Safety and Feasibility of Interventional Hybrid Fluoroscopy and Nuclear Imaging in the Work-up Procedure of Hepatic Radioembolization.

Purpose To evaluate the safety and feasibility of a novel hybrid nuclear and fluoroscopy C-arm scanner to be used during the work-up procedure of hepatic radioembolization. Materials and Methods In this prospective first-in-human clinical study, 12 participants (median age, 67 years [range: 37-78 years]; nine [75%] male, three [25%] female) with liver tumors undergoing work-up for yttrium 90 radioembolization were included (ClinicalTrials.gov NCT06013774). Work-up angiography and technetium 99m-macroaggregated albumin injection were performed in an angiography suite equipped with a hybrid C-arm that could simultaneously perform fluoroscopy and planar nuclear imaging. Technetium 99m-macroaggregated albumin was injected under real-time hybrid imaging, followed by in-room SPECT imaging. Safety and feasibility were studied by assessing adverse events, technical performance, additional x-ray radiation dose, and questionnaires completed by radiologists and technologists. Results No adverse events were attributed to the hybrid C-arm scanner. The additional x-ray radiation dose was low (median, 19 Gy · cm2; minimum: 12 Gy · cm2; maximum: 21 Gy · cm2 for participants who completed all imaging steps). The interventional personnel considered use of the hybrid C-arm scanner safe and feasible, although the additional time spent in the intervention room was considered long (median, 64 minutes; minimum: 55 minutes; maximum: 77 minutes for participants who completed all imaging steps). Conclusion Use of the hybrid C-arm scanner during the work-up procedure of hepatic radioembolization was found to be safe and feasible in this first-in-human clinical study. Keywords: Angiography, Fluoroscopy, Interventional-Vascular, Radionuclide Studies, Radiosurgery, Gamma Knife, Cyberknife, SPECT, Instrumentation, Physics, Technical Aspects, Technology Assessment Supplemental material is available for this article. Published under a CC BY 4.0 license. Clinical trial registration no. NCT06013774.

Alopecia Induced by Fluoroscopy-guided Embolization: A Case Report.

Alopecia resulting from radiation exposure occurs 2-8 weeks after exposure. It can be temporary or permanent depending on the dose of exposure. Alopecia following fluoroscopy-guided procedures are increasing in frequency. We report the case of a 22-year-old female who underwent fluoroscopically-guided embolization of an arteriovenous malformation. Twelve days after embolization, significant hair shedding was noted, resulting in a large rectangular hairless patch with no erythema or pain on the irradiated site. Hair pull test was positive and the hair mount showed dystrophic anagen hairs. Hair tug test was negative. Trichoscopy showed yellow dots, black dots, vellus hairs, and flame hairs. Histopathologic examination showed an increase in catagen and telogen hairs. On review of the procedure, she received a total peak skin dose of 4.67 Gray from the procedure. The diagnosis of radiation-induced alopecia was made and topical minoxidil was started, resulting in complete hair growth after six months. Patients undergoing fluoroscopy-guided procedures should have adequate follow-up weeks to months post-procedure to monitor for skin and hair reactions. Physicians should also consider delayed radiation reactions in patients with a history of radiation exposure. Safety protocols must be in place, and measures should be done to minimize the dose delivered.

Comparing Low-to-Zero Fluoroscopic Navigation Systems for AVNRT Catheter Ablation: A Network Meta-Analysis.

