All the king's men (and women): Fluoro-less leadless pacemaker implant in a severely obese patient.

INTRODUCTION: Severe obesity presents significant challenges in imaging and delivery of therapy, including pacemaker implant. METHODS AND RESULT: We present our experience implanting a leadless pacemaker (LP) in a severely obese man presenting with heart block. We describe our multidisciplinary approach using right internal jugular venous access and transesophageal imaging in lieu of fluoroscopy which failed to provide workable images in this instance. CONCLUSION: Ultrasound guided LP placement may have wider application in the midst of an ongoing obesity epidemic where fluoroscopy imaging is both limited and unsafe.

Comparison of clinical outcomes between transthoracic echocardiography- and X-ray-guided left bundle branch pacing for bradycardia: A randomized controlled trial.

INTRODUCTION: Left bundle branch pacing (LBBP) is a physiological pacing modality. However, the long procedure and fluoroscopy time of LBBP is still a problem. This study aims to compare the clinical outcomes between transthoracic echocardiography (TTE)- and X-ray-guided LBBP. METHODS: This is a single-center, prospective, randomized controlled study. Consecutive patients who underwent LBBP in our team from June 2022 to November 2022 were enrolled. Procedure and fluoroscopy time, pacing parameters, electrophysiological and echocardiographic characteristics, as well as complications were recorded at implantation and during follow-up. RESULTS: In this study, 60 patients were enrolled and divided into two groups: 30 patients were allocated to the X-ray group and the remaining 30 to the TTE group. There was no significant difference in the success rate between the two groups (86.7% vs. 76.7%, p = .317). The procedure time of TTE group was comparable to that of the X-ray group (9.0 vs. 12.0 min, p = .063). However, the fluoroscopy time in the TTE group was significantly lower than that of the X-ray group (2.5 vs. 5.0 min, p = .002). There were no statistically significant differences in pacing parameters, electrophysiological and echocardiographic characteristics, or complications between the two groups at implantation and during follow-up. CONCLUSION: TTE-guided LBBP is a feasible and safe method. Compared with X-ray, TTE showed a comparable success rate and procedure time, but it could significantly reduce the fluoroscopy time of LBBP.

Caudal fluoroscopic guidance for the insertion of transvenous pacing leads.

BACKGROUND: Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion. METHODS: Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography. RESULTS: Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01). CONCLUSION: Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

The addition of a leaded arm sleeve to leaded aprons further decreases operator upper outer quadrant chest wall radiation dose during fluoroscopically guided interventions.

OBJECTIVE: Breast cancer most commonly occurs in the upper outer quadrant (UOQ) chest wall (CW). The effectiveness of routine leaded aprons to protect this region of the body in interventionalists during fluoroscopically guided interventions (FGIs) is unknown. Given the high lifetime attributable risks of prolonged occupational exposure to ionizing radiation and the increasing number of practicing female vascular surgeons and interventionalists, we sought to determine if the use of a leaded arm shield would offer additional protection to the lateral CW and axilla in operators compared with routine leaded aprons. METHODS: Effectiveness of leaded sleeves in attenuating radiation dose to the axilla and UOQ was evaluated in clinical practice and simulated scenarios. In the clinical setting, optically stimulated luminescence nanoDot detectors were placed at the UOQ lateral CW position, both over and under a standard leaded apron vest with and without the addition of an antimony/bismuth Enviro-Lite sleeve on two vascular surgeons performing FGIs. In the simulation, nanoDots were similarly placed on an anthropomorphic phantom positioned to represent a primary operator performing right femoral access. Fluorography was performed on 12-inch-thick acrylic scatter phantom at 80 kVp for an exposure of 3 Gy reference air kerma. Experiments were done with and without the sleeve. Paired Wilcoxon and χ2 tests were performed to identify the statistical significance of radiation attenuation. RESULTS: Operator UOQ CW dose was measured during 61 FGIs: 33 cases (54%) with and 28 cases (46%) without the sleeve. Median procedure reference air kerma and fluoroscopy time was 180 mGy (interquartile range [IQR], 85-447 mGy) and 21 minutes (IQR, 11-39 minutes) when the sleeve was worn vs 100 mGy (IQR, 67-270 mGy) and 11 minutes (IQR, 6.3-25 minutes) without the sleeve. Radiation dose to the operator's UOQ was reduced by 96% (IQR, 85%-96%) when the sleeve was present and by 62% (IQR, 44%-82%; P < .001) without the sleeve. In the simulated setting, the sleeve reduced the radiation dose to the UOQ compared with the apron alone (96% vs 67%; P < .001). CONCLUSIONS: Routine leaded aprons do attenuate the majority of UOQ chest wall radiation dose; however, the addition of a lead-equivalent sleeve further significantly reduces this dose. Because this area of the body has a high incidence of cancer formation, additional protection, especially to female interventionalists, seems prudent. Vascular surgeons should consider using a protective sleeve with their personal protective equipment when performing complex fluoroscopically guided procedures.

