Transcatheter Closure of Large Coronary-Cameral Fistulas Using the Patent Ductus Arteriosus Occluder or Amplatzer Vascular Plugs.

Transcatheter closure (TCC) has emerged as the first-line treatment for coronary artery fistulas. However, limited data exist regarding the long-term outcomes and technical aspects of this procedure. We aimed to report the long-term outcomes and technical aspects of TCC of large coronary-cameral fistulas (CCFs).All patients with large CCFs who underwent attempted TCC using the patent ductus arteriosus (PDA) occluder or Amplatzer vascular plug (AVP), from June 2002 to December 2017, were retrospectively reviewed. A total of 23 patients with large CCFs underwent attempted TCC using the PDA occluder or AVP. Most CCFs originated from the right coronary artery and drained predominantly into the right heart chamber. Procedural success was achieved in 21 (91.3%) patients. Devices were deployed using the arteriovenous loop in 15, transarterial approach in 4, and arterio-artery loop approach in 2 patients. Procedural complications included coronary spasm in one and side branch occlusion in one patient. Among these 21 patients with successful device implantation, follow-up angiograms or computed tomography angiograms were obtained in 14 (66.7%) patients at a median of 11.0 (range, 9.8-16.3) months. Late complications included thrombosis of residual fistula segment without myocardial infarction (MI) in one, coronary thrombosis resulting in MI in one, and recanalization necessitating re-intervention in one patient. No death and device embolization occurred.TCC of large CCFs using the PDA occluder or AVP is an effective therapy in anatomically suitable candidates, with favorable long-term outcomes. Given that potentially hazardous complications may occur late after the procedure, long-term periodic evaluation is mandatory.

Electrospun LiFePO4/C Composite Fiber Membrane as a Binder-Free, Self-Standing Cathode for Power Lithium-Ion Battery.

A LiFePO4/C composite fiber membrane was fabricated by the electrospinning method and subsequent thermal treatment. The thermal decomposition process was analyzed by TG/DSC, the morphology, microstructure and composition were studied using SEM, TEM, XRD, Raman, respectively. The results indicated that the prepared LiFePO4/C composite fibers were composed of nanosized LiFePO4 crystals and amorphous carbon coatings, which formed a three dimensional (3D) long-range networks, greatly enhanced the electronic conductivity of LiFePO4 electrode up to 3.59× 10-2 S · cm-2. The 3D LiFePO4/C fiber membrane could be directly used as a binder-free, self-standing cathode for lithium-ion battery, and exhibited an improved capacity and rate performance. The LiFePO4/C composite electrode delivered a discharge capacity of 116 mAh·g-1, 109 mAh·g-1, 103 mAh·g-1, 91 mAh·g-1, 80 mAh·g-1 at 0.1 C, 0.5 C, 1 C, 3 C, 5 C, respectively. And a stable cycling performance was also achieved that the specific capacity could retain 75 mA·g-1 after 500 cycles at 5 C. Therefore, this LiFePO4/C composite fiber membrane was promising to be used as a cathode for power lithium ion battery.

Pharyngoesophageal Reconstruction With the Medial Sural Artery Perforator Flap After Total Laryngopharyngectomy: A New Method.

BACKGROUND: The medial sural artery perforator (MSAP) flap has become a popular target in head and neck reconstruction. This flap has many advantages compared with other free flaps but has not yet been used in the reconstruction of circumferential haryngoesophageal defects. METHODS: Reconstruction of pharyngoesophageal circumferential defects using the MSAP flap was performed in 4 patients. The design of the flap was based on the perforators, which were confirmed by endoscopy. The MSAP flap was tubed and anastomosed end to end to the esophagus. The artery was anastomosed to the superior thyroid arteries, whereas the vein was anastomosed to the internal jugular vein. RESULTS: All the flaps survived. All 4 patients gained acceptable speech and swallow function. One patient developed an infection at the donor site, a second developed fistulas, and a third experienced stricture. All complications were successfully treated. CONCLUSIONS: Here, we demonstrated the use of the MSAP flap in reconstruction of circumferential pharyngoesophageal defects. Further application and follow-up studies should be performed.

Association of serum cystatin C levels with myocardial perfusion and cardiac functional recovery in patients with anterior wall ST elevation myocardial infarction treated with primary coronary intervention.

