± 17.1 months. The short-term (<30 days) complication rate was low at 4.7% and most commonly included access site hematomas, pseudoaneurysms, and radial artery perforation or re-thrombosis. Nearly 20% of patients required an amputation, and most (96%) were minor (either distal phalanges or digits). Only 2 patients required above-wrist amputations. The primary and secondary patency rate at 5 years were 38% and 54%, respectively. The cumulative 5-year mortality rate was 33.1%. CONCLUSIONS: PTA for CHI due to BTE obstructive arterial disease is feasible with a high technical success rate and a low short-term complication rate. Additional long-term comparative studies are required to unequivocally establish the clinical benefit of endovascular treatment compared with conservative management or surgical bypass.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

OBJECTIVE: To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. METHODS: We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. RESULTS: Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. CONCLUSION: In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar.

Placenta percreta is the abnormal invasion of the placenta through the myometrium and serosa of the uterus. It is the most invasive of the placenta accreta spectrum followed by placenta increta. This paper presents a case of a maternal and fetal death in the second trimester due to rupture of the uterus at the site of placenta percreta in a C-section scar. Postmortem MRI showed a large hemoperitoneum and thinning of the anterolateral uterine wall. Internal examination revealed two liters of blood in the abdomen and rupture of the anterolateral uterine wall at the site of placenta percreta in a previous C-section scar. Placenta percreta is a rare complication of pregnancy, however, it is becoming more common with the increasing rate of C-section, the most common and significant risk factor.