Laser Atherectomy for the Treatment of Peripheral Arterial Disease.

BACKGROUND: The aim of the study was to investigate the clinical results of laser atherectomy in the treatment of peripheral arterial disease. METHODS: Retrospective analysis of consecutive patients underwent laser atherectomy at a single institution during a 7-year period by vascular surgeons and interventional cardiologists in a tertiary university-affiliated hospital. Clinical data were retrieved from patient charts and hospital electronic medical records along with the associated arteriograms. RESULTS: A total of 461 lesions in 343 limbs were treated in 300 patients with a mean age of 70 years. The indication was critical limb ischemia (CLI) with rest pain or tissue loss in 227 (66%) of interventions and claudication in 116 (34%). All procedures included an associated balloon angioplasty, while stenting was performed in 33%. Technical success was achieved in 99% with only 2 (<1%) cases with an acute procedure-related complication requiring surgical intervention. At a mean follow-up of 28 months (range, 1-87 months; median 24 months), 156 patients (45%) became asymptomatic or achieved significant clinical improvement (resolution of tissue loss or rest pain), 60 (17%) remained with CLI, 30 (9%) had a major proximal amputation, and 18 (5%) had a minor amputation. Freedom from major amputation was 90% at 5 years by life-table analysis. Univariate statistical analysis demonstrated the risk of a major amputation to be associated with diabetes, hemodialysis, and tissue loss (P < 0.05 to P < 0.005), while multivariate logistic regression analysis indicated diabetes to be overwhelmingly important (RR: 4.84; 95% confidence interval [CI]: 1.1-21.3; P < 0.05). In a similar manner, multivariate analysis indicated dialysis (RR: 2.46; 95% CI: 1.01-5.98; P < 0.05) and CLI (RR: 2.27; 95% CI: 1.42-3.65; P < 0.01) were associated with higher likelihood for lack of clinical improvement. There was no difference in major amputation rates between surgeons and interventional cardiologists (RR: 1.5; 95% CI: 0.7-2.1; P < 0.1) although it was 3 times more likely for the patients treated by surgeons to suffer from CLI (odds ratio: 3.2; 95% CI: 1.9-5.4; P < 0.0001). CONCLUSIONS: Laser atherectomy is a safe and useful adjunct in limb salvage. Diabetics have much higher probability of requiring a proximal amputation, while those on dialysis and with CLI are least likely to gain clinical benefit.

Adjuvant Radiotherapy in Grade II, Atypical Meningioma of the Skull Base.

Introduction Atypical meningiomas (AM) are meningiomas that are more aggressive than their grade-I counterparts and have a higher rate of recurrence. The effect of adjuvant radiotherapy (ART) on AM of the skull base is not defined. Methods A retrospective review of all AM's of the skull base primarily resected at our institution from 1996 to 2018 was completed. ART was defined as radiotherapy (RT) that occurred within 6 months of initial resection, regardless of Simpson's grade. Minimum time length of follow-up after resection was 2 years. Statistical analysis was performed using SAS. Results There were a total of 59 skull base-located (SBL) AMs resected at our institution from 1996 to 2018. The average age of our cohort was 53.2 years. Gross total resection, defined as Simpson's grades I to III resection, was achieved in 36 (61%) of cases. Thirty-five of 59 (59%) patients received ART. Recurrence was observed in 14 patients (24%), and mean time to recurrence was 63.8 months. Patients who received ART had a lower observed rate of recurrence (8 vs. 46%); however, time to recurrence was not significantly different between the two populations. Conclusion We observe that AM in the skull base location have higher recurrence rates than we would expect from grade-I meningioma. These data suggest that ART may offer benefit to the overall observed frequency of recurrence of SBL AM; however, the time to recurrence between patients who received ART and those who did not was not statistically significant in survival analysis.

Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity.

OBJECTIVE: The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children. METHODS: The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision. RESULTS: The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion. CONCLUSIONS: Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

Survival and failure trends of cerebrospinal fluid shunts with distal slit valves: comparative study and literature review.