This study sought to investigate the association of baseline serum cystatin C levels with myocardial perfusion and cardiac functional recovery in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). 108 patients with a first anterior STEMI who underwent PPCI were enrolled. Serum cystatin C was measured by immunoturbidimetric method. Patients were divided into two groups according to the median cystatin C levels on admission: group 1 (≥median, n = 54) and group 2 (

Surgically treated solitary giant gluteal and retroperitoneal neurofibroma: a case report.

BACKGROUND: Giant neurofibromas in patients with neurofibromatosis type 1 involve multiple regions and are often difficult to surgically extirpate. However, surgical intervention is the most effective means for improving quality of life. The case reported herein is unique in that it involves a giant neurofibroma, involving the patient's peritoneal and pelvic cavities, retroperitoneal space, and buttock, which was causing compressive displacement of abdominal and pelvic organs. A challenging surgical intervention was required to accomplish near-total resection to relieve organ compression while preserving visceral and genitoanal function. CASE PRESENTATION: The case reported is of a patient presenting with a solitary giant retroperitoneal neurofibroma that threatened to obliterate both peritoneal and pelvic cavities and protruded conspicuously into the right gluteal region. The enormous dumbbell-shaped mass was surgically removed in three parts. Postoperative pathology studies confirmed a diagnosis of neurofibroma. Follow-up computed tomography images taken three months postoperatively revealed residual tumor in the perianal region. The patient's quality of life had measurably improved on follow-up at eight months. CONCLUSIONS: Surgical intervention in such extraordinary circumstances of a giant neurofibroma causing compressive displacement of critical organs reduces tumor burden, restores appearance and function of patient's body and internal organs, and improves the patient's quality of life.

Severe Mechanical Hemolysis After Transcatheter Closure of a Traumatic Ventricular Septal Defect Using the Amplatzer Atrial Septal Occluder.

Traumatic ventricular septal defect (VSD) resulting from chest trauma, either penetrating or blunt, is a relatively rare occurrence. Herein, we describe the case of a previously healthy 26-year-old man who presented with congestive heart failure, which was secondary to a large traumatic VSD following violent blunt chest trauma. The traumatic VSD was initially closed percutaneously using an Amplatzer atrial septal defect occluder. Post-device closure, however, the patient developed severe intravascular hemolysis refractory to medical treatment. The patient subsequently underwent surgical removal of the Amplatzer device, with concomitant VSD patch closure.

Asymmetric Dimethyl-L-Arginine is a Biomarker for Disease Stage and Follow-Up of Pulmonary Hypertension Associated with Congenital Heart Disease.

This study investigated the clinical value of plasma asymmetrical dimethyl-L-arginine (ADMA) level in the diagnosis, staging, and treatment response in congenital heart disease (CHD) patients with pulmonary arterial hypertension (PAH). This was a single-center prospective observational study in 80 CHD patients. Plasma ADMA levels were measured by enzyme-linked immunosorbent assay. Plasma ADMA levels were significantly increased in CHD patients with PAH compared with CHD patients without PAH (P < 0.01) and healthy controls (P < 0.001). In CHD patients with severe PAH, plasma ADMA levels were significantly higher in patients with Eisenmenger's syndrome (ES) than in patients exhibiting low pulmonary vascular resistance (P < 0.001). The plasma ADMA levels significantly correlated with pulmonary arterial pressure (P < 0.001) and pulmonary vascular resistance (P < 0.001) in patients with CHD. Severe PAH was identified by plasma ADMA with a cutoff value of 0.485 µmol/L (P < 0.001) with a specificity of 82.8 % and a sensitivity of 90 %. ES was identified by plasma ADMA with a cutoff value of 0.85 µmol/L (P < 0.05) with a specificity of 85.2 % and a sensitivity of 64.3 %. ADMA levels were significantly decreased after sildenafil therapy for 6 months compared with before therapy levels (0.91 ± 0.22 vs. 0.57 ± 0.30, P < 0.01). Our study suggests that plasma ADMA level may be used as a biomarker for identifying PAH in patients with CHD, assessing pulmonary vascular remodeling, and evaluating the treatment response of CHD patients with PAH to sildenafil.

Long-term outcomes of transcatheter closure of ruptured sinus valsalva aneurysms using patent ductus arteriosus occluders.