BACKGROUND: Low-to-zero fluoroscopic navigation systems lower radiation exposure which improves health outcomes. Conventional x-ray fluoroscopy (CF) has long been the standard to guide to catheter location for cardiac ablation. With advancements in technology, alternative safety navigation systems have been developed. Three primary modalities commonly utilized are three-dimensional electroanatomic mapping (3D-EAM), magnetic navigation system (MNS), and intracardiac echocardiography (ICE), all of which can reduce radiation exposure during the procedure. OBJECTIVE: We aim to compare the efficacy and safety among ICE, EAM, MNS, and CF in ablation of atrioventricular nodal reentrant tachycardia (AVNRT). METHODS: This is a meta-analysis consisting of observational studies and randomized controlled trials, which evaluated the performance of navigation systems of catheter ablation in AVNRT patients. Primary endpoint was to access the AVNRT recurrence after the procedure during follow-up periods. Secondary endpoints were technical success, fluoroscopic time, fluoroscopic dose area product, radiofrequency ablation time, and adverse events. Random-effect model was applied for pooled estimated effects of included studies. RESULTS: A total of 21 studies (21 CF, 2 ICE, 9 EAM, 11 MNS) including 1716 patients who underwent catheter ablation for AVNRT treatment were analyzed. Of these, 16 were observational studies and 5 were randomized controlled trials. PRIMARY OUTCOME: Point estimation of AVNRT recurrence showed ICE exhibited a pooled odds ratio (ORs) of 1.06 (95% confidence interval [CI]: 0.064-17.322), MNS with ORs of 0.51 (95% CI: 0.214-1.219], and EAM with ORs of 0.394 (95% CI: 0.119-1.305) when compared to CF. SECONDARY OUTCOMES: EAM had significant higher technical success with ORs of 2.781 (95% CI: 1.317-5.872) when compared to CF. Regarding fluoroscopy time, EAM showed the lowest time with mean differences (MD) of -10.348 min (95% CI: -13.385 to -7.3101) and P-score of 0.998. It was followed by MNS with MD of -3.712 min (95% CI: -7.128 to -0.295) and P-score of 0.586, ICE with MD of -1.150 min (95% CI: -6.963 to 4.662) with a P-score of 0.294 compared to CF, which has a P-score of 0.122. There were insignificant adverse events across the procedures. CONCLUSION: AVNRT ablation navigated by low-to-zero fluoroscopic navigation systems achieves higher efficacy and comparable safety to conventional fluoroscopywhile also reducing risk of radiation exposure time.

Fluoroscopy-free cardioneuroablation for functional bradycardia: a single-center experience.

BACKGROUND: Cardioneuroablation (CNA) is an emerging treatment for cardioinhibitory syncope and functional AV block. This study aimed to evaluate the safety and efficacy of a fluoroless CNA approach using three-dimensional mapping and extracardiac vagal stimulation (ECVS). METHODS: This prospective observational study included 22 patients (mean age 21 years) with clinically significant functional bradycardia who underwent fluoroless CNA. Procedural success was defined as elimination or significant attenuation of the vagal response to ECVS. RESULTS: CNA was successfully performed in all patients with a mean procedure time of 251 min. Fluoroscopy was avoided in 91% of cases. At a mean follow-up of 11.4 months, 77% of patients remained symptom-free. Among pacemaker patients, 90% did not require further pacing, and 6/10 (60%) have had their pacemakers turned off. No complications were seen during the procedure. CONCLUSIONS: Fluoroscopy-free CNA is a safe and effective treatment for functional bradycardia, offering high procedural success rates and favorable symptom-free outcomes while minimizing radiation exposure.

Effect of asymptomatic intervertebral flexion patterns on lumbar disc pressure: A finite element analysis study.