Using cryoprobes of different sizes combined with cone-beam computed tomography-derived augmented fluoroscopy and endobronchial ultrasound to diagnose peripheral pulmonary lesions: a propensity-matched study.

BACKGROUND: Endobronchial ultrasound (EBUS) and cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) are utilized for the diagnosis of peripheral pulmonary lesions (PPLs). Combining them with transbronchial cryobiopsy (TBC) can provide sufficient tissue for genetic analysis. However, cryoprobes of different sizes have varying degrees of flexibility, which can affect their ability to access the target bronchus and potentially impact the accuracy. The aim of this study was to compare the diagnostic efficacy of cryoprobes of varying sizes in CBCT-AF and EBUS for the diagnosis of PPLs. METHODS: Patients who underwent endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) and TBC combined with CBCT-AF for PPLs diagnosis between January 2021 and May 2022 were included. Propensity score matching and competing-risks regression were utilized for data analysis. Primary outcome was the diagnostic accuracy of TBC. RESULTS: A total of 284 patients underwent TBC, with 172 using a 1.7-mm cryoprobe (1.7 group) and 112 using a 1.1-mm cryoprobe (1.1 group). Finally, we included 99 paired patients following propensity score matching. The diagnostic accuracy of TBC was higher in the 1.1 group (80.8% vs. 69.7%, P = 0.050), with a similar rate of complications. Subgroup analysis also revealed that the 1.1 group had better accuracy when PPLs were located in the upper lobe (85.2% vs. 66.1%, P = 0.020), when PPLs were smaller than 20 mm (78.8% vs. 48.8%, P = 0.008), and when intra-procedural CBCT was needed to be used (79.5% vs. 42.3%, P = 0.001). TBC obtained larger specimens than TBB in both groups. There is still a trend of larger sample size obtained in the 1.7 group, but there is no statistically different between our two study groups (40.8 mm2 vs. 22.0 mm2, P = 0.283). CONCLUSIONS: The combination of TBC with CBCT-AF and EBUS is effective in diagnosing PPLs, and a thin cryoprobe is preferred when the PPLs located in difficult areas.

Long-term outcomes after echocardiography versus fluoroscopy-guided left atrial appendage closure: Is there still a role for a simplified approach?

BACKGROUND: Left atrial appendage closure (LAAC) represents an alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (AF). While transoesophageal echocardiography is the current standard for guiding LAAC procedures, several centers have employed fluoroscopic guidance alone. However, data on long-term outcomes are lacking. METHODS: A total of 536 patients with AF undergoing LAAC and with available data on long-term follow-up were included in the retrospective, single-center analysis. Outcomes of patients undergoing fluoroscopy-guided LAAC were compared with those undergoing echocardiography guided LAAC. Time-dependent analysis was performed with the Kaplan-Meier method. RESULTS: A total of 234 (44%) and 302 (56%) patients were treated with echocardiography and fluoroscopy guidance, respectively. Baseline characteristics did not differ between the two groups. Procedural success rates were high in both groups (97% of fluoroscopy vs. 98% of echocardiography guided procedures; p = 0.92) and rates of relevant peri-device leaks (p = 0.50) and device-related thrombus formation (p = 0.22) did not differ between groups. Median clinical follow-up time was 48 (IQR 19-73) months. Rates of all-cause mortality (p = 0.15, HR 0.83, CI 0.64-1.07) and stroke (p = 0.076, HR 2.23, CI 0.90-5.54) were comparable among groups. CONCLUSION: LAAC with fluoroscopy guidance alone is equally safe and leads to similar clinical outcome compared to LAAC with additional echocardiography guidance.