BACKGROUND: Transcatheter closure (TCC) of ruptured sinus of Valsalva aneurysm (RSVA) is an alternative strategy to surgery, but there is a lack of long-term outcome data. METHODS AND RESULTS: From 2004 to 2012, 17 patients (8 males, 9 females) were treated with patent ductus arteriosus (PDA) occluders by antegrade venous approach and were followed for 18-102 months. Of the 17 patients, transthoracic echocardiography revealed rupture of the right coronary sinus into the right ventricle in 9 and into the right atrium in 4, and noncoronary sinus rupture into the right ventricle in 3 and into the right atrium in 1. Most (10/17) were in New York Heart Association (NYHA) functional class III or IV. Aortography showed that the size of the defect was 7.71±2.84 mm (4-15 mm). TCC was attempted using PDA occluders 2-5 mm larger than the aortic end of the defects. The device sizes ranged from 8/6 to 18/16 mm (median, 10/8 mm). The procedure was successful in 16 (94.1%), and all of them had complete occlusion at discharge. On a median follow-up of 42 months, 14 patients were in NYHA class I and 2 were in class II, and there was no residual shunt, device embolization, infective endocarditis, or aortic regurgitation. CONCLUSIONS: TCC of RSVA is a safe and effective alternative to surgery with favorable long-term follow-up results.

Color Doppler imaging of an ulnar artery perforator forearm flap for resurfacing finger defects.

BACKGROUND: Fingertip defect reconstruction with various free perforator flaps has been widely reported. We recommend a technique of using color Doppler imaging to locate ulnar artery perforator. And we used a free mesioforearm flap based on ulnar artery perforator for the reconstruction of fingertip defect. PATIENTS AND METHODS: Since 2010, 7 fingertip defect cases have been repaired at our hospital using free mesioforearm flaps, based on the ulnar artery perforator. The free flap was designed according to Doppler detection. The flap contained perforator vessels and cutaneous nerves. The donor site was directly sutured or skin grafted. RESULTS: All 7 flaps survived with good quality and esthetic contours and grasp function of the hand was satisfactory. They were evaluated by 2-point discrimination, with 5 cases with neurorrhaphy of 6 to 8 mm and 2 cases without neurorrhaphy of 10 to 12 mm. CONCLUSIONS: Ultrasound is a suitable method for preoperatively locating the vascular pedicle. The free mesioforearm flap based on ulnar artery perforator is a good option to repair fingertip defect.

Magnetic core-shell nano-TiO2/Al2O3/NiFe2O4 microparticles with enhanced photocatalytic activity.

The core-shell nano-TiO2/Al2O3/NiFe2O4 microparticles of 5-8 microm were prepared by the heterogeneous precipitation followed by calcination treatment. The morphologies, structure, crystalline phase, and magnetic property were characterized by optical biomicroscopy (OBM), scanning electron microscopy (SEM), X-ray diffractometry (XRD) and vibrating sample magnetometer (VSM) respectively. The photocatalytic activity was evaluated by degrading methyl orange solution either under UV light and sunlight. The results indicate that the nano-TiO2 layer consists of needle-like nanoparticles and the intermediate layer of Al2O3 avoids the nano-TiO2 agglomeration, shedding and uneven loading. The nano-TiO2/Al2O3/NiFe2O4 composite particles show high magnetization of 31.5 emu/g and enhanced photocatalytic activity to completely degrade 50 mg/L methyl orange solution either under UV light and sun light. The enhanced activity of the composite is attributed to the unique structure, insulation effect of Al2O3 intermediate layer and the hybrid effect of anatase TiO2 and NiFe2O4. The obtained catalyst may be magnetically separable and useful for many practical applications due to the improved photocatalytic properties under sunlight.

A novel approach to facilitating balloon crossing chronic total occlusions: the "wire-cutting" technique.