Movement patterns may be a factor for manipulating the lumbar load, although little information is yet available in the literature about the relationship between this variable and intervertebral disc pressure (IDP). A finite element model of the lumbar spine (49-year-old asymptomatic female) was used to simulate intervertebral movements (L2-L5) of 127 asymptomatic participants. The data from participants that at least completed a simulation of lumbar vertebral movement during the first 53% of a movement cycle (flexion phase) were used for further analyses. Then, for each vertebral angular motion curve with constant spatial peaks, different temporal patterns were simulated in two stages: (1) in lumbar pattern exchange (LPE), each vertebral angle was simulated by the corresponding vertebrae of other participants data; (2) in vertebral pattern exchange (VPE), vertebral angles were simulated by each other. The k-mean algorithm was used to cluster two groups of variables; peak and cumulative IDP, in both stages of simulations (i.e., LPE and VPE). In the second stage of the simulation (VPE), Kendall's tau was utilized to consider the relationship between different temporal patterns and IDPs for each individual lumbar level. Cluster analyses showed that the temporal movement pattern did not exhibit any effect on the peak IDP while the cumulative IDP changed significantly for some patterns. Earlier involvement in lumbar motion at any level led to higher IDP in the majority of simulations. There is therefore a possibility of manipulating lumbar IDP by changing the temporal pattern with the same ROM, in which optimal distribution of the loads among lumbar levels may be applied as preventive or treatment interventions. Evaluating load benefits, such as load, on biomechanically relevant lumbar levels, dynamically measured by quantitative fluoroscopy, may help inform interventional exercises.

A new method to evaluate fluoroscopic system collimator performance.

INTRODUCTION: Fluoroscopy uses collimators to limit the radiation field size. Collimators are often evaluated annually during equipment performance evaluations to maintain compliance with regulatory and/or accreditation bodies. A method to evaluate and quantify fluoroscopy collimator performance was developed. METHODS: A radiation field and displayed image measurement device consisting of radiopaque rulers and radiochromic film strips was placed on the x-ray source assembly exit window to evaluate fluoroscopy collimator performance. This method was used to evaluate collimator performance on 79 fluoroscopic imaging systems including fixed C-arms, mobile C-arms, mini C-arms, and radiographic fluoroscopic systems. RESULTS: The excess length (EL), excess width (EW), and sum EL + EW of the radiation field relative to the displayed image were measured and compared to the limits specified in 21CFR1020.32. Four systems exceeded these limits. Placing the radiation measurement device at the x-ray source assembly exit window relative to the image receptor cover increased the film exposure rate by a factor up to 14.6. The time required to set up and complete the fluoroscopy collimator performance measurements using this method ranged from 5 to 10 min. CONCLUSIONS: This method provides an easily implemented quantitative measure of fluoroscopy system collimator performance that satisfies regulatory and accreditation body requirements.

Clinical value of flexion-extension radiographs with bracket support for lumbar stability assessment.

OBJECTIVES: This study proposes a novel standardized technique to evaluate lumbar stability in lumbar lateral flexion-extension radiographs and determine whether the most reliable intraoperative reference level of extension can be attained. METHODS: A total of 104 patients undergoing surgical treatment for lumbar degenerative disease were included in the study. Radiographs in the conventional extension position (CE) and the extension position with bracket support (CEB) and intraoperative prone fluoroscopic radiographs of patients were included in this study. The slip angle (SA) and slip percentage (SP) were compared for these three radiographic methods. Furthermore, the correlation of differences in the SA and SP were examined among different spinal segments. RESULTS: Among 104 patients (mean age 58 years, 54% women) with a total of 147 operated segments examined, the average SA (10.65°±3.65°) and SP (12.18%±4.91%) with bracket support and SA (10.62°±3.67°) and SP (12.19%±4.90%) during intraoperative muscle relaxation were not significantly different (P=0.54; 0.91). However, the SA and SP in the CEB and intraoperative muscle relaxation conditions were significantly increased compared with the SA (6.46°±3.23°) and SP (7.87%±4.26%) obtained in the CE condition (all P<0.001). Both surgeons demonstrated high reliability, with intraclass correlation coefficient values ranging from 0.8 to 1.0 (P<0.001) for SP and SA measurements. CONCLUSIONS: CE radiographs underestimate the degree of displacement of lumbar instability. The CEB position reduces patient back pain and increases the feeling of safety, leading to a greater level of extension. This outcome aligns with the intraoperative muscle relaxation findings.

Coccygeal Nerve Blockade vs. Impar Ganglion Blockade in Coccydynia: A Randomised Clinical Trial.