A preliminary study of minimal left atrial appendage occlusion using Watchman under the guidance of fluoroscopy.

BACKGROUND: Left atrial appendage occlusion (LAAO) has been considered an alternative treatment to prevent embolic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it carries a risk of general anesthesia or esophageal injury if guided by transesophageal echocardiography (TEE). AIMS: We aimed to investigate the feasibility and safety of minimal LAAO (MLAAO) using Watchman under fluoroscopy guidance alone in patients with NVAF. METHODS: A total of 249 consecutive patients with NVAF who underwent LAAO using the WATCHMAN device were divided into two groups: the Standard LAAO (SLAAO) group and the MLAAO group. Procedural characteristics and follow-up results were compared between the two groups. RESULTS: There was no statistically significant difference in the rate of successful device implantation (p > 0.05). Fluoroscopy time, radiation exposure dose, and contrast medium usage in the MLAAO group were higher than those in the SLAAO group (p < 0.001). The procedure time and hospitalization duration were significantly lower in the MLAAO group than those in the SLAAO group (p < 0.001). The occluder compression ratio, measured with fluoroscopy, was lower than that measured with TEE (17.63 ± 3.75% vs. 21.69 ± 4.26%, p < 0.001). Significant differences were observed between the SLAAO group and the MLAAO group (p < 0.05) in terms of oropharyngeal/esophageal injury, hypotension, and dysphagia. At 3 months after LAAO, the MLAAO group had a higher incidence of residual flow within 1-5 mm compared to the SLAAO group, although the difference was not statistically significant. CONCLUSION: MLAAO guided by fluoroscopy, instead of TEE, without general anesthesia simplifies the operational process and may be considered safe, effective, and feasible, especially for individuals who are unable to tolerate or unwilling to undergo TEE or general anesthesia.

Trends in the use of radiation protection and radiation exposure of European endourologists: a prospective trial from the EULIS-YAU Endourology Group.

INTRODUCTION: Due to the radiation exposure for the urology staff during endourology, our aim was to evaluate the trends of radiation protection in the operation room by endourologists from European centers and to estimate their annual radiation. METHODS: We conducted a multicenter study involving experienced endourologists from different European centers to evaluate whether the protection and threshold doses recommended by the International Commission on Radiation Protection (ICRP) were being followed. A 36-question survey was completed on the use of fluoroscopy and radiation protection. Annual prospective data from chest, extremities, and eye dosimeters were collected during a 4-year period (2017-2020). RESULTS: Ten endourologists participated. Most surgeons use lead aprons and thyroid shield (9/10 and 10/10), while leaded gloves and caps are rarely used (2/10 both). Six out of ten surgeons wear leaded glasses. There is widespread use of personal chest dosimeters under the apron (9/10), and only 5/10 use a wrist or ring dosimeter and 4 use an eye dosimeter. Two endourologists use the ALARA protocol. The use of ultrasound and fluoroscopy during PCNL puncture was reported by 8 surgeons. The mean number of PCNL and URS per year was 30.9 (SD 19.9) and 147 (SD 151.9). The mean chest radiation was 1.35 mSv per year and 0.007 mSv per procedure. Mean radiation exposure per year in the eyes and extremities was 1.63 and 11.5 mSv. CONCLUSIONS: Endourologists did not exceed the threshold doses for radiation exposure to the chest, extremities and lens. Furthermore, the ALARA protocol manages to reduce radiation exposure.