OBJECTIVE: The malfunction rates of and trends in various cerebrospinal fluid (CSF) shunt designs have been widely studied, but one area that has received little attention is the comparison of the peritoneal distal slit valve (DSV) shunt to other conventional valve (CV) type shunts. The literature that does exist comes from older case series that provide only indirect comparisons, and the conclusions are mixed. Here, the authors provide a direct comparison of the overall survival and failure trends of DSV shunts to those of other valve type shunts. METHODS: Three hundred seventy-two new CSF shunts were placed in pediatric patients at the authors' institution between January 2011 and December 2015. Only ventriculoperitoneal (VP) shunts were eligible for study inclusion. Ventriculoatrial, lumboperitoneal, cystoperitoneal, subdural-peritoneal, and spinal shunts were all excluded. Rates and patterns of shunt malfunction were compared, and survival curves were generated. Patterns of failure were categorized as proximal failure, distal failure, simultaneous proximal and distal (proximal+distal) failure, removal for infection, externalization for abdominal pseudocyst, and addition of a ventricular catheter for loculated hydrocephalus. RESULTS: A total of 232 VP shunts were included in the final analysis, 115 DSV shunts and 117 CV shunts. There was no difference in the overall failure rate or time to failure between the two groups, and the follow-up period was statistically similar between the groups. The DSV group had a failure rate of 54% and a mean time to failure of 17.8 months. The CV group had a failure rate of 50% (p = 0.50) and a mean time to failure of 18.5 months (p = 0.56). The overall shunt survival curves for these two groups were similar; however, the location of failure was significantly different between the two groups. Shunts with DSVs had proportionately more distal failures than the CV group (34% vs 14%, respectively, p = 0.009). DSV shunts were also found to have proximal+distal catheter occlusions more frequently than CV shunts (23% vs 5%, respectively, p = 0.005). CV shunts were found to have significantly more proximal failures than the DSV shunts (53% vs 27%, p = 0.028). However, the only failure type that carried a statistically significant adjusted hazard ratio in a multivariate analysis was proximal+distal catheter obstruction (CV vs DSV shunt: HR 0.21, 95% CI 0.05-0.81). CONCLUSIONS: There appears to be a difference in the location of catheter obstruction leading to the malfunction of shunts with DSVs compared to shunts with CVs; however, overall shunt survival is similar between the two. These failure types are also affected by other factors such etiology of hydrocephalus and endoscope use. The implications of these findings are unclear, and this topic warrants further investigation.

Endovascular repair of ruptured abdominal aortic aneurysms with the endurant stent-graft: a combined experience from three centers.

BACKGROUND: Endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) has been previously reported to reduce mortality rates compared to open repair. Newer stent-grafts may provide even better results with applicability in a larger number of patients. We present our experience with the Medtronic Endurant endograft over a three-year period. METHODS: Consecutive cases of RAAAs which have been managed with the Endurant stent-graft were recruited from three centers and were analyzed retrospectively. Twenty-three patients (22 males; mean age 74±9 years) were treated between June 2010 and May 2013. RESULTS: The technical success rate was 100% with no intraoperative endoleaks. Thirty-day mortality was 13% (3/23 patients). Two patients required prolonged hospitalization and mechanical ventilation. For the remaining 18 patients, the average hospitalization length was 5.5 days. Two major risk factors were found to be significantly associated with increased mortality: low systolic blood pressure on arrival at the hospital (63±6 vs. 99±22; P=0.01), and post-operative development of an abdominal compartment syndrome (Relative Risk - RR=13.3, 95% confidence interval - CI: 1.6-106; P=0.03). Other important clinical variables which did not significantly affect mortality included age (mean age 83±9 years in those who died vs. 73±9 years in the survivors; P=0.09), type of graft (bifurcated vs. aorto-uni-iliac; RR=2.2, 95% CI: 0.3-15; P=0.4), aneurysm diameter (11±4 cm vs. 9±2 cm; P=0.28), and proximal neck angulation (68±14 vs. 57±26 degrees; P=0.5). A proximal neck angulation >75° was not associated with a higher mortality rate (RR=1.33, 95% CI: 0.22-7.8; P=1). CONCLUSIONS: Endovascular repair of RAAAs resulted in high technical success and low mortality rates in this series of patients treated with the Endurant stent graft. Hypotension on arrival to the hospital and development of an abdominal compartment syndrome were predictive of increased risk of death. Patient age, aneurysm diameter and graft configuration did not negatively impact survival. Non-compliance with the device instructions for use (IFU) did not adversely affect results in this small patient series. Larger studies are needed to confirm our results.

Vertebral artery injury in patients with isolated transverse process fractures.