BACKGROUND: Following successful guidewire passage, inability to cross the occluded lesion with a balloon is the most common cause of procedural failure for percutaneous recanalization of chronic total occlusions (CTOs). We sought to evaluate the efficacy of "wire-cutting" technique for facilitating the balloon passage through the lesion during CTO-percutaneous coronary intervention. METHODS: Sixteen consecutive patients with CTOs were treated by "wire-cutting" technique when a lubricious balloon could not be passed through the lesion after successful guidewire crossing. The main process of the "wire-cutting" technique involved: inserting 2 percutaneous transluminal coronary angioplasty (PTCA) guidewires (A and B) into the distal true lumen; advancing a balloon over guidewire A to the site of the occlusion abutting the proximal cap, the balloon was then inflated and guidewire B was pressed between the balloon and the proximal cap; rapidly withdrawing guidewire B produced a cutting power that crushed the proximal cap thus facilitating balloon crossing. Technique success was defined as balloon having crossed CTO lesions successfully after performing wire-cutting procedure. RESULTS: Both technical success and procedural success were obtained in 10 (62.5%) cases. Technique failure occurred in 6 (37.5%) cases, of which 2 were due to the inability to place a second guidewire into the distal true lumen and the other 4 were due to severe coronary calcification. Of these 4 failures, 2 have final procedure success with the use of Rotablator and the remaining 2 patients were referred for bypass surgery. Major complication included severe coronary dissection that occurred in 1 (6.3%) patient, which was successfully treated by stenting. No other complications were observed. CONCLUSION: The wire-cutting technique may be considered as a simple and effective approach for facilitating balloon crossing resistant CTO lesions.

A Multifunctional Gradient Solid Electrolyte Remarkably Improving Interface Compatibility and Ion Transport in Solid-State Lithium Battery.

Solid electrolytes with both interface compatibility and efficient ion transport have been an urgent technical requirement for the practical application of solid-state lithium batteries. Herein, a multifuctional poly(1,3-dioxolane) (PDOL) electrolyte combining the gradient structure from the solid state to the gel state with the Li6.4La3Zr1.4Ta0.6O12 (LLZTO) interfacial modification layer was designed, in which the "solid-to-gel" gradient structure greatly improved the electrode/electrolyte interface compatibility and ion transport, while the solid PDOL and LLZTO layers effectively improved the interface stability of the electrolyte/lithium anode and the inhibition of the lithium dendrites via their high mechanical strength and forming a stable interfacial SEI composite film. This gradient PDOL/LLZTO composite electrolyte possesses a high ionic conductivity of 2.9 × 10-4 S/cm with a wide electrochemical window up to 4.9 V vs Li/Li+. Compared with the pristine PDOL electrolyte and PDOL solid electrolyte membrane coated with a layer of LLZTO, the gradient PDOL/LLZTO composite electrolyte shows better electrode/electrolyte interfacial compatibility, lower interface impedance, and smaller polarization, resulting in enhanced rate and cycle performances. The NCM622/PDOL-LLZTO/Li battery can be stably cycled 200 times at 0.3C and 25 °C. This multifunctional gradient structure design will promote the development of high-performance solid electrolytes and is expected to be widely used in solid-state lithium batteries.

Integrating high ionic conductive PDOL solid/gel composite electrolyte for enhancement of interface combination and lithium dentrite inhibition of solid-state lithium battery.

High interface impedance, slow ion transmission, and easy growth of lithium dendrites in solid-state lithium battery are main obstacles to its development and application. Good interface combination and compatibility between electrolyte and electrodes is an important way to solve these problems. In this work, we successfully combined a high ionic conductive polymerized 1,3-dioxolane (PDOL) solid-state electrolyte and a PDOL gel-state electrolyte to form a rigid-flexible composite structural electrolyte and realized the gelation modification of solid electrolyte/electrode interface. This "PDOL SE + PDOL Gel" composite structure not only improves the electrode/electrolyte interfacial contact, reduces the interfacial impedance, but also inhibits the growth of lithium dendrites in the interface between lithium anode and electrolyte by forming an uniform Li-Zr-O and LiF composite protection layer. This composite electrolyte has high ionic conductivity of 5.96 × 10-4 S/cm and wide electrochemical stability window of 5.0 V. The Li/PDOL SE + PDOL Gel/Li cells can be cycled stably for nearly 400 h at a current density of 1.0 mA/cm2. The assembled LiCoO2/PDOL SE + PDOL Gel/Li cells can be cycled for 250 cycles at 0.5 C with a capacity retention of 80%. This PDOL solid/gel composite electrolyte shows high promising commercial application prospect due to its high security performance, excellent interfacial properties and dendrite inhibition ability.

Enhanced ionic conductivity and lithium dendrite suppression of polymer solid electrolytes by alumina nanorods and interfacial graphite modification.