Background and objective Coccydynia is a condition that causes pain around the coccyx, severely limiting functionality. Interventional treatment options are available for cases that do not respond to conservative treatment. Coccygeal nerve block (CnB) is a novel method for treating coccydynia. This study compared the efficacy of CnB and ganglion impar block (GiB) and aimed to evaluate the efficacy of CnB in treating coccydynia. Methods  The 12-week results of 56 patients were analysed. One group underwent ultrasound (US)-guided CnB, while the other group underwent fluoroscopy (FL)-guided GiB. Pain intensity was assessed using the numerical rating scale (NRS), and functionality was assessed using the PARIS Coccydynia Functionality Questionnaire. Evaluations were conducted before treatment, as well as four and 12 weeks after treatment. Results The baseline median NRS score was eight in both groups, while at week 12, it was three in the CnB group and 2.5 in the GiB group. The median PARIS score at baseline was seven in the CnB group and 6.5 in the GiB group, while at week 12, it was four and three, respectively. At week 12, compared to baseline, both the CNB and GiB groups showed statistically significant improvements in NRS and PARIS scores (p<0.001). When comparing the two groups, no significant difference was observed in the NRS and PARIS scores before and four and 12 weeks after treatment. No serious adverse events were observed in any patient. Conclusions  Coccydynia is sometimes refractory to treatment. In our study, we found that CnB, a method recently used in the treatment of coccydynia, was as effective as GiB, which has been used for a long time, and we found no evidence of superiority. The lack of radiation exposure due to its US-guided application, the superficial course of the coccygeal nerves and the low depth of needle penetration make it easier to perform. These advantages suggest that it will be a preferable method in the treatment of coccydynia.

Liver Lymphatic Anatomy and Its Role in Systemic Health and Disease.

Lymphatic anatomy of the abdomen is reviewed with focus on hepatic and mesenteric vessels in normal and pathologic conditions. Anatomy and pathophysiology is highlight using both specialized fluoroscopy and T2 Dynamic Contrast MR lymphangiography (DCMRL). Plastic bronchitis, chylothorax, protein losing enteropathy, and both cirrhosis and ascites due to hepatic lymphatics are highlighted. Presented at the 2023 ISL International Congress of Lymphology, Genoa, Italy in a special symposium on central and regional lymphatic system in health and disease.

Neo-Omphaloplasty within a Vertical Scar: The Double Trapezium Flap Technique.

Background: Various techniques for neo-omphaloplasty (or umbilicoplasty/umbiliconeoplasty) have been established in recent decades. However, when the omphaloplasty must be integrated into a vertical scar, most of these techniques are unsuitable. Method: We established a technique comprising two "cross-border" trapezium flaps that come together in a key-lock fashion to be applicable for umbilical reconstruction in vertical scars. Between 2020 and 2023, we performed the double trapezium flap technique in 11 patients requiring abdominal wall correction due to previous operations resulting in the loss of the original navel and a vertical midline scar. The follow-up period was 12 months. Results: We encountered two minor wound healing disorders not involving the omphaloplasty. One patient experienced a more severe wound healing complication involving the vertical scar and the lower flap of the neo-umbilicus. No cases of umbilical flattening or detachment of the anchorage stitches were detected. Patients ranked the aesthetic outcomes as "excellent" (n = 9) or "good" (n = 2). Physicians ranked the results as "excellent" (n = 7), "good" (n = 4), and "average" (n = 1). Conclusions: For the selected patients, this technique appears to be a good and reliable option to create a natural looking neo-umbilicus, creating sufficient umbilical depth with minimal scarring. While a study population of 11 patients is hardly enough to endorse a new technique, appropriate cases are comparatively rare and very specific.

More is less: image enhancement technology reduces radiation exposure during anterior lumber interbody fusion.