We sought to assess the rate of CTA-diagnosed vertebral artery injury in patients with isolated transverse process fractures, with and without extension into the transverse foramen, in the blunt-trauma population served by our hospital. We queried our universities trauma registry between January 2009 and July 2014 for ICD-9 codes pertaining to cervical spine fractures. Of 330 patients identified, 45 patients had fractures limited to the transverse process and were selected for the study population. For each patient identified, demographics, injury mechanism, imaging reports, angiography findings, and treatments were recorded. In total, 69 fractures were identified in 45 patients. Of the 45 patients, 15 (33%) had transverse process fractures at multiple cervical levels. 23/45 (51%) patients had at least one fracture extending into TF. Four patients with transverse process fractures and one patient without transverse process fractures were diagnosed with vertebral artery injury by CT angiogram (17.4% vs. 4.5%, p=0.35). The number of transverse process fractures in patients with VAI was greater than those without VAI (3.0 vs. 1.4, p<0.001). None of the 30 patients with any one-level TPF (with or without extension into TF) was diagnosed with VAI (p=0.003). None of 17 patients with isolated C7-level TPFs were diagnosed with VAI (p=0.15). The incidence of cervical VAI was greater in patients with multiple-level TPFs than in patients with single-level TPFs. While patients with a single, isolated TPF have a low probability of VAI, patients with numerous TPF fractures may benefit from CTA.

Proximal ventricular shunt malfunctions in children: Factors associated with failure.

Ventricular shunt failures and subsequent revisions are a significant source of patient morbidity. We conducted a review of pediatric patients undergoing placement or revision of ventricular shunts at our institution between January 2007 and December 2008. Patients were followed through to July 2014. Data collected included patient demographics, shunt history and indication for procedure, approach taken for shunt placement, and location of shunt tip in relation to the foramen of Monro. Univariate and multivariate analyses were conducted to identify factors associated with proximal failure. A total of 87 procedures were identified in 40 patients, consisting of 23 initial placements and 64 revisions. Thirty-nine proximal catheter malfunctions were identified. Indications for shunt placement included Chiari II malformation (33%) and intraventricular hemorrhage (33%). Mean follow-up period was 5.5 years. Median time to shunt failure was 1.57 years. In the multivariate model, younger age at placement was associated with decreased time to proximal failure (hazard ratio [HR]=0.80 per increasing year of age, 95% confidence interval [CI] 0.64-0.98). Both anterior approach (HR=0.39, 95% CI 0.23-0.67) and farther distance to foramen of Monro (HR=0.02 per increasing 10mm, 95% CI 0.00-0.22) were associated with increased time to proximal failure when the catheter tip was located within the contralateral lateral ventricle. Optimizing outcomes in patients with shunt-dependent hydrocephalus continues to be a challenge. Despite unsatisfactory outcomes, particularly in the pediatric population, few conclusions can be drawn from studies assessing operative variables.

Size matters: room temperature P-C bond formation through C-H activation in m-terphenyldiiodophosphines.

m-Terphenyl- and biphenyl-2-diiodophosphines, TerphPI 2 and BiphPI 2, have been obtained by halide exchange from the chloro derivatives TerphPCl 2 and BiphPCl 2 and excess LiI in a benzene solution at room temperature. Whereas BiphPI 2 compounds are stable, the TerphPI 2 species undergo intramolecular C-H activation at room temperature and cyclize to form unsymmetrical 9-iodo-9-phosphafluorenes 1-(3,5-dimethylphenyl)-6,8-dimethyl-9-iodo-9-phosphafluorene, 4; 1-(4-t-butylphenyl)-7-t-butyl-9-iodo-9-phosphafluorene, 5; and 1-(2-methylphenyl)-5-methyl-9-iodo-9-phosphafluorene, 6, albeit the latter reaction is rather slow due to unfavorable steric interactions. Cyclization of the alkyl-substituted 4,4'-di- tert-butyl-biphenyl-2-diiodophosphine, 11, is slow in refluxing benzene solution, but faster than that for the parent biphenyl-2-diiodophosphine. Ab initio and density functional theory calculations are in agreement with an electrophilic aromatic substitution mechanism that is facilitated by steric strains in the terphenyl compounds 2,6-(3,5-Me2C6H3)2C6H3PI2, 1; 2,6-(4-t-BuC6H4)2C6H3PI 2, 2; and 2,6-(2-MeC6H4)2C6H3PI 2, 3. All new compounds have been characterized by multinuclear NMR spectroscopy and direct analysis in real time mass spectrometry. 9-Iodo-9-phosphafluorene, 12, was also analyzed by X-ray diffraction.