Radiation exposure of urologists during endourological procedures: a systematic review.

INTRODUCTION: Ionizing radiation is used daily during endourological procedures. Despite the dangers of both deterministic and stochastic effects of radiation, there is a lack of knowledge and awareness among urologists. This study reviewed the literature to identify the radiation exposure (RE) of urologists during endourological procedures. METHODS: A literature search of the Medline, Web of Science, and Google Scholar databases was conducted to collect articles related to the radiation dose to urologists during endourological procedures. A total of 1966 articles were screened. 21 publications met the inclusion criteria using the PRIMA standards. RESULTS: Twenty-one studies were included, of which 14 were prospective. There was a large variation in the mean RE to the urologist between studies. PCNL had the highest RE to the urologist, especially in the prone position. RE to the eyes and hands was highest in prone PCNL, compared to supine PCNL. Wearing a thyroid shield and lead apron resulted in a reduction of RE ranging between 94.1 and 100%. Educational courses about the possible dangers of radiation decreased RE and increased awareness among endourologists. CONCLUSIONS: This is the first systematic review in the literature analyzing RE to urologists over a time period of more than four decades. Wearing protective garments such as lead glasses, a thyroid shield, and a lead apron are essential to protect the urologist from radiation. Educational courses on radiation should be encouraged to further reduce RE and increase awareness on the harmful effects of radiation, as the awareness of endourologists is currently very low.

Radiation exposure of patients during endourological procedures.

PURPOSE: Considering the existing gaps in the literature regarding patient radiation dose (RD) and its associated risks, a systematic review of the literature on RD was conducted, focusing on percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (SWL), and ureteroscopy (URS). METHODS: Two authors conducted a literature search on PubMed, Web of Science, and Google Scholar to identify studies on RD during endourological procedures. Two thousand two hundred sixty-six articles were screened. Sixty-five publications met the inclusion criteria using the PRISMA standards. RESULTS: RD was generally highest for PCNL, reaching levels up to 33 mSv, 28,700 mGycm2, and 430.8 mGy. This was followed by SWL, with RD reaching up to 7.32 mSv, 13,082 mGycm2, and 142 mGy. URS demonstrated lower RD, reaching up to 6.07 mSv, 8920 mGycm2, and 46.99 mGy. Surgeon experience and case load were inversely associated with RD. Strategies such as optimizing fluoroscopy settings, implementing ultrasound (US), and following the ALARA (As Low As Reasonably Achievable) principle minimized RD. CONCLUSIONS: This is the first systematic review analyzing RD, which was generally highest during PCNL, followed by SWL and URS. There is no specific RD limit for these procedures. Implementation of strategies such as optimizing fluoroscopy settings, utilizing US, and adhering to the ALARA principle proved effective in reducing RD. However, further research is needed to explore the factors influencing RD, assess their impact on patient outcomes, and establish procedure-specific reference levels for RD.

Fully automatic algorithm for detecting and tracking anatomical shoulder landmarks on fluoroscopy images with artificial intelligence.