Poor room-temperature ionic conductivity and lithium dendrite formation are the main issues of solid electrolytes. In this work, rod-shaped alumina incorporation and graphite coating were simultaneously applied to poly (propylene carbonate) (PPC)-based polymer solid electrolytes (Wang et al., 2018). The obtained alumina modified solid electrolyte membrane (Al-SE) achieves a high ionic conductivity of 3.48 × 10-4 S/cm at room temperature with a wide electrochemical window of 4.6 V. The assembled NCM622/Al-SE/Li solid-state battery exhibits initial discharge capacities of 198.2 mAh/g and 177.5 mAh/g at the current density of 0.1 C and 0.5 C, with the remaining capacities of 165.8 mAh/g and 161.3 mAh/g after 100 cycles respectively. The rod-shaped structure of Al2O3 provides fast transport channels for lithium ions and its Lewis acidity promotes the dissociation of lithium salts and release of free lithium ions. The lithiophilic Al2O3 and Graphite form intimate contact with metallic Li and create fast Li+ conductive layers of Li-Al-O layer and LiC6 layer, thus facilitating the uniform deposition of Li and inhibiting Li dendrite formation during long-term cycling. This kind of composite Al-SE is expected to provide a promising alternative for practical application in solid electrolytes.

[Prevalence and risk factors of peri-procedure electrical storm in acute myocardial infarction patients underwent emergency percutaneous coronary intervention].

OBJECTIVE: To determine the prevalence and to identify risk factors of peri-procedure electrical storm (ES) in patients with acute myocardial infarction (AMI) underwent emergency percutaneous coronary intervention (PCI). METHODS: The clinical data of 228 AMI patients underwent emergency PCI were retrospectively analyzed and patients were divided into ES group (n = 39) and non-ES (n = 189) group. ES was referred to spontaneous ventricular tachycardia or ventricular fibrillation occurring twice or more within 24 h and requiring emergency treatment including anti-arrhythmic medicine and/or cardioversion or defibrillation. RESULTS: ES was diagnosed in 39 out of 228 patients (17.1%) during peri-procedure stage. The incidence of ES in patients with various infarct related arteries (IRA) was as follows: 55.6% with left main artery (LM), 23.7% with right coronary artery (RCA), 12.4% with anterior descending branch (LAD) and 0 with left circumflex artery (LCX). Older age, lager diameter of IRA, higher concentration of CK-MB and cTnT, higher incidence of reperfusion arrhythmia (RA), lower grade of TIMI after PCI and higher mortality were associated with increased risks of ES (The P value was 0.043, 0.012, 0.036, 0.018, 0.001, 0.049, respectively). Gender, systolic pressure, diastolic pressure, random blood glucose level, white blood count and concentration of hs-CRP were similar between ES and non-ES patients. Logistic analysis showed that the diameter of IRA (OR 2.381, 95%CI 1.127-5.028, P = 0.023), TIMI grade of IRA after PCI (OR 4.744, 95% CI 1.773-12.691, P = 0.002) and RA (OR 12.680, 95% CI 4.360-36.879, P = 0.000) were the independent risk factors of per-procedure ES in AMI patients underwent emergency PCI. CONCLUSIONS: The AMI patients with LM as IRA had the highest incidence of ES during emergency PCI and the diameter of IRA, TIMI grade of IRA after PCI and RA were independent risk factors for the development of ES during peri-PCI stage.

Electrochemical Behaviors of Sulfurized-Polyacrylonitrile with Synthesized Polyacrylonitrile Precursors Based on the Radical Polymerization Through Monomer Acrylonitrile.

Polyacrylonitrile (PAN) precursors have been polymerized at different radical polymerization temperatures for preparing sulfurized-polyacrylonitrile (S-PAN) composite cathodes in rechargeable lithium sulfur battery. The physical properties of these composites have been investigated using X-ray diffraction, Fourier transform infrared spectrometry, Raman spectroscopy, Brunner-Emmet-Teller measurement and Gel permeation chromatography analysis. The electrochemical performance of the S-PAN composite cathodes made from the PAN precursor was investigated. The results showed that the molecular weight distribution of the PAN precursors affected the electrochemical performance of the S-PAN made from the PAN precursor. S-PAN composites derived from PAN with a narrower molecular weight distribution at 65 °C were exhibit the best electrochemical performance in lithium-sulfur battery.