BACKGROUND CONTEXT: Fluoroscopy and radiation exposure occur during anterior lumbar interbody fusion (ALIF). Image enhancement technology is available that can potentially reduce radiation exposure. PURPOSE: The purpose of this study is to evaluate radiation exposure and fluoroscopy times comparing standard fluoroscopy (FL) with a low dose image enhancement platform (LD). STUDY DESIGN: Retrospective review of prospectively maintained database. PATIENT SAMPLE: Consecutive patients undergoing ALIF with either standard fluoroscopy or low dose image enhancement technology. OUTCOME MEASURES: Radiation dispersion and fluoroscopy times in ALIF patients with standard fluoroscopy and low dose image enhancement technology. METHODS: A retrospective review of a prospective database on consecutive patients who have undergone ALIF, stratified into 2 groups: subjects with standard fluoroscopy (FL), and low dose fluoroscopy with image enhancement technology (LD). RESULTS: A total of 487 ALIF patients were included (FL: 372 vs. LD: 115). LD patients were significantly older (66 vs. 60 years), with more deformity cases (28% vs. 12%), and less degenerative cases (71% vs. 87%), all p<.05; no differences in sex, BMI, or the number of levels operated on between groups. Fluoroscopy time (sec) was significantly higher in LD (51.4 vs. 45.5), with a statistically significant reduction in radiation (mGy) compared to FL (23.3 vs. 48.2), both p<.05. Furthermore, the results showed that radiation dispersion is increasingly reduced as fluoroscopy time increases in LD compared to FL (12%, 56%, and 65% reduction in radiation dispersion for fluoroscopy time <30 sec, between 30 to 60 sec, and >60 sec, respectively). CONCLUSIONS: The use of low dose fluoroscopy with image enhancement technology significantly reduces the cumulative dose of radiation during ALIF compared to standard dose fluoroscopy. Also, radiation dispersion increasingly decreases as fluoroscopy time increases using low dose image enhancement technology. Low dose image enhancement technology improves the safety profile of ALIF for patients and operating room staff.

[Balloon atrioseptostomy under echocardiographic and fluoroscopic guide in patients with congenital heart diseases under 3 months in a national reference pediatric center]. / Atrioseptostomía con balón bajo guía ecocardiográfica y fluoroscópica en pacientes con cardiopatías congénitas menores de 3 meses en un centro pediátrico de referencia nacional.

Objective: Balloon atrioseptostomy is an emergency procedure in congenital heart diseases requiring an atrial septal defect to increase cardiac output in right-sided obstructive lesions or to improve mixing in patients with transposition of the great arteries. This procedure is currently performed with both fluoroscopy and echocardiography. The main objective is to describe our experience with the use of balloon atrioseptostomy under echocardiographic and fluoroscopic guidance in patients under 3 months. Materials and methods: A descriptive, comparative and retrospective study in patients in whom balloon atrioseptostomy was performed under echocardiographic and fluoroscopic guidance between 2018 and 2023 in a referral hospital in Peru. Results: 36 patients were analyzed, of which 21 were from the fluoroscopy group. and 15 patients from the echocardiography group. More than 2/3 of the cases were males, and more than 60% of patients in both groups had transposition of the great vessels. No significant differences were found in terms of ventilatory support and inotropic support. The success of the procedure was 100% in both groups, without complications. Conclusion: Both balloon atrioseptostomy performed by fluoroscopy and those performed by echocardiography were successful and without complications, emphasizing that the one performed by echocardiography is performed in the patient's crib, avoiding the transfer of the critical unit to the angiography room and without the use of radiation.

Case report of a delayed diagnosis of radiation induced ulcer in a patient following angioplasty.

Diagnosis of fluoroscopy-induced radiodermatitis remains challenging for dermatologists. We present a case report where a patient had predictable risks of developing chronic radiodermatitis, yet the diagnostic was delayed for over a year and a half. In the current absence of appropriate follow-ups in some institutions, dermatologists should keep high suspicion for chronic fluoroscopy-induced radiodermatitis when encountering lesions characteristic of radiation dermatitis without a history of radiotherapy, prompting the necessity to inquire about antecedents of fluoroscopy-guided interventions.