OBJECTIVE: Patients with rotator cuff tears present often with glenohumeral joint instability. Assessing anatomic angles and shoulder kinematics from fluoroscopy requires labelling of specific landmarks in each image. This study aimed to develop an artificial intelligence model for automatic landmark detection from fluoroscopic images for motion tracking of the scapula and humeral head. MATERIALS AND METHODS: Fluoroscopic images were acquired for both shoulders of 25 participants (N = 12 patients with unilateral rotator cuff tear, 6 men, mean (standard deviation) age: 63.7 ± 9.7 years; 13 asymptomatic subjects, 7 men, 58.2 ± 8.9 years) during a 30° arm abduction and adduction movement in the scapular plane with and without handheld weights of 2 and 4 kg. A 3D full-resolution convolutional neural network (nnU-Net) was trained to automatically locate five landmarks (glenohumeral joint centre, humeral shaft, inferior and superior edges of the glenoid and most lateral point of the acromion) and a calibration sphere. RESULTS: The nnU-Net was trained with ground-truth data from 6021 fluoroscopic images of 40 shoulders and tested with 1925 fluoroscopic images of 10 shoulders. The automatic landmark detection algorithm achieved an accuracy above inter-rater variability and slightly below intra-rater variability. All landmarks and the calibration sphere were located within 1.5 mm, except the humeral landmark within 9.6 mm, but differences in abduction angles were within 1°. CONCLUSION: The proposed algorithm detects the desired landmarks on fluoroscopic images with sufficient accuracy and can therefore be applied to automatically assess shoulder motion, scapular rotation or glenohumeral translation in the scapular plane. CLINICAL RELEVANCE STATEMENT: This nnU-net algorithm facilitates efficient and objective identification and tracking of anatomical landmarks on fluoroscopic images necessary for measuring clinically relevant anatomical configuration (e.g. critical shoulder angle) and enables investigation of dynamic glenohumeral joint stability in pathological shoulders. KEY POINTS: • Anatomical configuration and glenohumeral joint stability are often a concern after rotator cuff tears. • Artificial intelligence applied to fluoroscopic images helps to identify and track anatomical landmarks during dynamic movements. • The developed automatic landmark detection algorithm optimised the labelling procedures and is suitable for clinical application.

Optimizing transseptal puncture guided by three-dimensional mapping: the role of a unipolar electrogram in a needle tip.

AIMS: A three-dimensional electroanatomic mapping system-guided transseptal puncture (3D-TSP), without fluoroscopy or echocardiography, has been only minimally reported. Indications for 3D-TSP remain unclear. Against this background, this study aims to establish a precise technique and create a workflow for validating and selecting eligible patients for fluoroless 3D-TSP. METHODS AND RESULTS: We developed a new methodology for 3D-TSP based on a unipolar electrogram derived from a transseptal needle tip (UEGM tip) in 102 patients (the derivation cohort) with intracardiac echocardiography (ICE) from March 2018 to February 2019. The apparent current of injury (COI) was recorded at the muscular limbus of the foramen ovalis (FO) on the UEGM tip (sinus rhythm: 2.57 ± 0.95 mV, atrial fibrillation: 1.92 ± 0.77 mV), which then disappeared or significantly reduced at the central FO. Changes in the COI, serving as a major criterion to establish a 3D-TSP workflow, proved to be the most valuable indicator for identifying the FO in 99% (101/102) of patients compared with three previous techniques (three minor criteria) of reduction in atrial unipolar or bipolar potential and FO protrusion. A total of 99.9% (1042/1043) patients in the validation cohort underwent successful 3D-TSP through the workflow from March 2019 to July 2023. Intracardiac echocardiography guidance was required for 6.6% (69/1042) of patients. All four criteria were met in 740 patients, resulting in a 100% pure fluoroless 3D-TSP success rate. CONCLUSION: In most patients, fluoroless 3D-TSP was successfully achieved using changes in the COI on the UEGM tip. Patients who met all four criteria were considered suitable for 3D-TSP, while those who met none required ICE guidance.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Zero-fluoroscopy ablation with multielectrode pulse field ablation system: Case series.

Pulse field ablation (PFA) is a novel nonthermal ablation modality for treatment of atrial fibrillation. While mostly lacking 3D electroanatomical mapping integration, reported radiation doses in procedures using multielectrode PFA catheters are relatively high. We report a first case series of three patients where a zero-fluoroscopy approach by intracardiac echocardiography was utilized and present a possible workflow for zero-fluoroscopy ablation with the Farapulse PFA system.

Percutaneous extraction of a Micra AV transcatheter pacing system due to a rare sudden battery failure after 19 months from implantation: A first experience worldwide.