Improved Interface Stability and Room-Temperature Performance of Solid-State Lithium Batteries by Integrating Cathode/Electrolyte and Graphite Coating.

Poor interface stability is a crucial problem hindering the electrochemical performance of solid-state lithium batteries. In this work, a novel approach for interface stability was proposed to integrate the cathode/solid electrolyte by forming an electrolyte buffer layer on the rough surface of the cathode and coating a layer of graphite on the side of the electrolyte facing the lithium anode. This hybrid structure significantly improves the integration and the interface stability of the electrode/electrolyte. The interfacial resistance was dramatically reduced, the stability of the plating/stripping of Li metal was enhanced, and the growth of lithium dendrites was also inhibited due to the formation of the LiC6 transition layer. The obtained solid-state lithium battery shows enhanced rate performance at room temperature from 0.5 to 4 C and stable cycling performance at 1 C with a retention capacity of 100 mAh g-1 after 200 cycles. This integrated electrode/electrolyte design approach is expected to be widely used to improve interfacial stability and room-temperature electrochemical performance of solid-state batteries.

An Overlapped Nano-Fe2O3/TiO2 Composite Coating on Activated Carbon Fiber Membrane with Enhanced Photocatalytic Performance.

Treatment of high concentration organic wastewater has always been a difficult problem in the field of water purification due to its high cost, low efficiency, long processing cycle and possible second pollution. An overlapped nano-Fe2O3/TiO2@activated carbon fiber membrane composite was successfully prepared by hydrothermal loading method. Nano-rod-like TiO2 and columnar Fe2O3 polyhedrals overlapped and formed a composite coating on the surface of activated carbon fiber membrane. This composite can absorb visible light and successfully remove the high concentration Congo red pollutant (400 mg/L) in 24 h. The enhanced photocatalytic performance should be attributed to the synergistic reaction of nano-Fe2O3 and nano-TiO2, which improves the separation of photo-generated electrons and holes thus enhances the photocatalytic efficiency. This multifunctional fiber membrane is expected to be widely applied in various organic wastewater treatments.

A novel all-fiber-based LiFePO4/Li4Ti5O12 battery with self-standing nanofiber membrane electrodes.

Electrodes with high conductivity and flexibility are crucial to the development of flexible lithium-ion batteries. In this study, three-dimensional (3D) LiFePO4 and Li4Ti5O12 fiber membrane materials were prepared through electrospinning and directly used as self-standing electrodes for lithium-ion batteries. The structure and morphology of the fibers, and the electrochemical performance of the electrodes and the full battery were characterized. The results show that the LiFePO4 and Li4Ti5O12 fiber membrane electrodes exhibit good rate and cycle performance. In particular, the all-fiber-based gel-state battery composed of LiFePO4 and Li4Ti5O12 fiber membrane electrodes can be charged/discharged for 800 cycles at 1C with a retention capacity of more than 100 mAh·g-1 and a coulombic efficiency close to 100%. The good electrochemical performance is attributed to the high electronic and ionic conductivity provided by the 3D network structure of the self-standing electrodes. This design and preparation method for all-fiber-based lithium-ion batteries provides a novel strategy for the development of high-performance flexible batteries.

Complications associated with transcatheter closure of perimembranous ventricular septal defects.

OBJECTIVES: To identify the complications associated with transcatheter closure of perimembranous ventricular septal defects (PmVSD) using the Amplazter PmVSD occluder (AGA Medical, USA). METHODS: Between October 2002 and November 2006, transcatheter closure PmVSD was attempted in 210 patients and performed in 206 patients. Those patients were followed-up for 6-24 months (mean, 10.6 +/- 3.9 months) to identify the complications. RESULTS: Device implantation was successfully accomplished in 206 of the 210 patients (98%). Serious complications such as high degree atrioventricular block (AV block), infective endocarditis, and device embolization occurred in eight cases (3.8%). Other complications including mild aortic or tricuspid regurgitation, femoral pseudoaneurysm, and femoral arteriovenous fistula occurred in four cases. CONCLUSIONS: Transcatheter closure of PmVSD can be performed safely and successfully. But further studies should continue to evaluate the potential complications associated with this procedure.