Has the cat got your tongue, or is something obstructing your throat? A review of imaging of ingested and aspirated foreign bodies in the paediatric population.

Children frequently swallow or inhale foreign objects, a situation that can be life-threatening. Radiographic imaging plays a lead role in the early identification and location of inhaled or swallowed objects is essential. Promptly identifying and locating inhaled or swallowed objects are essential, as some items require immediate removal. For example, button batteries in the throat can cause grave harm; magnets can attract each other through the gut and cause perforations; and other objects can obstruct the airway or intestinal tract. Radiologists must understand how these objects appear in images to assist doctors in treating patients effectively. Recognising signs of inhaled objects on radiographs is also crucial, as symptoms may not always be clear, and many inhaled objects are not visible on radiographs. Radiographs are the primary means of checking for swallowed or inhaled objects, although other tests like fluoroscopy and computed tomography may be used in complex cases. Doctors working with children should be acquainted with the appearance of these common objects on images and their clinical importance.

Echocardiography-guided percutaneous closure of oval-shaped secundum atrial septal defects.

BACKGROUND: An atrial septal defect (ASD) is considered oval-shaped when its shortest diameter is less than 75% of the longest diameter. Research on percutaneous closure of oval-shaped ASDs is limited, with no known reports of non-fluoroscopic closure for this population. OBJECTIVE: To assess the effectiveness of non-fluoroscopic percutaneous closure for oval-shaped ASDs. METHODS: This single-center retrospective study evaluates patients undergoing non-fluoroscopic percutaneous closure of oval-shaped ASDs, defined by the shortest to longest diameter ratio < 0.75, a circular index of 1.33, or ultrasound visualization of an oval shape. Device size was chosen to be 0-4 mm larger than the defect's longest diameter, based on transthoracic and transesophageal ultrasound measurements. RESULTS: We identified 78 patients (33.3% children, 20.5% males) with a mean age of 27.4 ± 16.3 years and a mean weight of 46.8 ± 19.8 kg. The mean longest diameter and mean shortest diameter of ASDs were 23.3 ± 6.8 mm and 15.8 ± 5 mm, respectively. The mean ratio of the shortest to longest diameter was 0.7 ± 0.1. Percutaneous closure was not attempted in 7/78 (9%) patients. Three out of 71 (4.2%) procedures were fluoroscopy-guided upfront due to technical difficulties, and 5/71 (7%) were converted to fluoroscopy-guided closure. Overall procedural success rate was 98.6% (70/71) including 63/71 (88.7%) performed with zero fluoroscopy. Mean device size was 26.5 ± 7.1 mm. Mean procedural time was 45.3 ± 22.6 min. Eleven intraprocedural complications occurred including 6 arrhythmias, 3 pericardial effusions, and 2 device dislodgements. CONCLUSION: Transcatheter closure of oval-shaped ASD is safe and feasible. Echocardiography is adequate for adequate operative guidance.

Retrospective study of detecting oesophageal injuries post neck trauma: CTA versus fluoroscopy.