INTRODUCTION: Micra AV Transcatheter Pacing System (TPS) represents an innovative second-generation leadless pacemaker which represents an effective alternative to conventional devices in selected cases. Intrinsic malfunctions of these devices are rare, requiring sometimes their retrieval. When performed in experienced centers, this procedure is safe. CASE PRESENTATION: We describe a case of sudden battery malfunction of a Micra AV TPS, which required the extraction and the placement of a new pacing system in the right ventricle. DISCUSSION: This case, which has never been reported, highlights the need to a careful fluoroscopic evaluation and the usefulness of remote monitoring.

Optimizing conduction system pacing lead placement utilizing the image overlay technique.

The His-bundle has several locations from which conduction system pacing can be achieved. Some locations offer better sensing, thresholds and paced QRS durations. Existing techniques to aid repositioning of an already deployed, but sub-optimally placed lead, include either simple memory of the initial lead position combined with its observation on an x-ray review screen or utilizing an additional vascular access and pacing lead with the first lead serving as a real-time marker (Two-lead technique). We describe a novel, readily available, cost-efficient, imaging-based approach to assist in the re-positioning of a pacing lead for His-bundle pacing (the Image Overlay Technique).

Evaluation of the position of the central venous catheter tip of implantable venous access devices in the occurrence of postoperative thrombotic and non-thrombotic complications.

BACKGROUND: The position of the catheter tip of totally implantable venous access devices (TIVAD) is a risk factor for postoperative complications. The study aim was to assess the early and late complications (EC and LC) associated with the position of the catheter tip in cancer patients. METHODS: We reviewed cancer patients who had a TIVAD placed in 2020. EC (≤ 90 days), LC (> 90 days) and risk factors for TIVAD-associated complications were assessed. The vertical mismatch of the catheter tip was compared to an "ideal position" (> 10 mm below the carina and ≥ 20 mm below the right main bronchus (RMB)) using chest x-ray, post-implantation. RESULTS: 301 patients were included. Median follow-up after TIVAD implantation was 9.4 months. All TIVAD catheters were inserted via the internal jugular vein (IJV). The mean distance between the catheter tip and the carina and the RMB was 21.3 mm and 6.63 mm respectively. In total, 11.3% patients developed EC and 5.6% had LC. An association was found between the position of the catheter tip from the carina (≤ 10 mm vs. > 10 mm) and the occurrence of EC (18.3% vs. 8.6%, p = 0.01) and for the catheter insertion side (left IJV vs. right IJV) (19.1% vs. 9.0% p = 0.02). Multivariate analysis showed that left IJV catheter insertion (OR 2.76), and a catheter tip located ≤ 10 mm below the carina (OR 2.71) are significant independent risk factors of EC. CONCLUSIONS: TIVAD catheter tip located at ≤ 10 mm below the carina, and a left-side inserted catheter, are higher risk of EC.

Comparison of tibial nerve pulsed radiofrequency and intralesional radiofrequency thermocoagulation in the treatment of painful calcaneal spur and plantar fasciitis: a randomized clinical trial.

OBJECTIVE: Ultrasound-guided tibial nerve pulsed radiofrequency (US-guided TN PRF) and fluoroscopy-guided intralesional radiofrequency thermocoagulation (FL-guided intralesional RFT) adjacent to the painful calcaneal spur are two interventions for pain management in painful calcaneal spur and plantar fasciitis. This study aimed to compare the effectiveness of the two procedures. DESIGN: A prospective, randomized, single-blind study. SETTING: Single-center pain clinic. SUBJECTS: Forty-nine patients who met the inclusion criteria were randomized into two groups. METHODS: Group U (25 patients) received US-guided TN PRF at 42°C for 240 s, whereas Group F (24 patients) received FL-guided intralesional RFT at 80°C for 90 s. The most severe numeric rating scale (NRS) score during the first morning steps and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were used to evaluate the effectiveness of the procedures. The study's primary outcome assessed treatment effectiveness via the NRS, whereas the secondary outcomes included changes in the AOFAS score and the incidence of procedure-related mild adverse events. RESULTS: NRS and AOFAS scores significantly improved in Groups U and F at 1 and 3 months compared with baseline (P < .05), and there was no significant difference between the groups. At month 1, 50% or greater pain relief was achieved in 72% of patients in Group U and 75% of patients in Group F. No significant difference was observed in the incidence of mild adverse events between the groups. CONCLUSIONS: US-guided TN PRF and FL-guided intralesional RFT have shown significant effectiveness in the treatment of painful calcaneal spur and plantar fasciitis. Larger randomized controlled trials are needed. CLINICAL TRIAL NUMBER: NCT06240507.