Background: Timely detection of oesophageal injuries post-penetrating neck trauma is imperative because of the associated high morbidity and mortality. Patients commonly undergo both CT angiography (CTA) and contrast swallow studies (fluoroscopic oesophagography) when oesophageal injury is suspected. Objectives: To determine the radiological findings of oesophageal injury after penetrating neck trauma comparing CTA and fluoroscopic oesophagography at a single tertiary centre. Method: The study retrospectively reviewed the data from CTA and fluoroscopic oesophagography reports of patients suspected of oesophageal injuries secondary to penetrating neck trauma at a tertiary hospital in South Africa from January 2018 to December 2022. Results: A total of 76 records were reviewed. The mean age for the participants was 31.5 years, ranging from 0.75-66 years. In this study 6/76 (8%) patients had confirmed oesophageal injury on fluoroscopy, which is considered the gold standard. The majority of penetrating neck injuries were in the 20-29 year age group, with 33/76 (43%) injuries. Stab wounds as the mechanism of injury accounted for 57/76 (75%). Dysphagia was experienced by 10/76 (13%) of those who had injuries. Zone I injuries accounted for 33/76 (43%) of the injuries. Conclusion: The incidence of oesophageal injuries secondary to penetrating neck injuries is comparable to previous studies. This study determined that CTA has a high sensitivity but low specificity. Contribution: Fluoroscopic oesophagography should, therefore, be performed in patients who have an abnormal CTA coupled with clinical signs and symptoms of oesophageal injury.

DOES CRUCIATE LIGAMENT SUBSTITUTION AND IMPLANT ASYMMETRY MAKE A DIFFERENCE FOR TOTAL KNEE ARTHROPLASTY KINEMATICS? A MULTI-IMPLANT EVALUATION.

BACKGROUND: The non-implanted knee differs in comparison to total knee arthroplasty (TKA) designs, with regard to asymmetry and functionality of the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). While surgeons may choose to implant either posterior stabilized (PS) or bi-cruciate stabilized (BCS) TKAs, substituting for one or both cruciate ligaments, the effects of symmetry versus asymmetry in substituting TKA designs have not been widely analyzed to determine possible benefits. Therefore, the objective of this research study was to determine if either TKA asymmetry and/or anterior ligament stabilization can lead to more normal-like kinematics and clinical benefit for patients. METHODS: In vivo, femoro-tibial kinematics for 64 subjects were evaluated in this retrospective study. Overall, ten subjects had a normal, non-implanted knee, 20 had a BCS TKA, and 34 had one of two different PS TKAs. All three TKAs had varying degrees of symmetry incorporated into the design, and all were implanted by the same surgeon and were analyzed using fluoroscopy during a deep knee bend. RESULTS: At full extension, the BCS TKA subjects demonstrated a statistically more anterior position of both condyles compared to both PS TKAs. The BCS TKA subjects also experienced more posterior femoral rollback and axial rotation in early flexion and from full extension to maximum knee flexion. Additionally, the TKAs in this study having asymmetry experienced greater amounts of posterior femoral rollback and weight-bearing knee flexion. CONCLUSION: The results from this study indicated that in early flexion, the anterior cam/post mechanism does pull the femoral component more anterior, and all TKAs experienced posterior femoral rollback when the posterior cam engaged the post. The asymmetric designs also achieved greater rollback and axial rotation compared to the symmetric designs.

Infrarenal Aortic Treatment With AFX2 Endograft: Results From a Multicentric, International, Non-Randomized, Prospective Registry-the AFX2-LIVE Study.