Assessment of MMP-9 and clinical characteristics in dogs with tracheal collapse based on cough severity and fluoroscopic findings: a cross-sectional study.

BACKGROUND: Tracheal collapse (TC), a common disease in dogs, is characterized by cough; however, little is known about the serum biomarkers that can objectively evaluate the severity of cough in canine TC. Furthermore, studies elucidating the relationship of fluoroscopic characteristics with the severity of cough are lacking. Therefore, this study aimed to evaluate the relationship between cough severity and clinical characteristics, fluoroscopic images, and new serum biomarkers in canine TC. RESULTS: Fifty-one client-owned dogs diagnosed with TC based on fluoroscopic and clinical signs were enrolled in this study and divided into three groups according to the severity of cough (grade of cough: 0, 1, and 2). Signalments, comorbidities, and fluoroscopic characteristics were compared among the groups retrospectively. The serum matrix metalloproteinase-9 (MMP-9), interleukin-6 (IL-6), surfactant protein-A (SP-A), and syndecan-1 (SDC-1) levels were measured in all groups. No significant differences in age, breed, sex, or clinical history were observed among the groups. Concomitant pharyngeal collapse increased significantly with the severity of cough (p = .031). Based on the fluoroscopic characteristics, the TC grade of the carinal region increased significantly and consistently with the grade of cough (p = .03). The serum MMP-9 level was significantly higher in the grade 2 group than that in the grade 0 group (p = .014). The serum IL-6 level was significantly lower in the grade 1 group than that in the grade 0 group (p = .020). The serum SP-A and SDC-1 levels did not differ significantly among the groups. CONCLUSIONS: The severity of cough with the progression of TC can be predicted with the fluoroscopic TC grade at the carinal region. MMP-9 may be used as an objective serum biomarker that represents cough severity to understand the pathogenesis.

Early Pneumatocele Identification Post-Robotic Assisted Bronchoscopy Cryobiopsy: A Case Series Experience.

INTRODUCTION: The use of cryobiopsy in conjunction with robotic assisted bronchoscopy is on the rise due to the safety and increased diagnostic yield of cryobiopsy. The incorporation of 3D fluoroscopy in the procedure improves the workflow and helps confirm the accuracy of sampling of peripheral pulmonary nodules. METHODS: We describe an observational series of 12 patients comprising 14 nodules where cryobiopsy was performed during shape-sensing robot-assisted bronchoscopy cryobiopsy under general anesthesia. 3D fluoroscopy was used to confirm accurate placement of the cryoprobe. All these patients underwent a second spin with the 3D fluoroscopy either to sample a second lesion intraoperatively or to investigate suspected pneumothorax. RESULTS: The development of a pneumatocele was noted after cryobiopsy in each of the cases. The majority of these were in the upper lobe with the median size of a sampled nodule being 14 mm. The majority of patients were asymptomatic with 1 patient developing mild hemoptysis and 4 patients developing chest tightness or dyspnea. None of the patients required an intervention for the pneumatocele. CONCLUSION: The development of pneumatoceles appears to be a fairly frequent and benign occurrence following cryobiopsy, likely due to increased tissue destruction. The increased use of intraoperative 3D fluoroscopy is likely to highlight changes to the pulmonary parenchyma that were previously not known. The occurrence of pneumatoceles does not appear to adversely impact the safety or tolerability profile of cryobiopsy.