INTRODUCTION: To confirm real-world clinical practice results reported with anatomically fixed bifurcated endograft, a physician-initiated study was designed-AFX2-LIVE registry. MATERIALS AND METHODS: From November 2019 to August 2021, investigators enrolled all consecutive patients treated with AFX2 (Endologix Inc., Irvine, CA, USA) endograft. Patients with abdominal aortic aneurysms (AAAs), penetrating aortic ulcers (PAU), and isolated infrarenal aortic dissections were included. Clinical and anatomical data, including baseline, intraoperative, and in-hospital details, as well as follow-up data, were collected in an anonymized prospectively compiled database. The primary endpoint of this study was to evaluate the technical and clinical success of endovascular aortic repair (EVAR) using AFX2 endograft. RESULTS: A total of 535 patients were enrolled from 43 Italian and Spanish centers and analyzed according to the protocol. Four hundred eighty-nine patients were male (91.4%), with a mean age of 75±8.92 years (range 52-94). Four hundred sixty-six patients (87.1%) were treated for AAA, 49 (9.3%) for PAU, and 20 (3.6%) for isolated abdominal aortic dissection. A proximal extension was needed in 48% of the cases. Assisted technical success was achieved in all but one patient (99.8%). At 30 days follow-up, no AAA-related deaths were recorded, and nine patients (1.6%) required reintervention. At a mean follow-up period of 15.22±13.65 (range 1-53) months, data were available for 479 patients (89.5%). Clinical success was achieved in 98.2% (95% confidence interval [CI]: 96.4-99.1) at 3 months, 93.9% (95% CI: 90.1-96.1) at 1 year, and 74.1% (95% CI: 62.8-82.4) at 4 years follow-up. The estimated freedom from all-cause mortality was 97.7%, 93.4%, 81.6%, 77.5%, and 70.9%, and freedom from AAA-related mortality was 100%, 99.6%, 99.6%, 99.6%, and 97.3% at 3, 12, 24, 36, and 48 months, respectively. Twenty reinterventions (3.7%) were required in 19 patients, of which 3 late open conversions (0.6%) were performed, and 2 AAA-related deaths were observed. CONCLUSION: This study demonstrated excellent clinical and technical success rates of EVAR with anatomically fixed endografts, providing valuable insights into real-world clinical outcomes. CLINICAL IMPACT: The AFX2-LIVE study could have a significant impact by providing robust evidence supporting the effectiveness and safety of EVAR using bifurcated endografts with anatomical fixation in real-world clinical practice, ultimately leading to improved outcomes and enhanced patient care in the management of abdominal aortic pathologies.

Intentionally unilateral prostatic artery embolization: Patient selection, technique and potential benefits.

BACKGROUND: Prostatic artery embolization (PAE) is a promising but also technically demanding interventional radiologic treatment for symptomatic benign prostatic hyperplasia. Many technical challenges in PAE are associated with the complex anatomy of prostatic arteries (PAs) and with the systematic attempts to catheterize the PAs of both pelvic sides. Long procedure times and high radiation doses are often the result of these attempts and are considered significant disadvantages of PAE. The authors hypothesized that, in selected patients, these disadvantages could be mitigated by intentionally embolizing PAs of only one pelvic side. AIM: To describe the authors' approach for intentionally unilateral PAE (IU-PAE) and its potential benefits. METHODS: This was a single-center retrospective study of patients treated with IU-PAE during a period of 2 years. IU-PAE was applied in patients with opacification of more than half of the contralateral prostatic lobe after angiography of the ipsilateral PA (subgroup A), or with markedly asymmetric prostatic enlargement, with the dominant prostatic lobe occupying at least two thirds of the entire gland (subgroup B). All patients treated with IU-PAE also fulfilled at least one of the following criteria: Severe tortuosity or severe atheromatosis of the pelvic arteries, non-visualization, or visualization of a tiny (< 1 mm) contralateral PA on preprocedural computed tomographic angiography. Intraprocedural contrast-enhanced ultrasonography (iCEUS) was applied to monitor prostatic infarction. IU-PAE patients were compared to a control group treated with bilateral PAE. RESULTS: IU-PAE was performed in a total 13 patients (subgroup A, n = 7; subgroup B, n = 6). Dose-area product, fluoroscopy time and operation time in the IU-PAE group (9767.8 µGy∙m2, 30.3 minutes, 64.0 minutes, respectively) were significantly shorter (45.4%, 35.9%, 45.8% respectively, P < 0.01) compared to the control group. Clinical and imaging outcomes did not differ significantly between the IU-PAE group and the control group. In the 2 clinical failures of IU-PAE (both in subgroup A), the extent of prostatic infarction (demonstrated by iCEUS) was significantly smaller compared to the rest of the IU-PAE group. CONCLUSION: In selected patients, IU-PAE is associated with comparable outcomes, but with lower radiation exposure and a shorter procedure compared to bilateral PAE. iCEUS could facilitate patient selection for IU-PAE.