Damage-control vascular surgery in Canada: supporting surgeons and teams.

SummaryIn Canada, trauma patients often present initially to non-trauma hospitals without vascular surgeons on site. Local surgeons need skills and support for damage-control vascular surgery. Canadian training programs in general surgery should equip trainees with skills in this area, including resuscitation, identification of vascular injury, hemorrhage control, and temporizing measures (e.g., shunts, ligation). Caring for trauma patients is a multidisciplinary endeavour; understanding local/regional skill sets and from whom to seek help is vital. Opportunities for skills maintenance should also be encouraged for surgeons practising at sites where acutely injured patients present.

Cardiopulmonary resuscitation outcomes of dogs and cats at a veterinary teaching hospital before and after publication of the RECOVER guidelines.

OBJECTIVES: To describe and compare cardiopulmonary resuscitation outcomes at a Swiss veterinary teaching hospital before and after publication of the Reassessment Campaign on Veterinary Resuscitation guidelines. MATERIALS AND METHODS: Between 2018 and 2020, hospital staff underwent various types of yearly Reassessment Campaign on Veterinary Resuscitation-based cardiopulmonary resuscitation trainings. Canine and feline cardiopulmonary resuscitation events during that period (post-Reassessment Campaign on Veterinary Resuscitation) and between 2010 and 2012 (pre-Reassessment Campaign on Veterinary Resuscitation) were identified and animal, arrest and outcome variables recorded retrospectively. RESULTS: Eighty-one animals were included in the pre-Reassessment Campaign on Veterinary Resuscitation group and 190 in the post-Reassessment Campaign on Veterinary Resuscitation group. Twenty-three percent in the pre-Reassessment Campaign on Veterinary Resuscitation group and 28% in the post-Reassessment Campaign on Veterinary Resuscitation group achieved return of spontaneous circulation and 1% and 4% survived to hospital discharge, respectively. Patients undergoing anaesthesia [odds ratio 4.26 (1.76 to 10.27)], elective [odds ratio 5.16 (1.06 to 25.02)] or emergent surgery [odds ratio 3.09 (1.20 to 8.00)], or experiencing cardiopulmonary arrest (CPA) due to arrhythmias [odds ratio 4.31 (1.44 to 12.93)] had higher odds of return of spontaneous circulation, while those with unknown cause of CPA [odds ratio 0.25 (0.08 to 0.78)] had lower odds. Undergoing cardiopulmonary resuscitation in the post-Reassessment Campaign on Veterinary Resuscitation period was not statistically significantly associated with return of spontaneous circulation [odds ratio 1.38 (0.68 to 2.79)]. CLINICAL SIGNIFICANCE: Unchanged odds of return of spontaneous circulation observed in this study could suggest that once-yearly cardiopulmonary resuscitation training is insufficient, effects of animal and tertiary referral hospital variables confounded results, guideline benefit is limited, or that compliance during clinical cardiopulmonary resuscitation efforts is too poor for guideline recommendations to have a positive impact.

Plasma-Enhanced Atomic Layer Deposition of Nickel Nanotubes with Low Resistivity and Coherent Magnetization Dynamics for 3D Spintronics.

We report plasma-enhanced atomic layer deposition (ALD) to prepare conformal nickel thin films and nanotubes using nickelocene as a precursor, water as the oxidant agent, and an in-cycle plasma-enhanced reduction step with hydrogen. The optimized ALD pulse sequence, combined with a post-processing annealing treatment, allowed us to prepare 30 nm-thick metallic Ni layers with a resistivity of 8 µΩ cm at room temperature and good conformality both on the planar substrates and nanotemplates. Thus, we fabricated several micrometers-long nickel nanotubes with diameters ranging from 120 to 330 nm. We report the correlation between ALD growth and functional properties of individual Ni nanotubes characterized in terms of magnetotransport and the confinement of spin-wave modes. The findings offer novel perspectives for Ni-based spintronics and magnonic devices operated in the GHz frequency regime with 3D device architectures.

Pharmacodynamics and proteomic analysis of acalabrutinib therapy: similarity of on-target effects to ibrutinib and rationale for combination therapy.

Acalabrutinib, a highly selective Bruton's tyrosine kinase inhibitor, is associated with high overall response rates and durable remission in previously treated chronic lymphocytic leukemia (CLL); however, complete remissions were limited. To elucidate on-target and pharmacodynamic effects of acalabrutinib, we evaluated several laboratory endpoints, including proteomic changes, chemokine modulation and impact on cell migration. Pharmacological profiling of samples from acalabrutinib-treated CLL patients was used to identify strategies for achieving deeper responses, and to identify additive/synergistic combination regimens. Peripheral blood samples from 21 patients with relapsed/refractory CLL in acalabrutinib phase I (100-400 mg/day) and II (100 mg BID) clinical trials were collected prior to and on days 8 and 28 after treatment initiation and evaluated for plasma chemokines, reverse phase protein array, immunoblotting and pseudoemperipolesis. The on-target pharmacodynamic profile of acalabrutinib in CLL lymphocytes was comparable to ibrutinib in measures of acalabrutinib-mediated changes in CCL3/CCL4 chemokine production, migration assays and changes in B-cell receptor signaling pathway proteins and other downstream survival proteins. Among several CLL-targeted agents, venetoclax, when combined with acalabrutinib, showed optimal complementary activity in vitro, ex vivo and in vivo in TCL-1 adoptive transfer mouse model system of CLL. These findings support selective targeting and combinatorial potential of acalabrutinib.

Prognostic value of pretreatment circulating neutrophils, monocytes, and lymphocytes on outcomes in lung stereotactic body radiotherapy.

PURPOSE: In the present study, we determined the association of pretreatment circulating neutrophils, monocytes, and lymphocytes with clinical outcomes after lung stereotactic body radiotherapy (sbrt). METHODS: All patients with primary lung cancer and with a complete blood count within 3 months of lung sbrt from 2005 to 2012 were included. Overall survival (os) was calculated using the Kaplan-Meier method. Factors associated with os were investigated using univariable and multivariable Cox proportional hazards regression. Fine-Gray competing risk regression was performed to test the association of the neutrophil:lymphocyte (nlr) and monocyte:lymphocyte (mlr) ratios with two types of failure: disease-related failure and death, and death unrelated to disease. RESULTS: Of the 299 sbrt patients identified, 122 were eligible for analysis. The median and range of the nlr and mlr were 3.0 (0.3-22.0) and 0.4 (0.1-1.9) respectively. On multivariable analysis, sex (p = 0.02), T stage (p = 0.04), and nlr (p < 0.01) were associated with os. On multivariable analysis, T stage (p < 0.01) and mlr (p < 0.01) were associated with disease-related failure; mlr (p = 0.03), nlr (p < 0.01), and sbrt dose of 48 Gy in 4 fractions (p = 0.03) and 54 Gy or 60 Gy in 3 fractions (p = 0.02) were associated with disease-unrelated death. Median survival was 4.3 years in the nlr≤3 group (95% confidence interval: 3.5 to not reached) and 2.5 years in the nlr>3 group (95% confidence interval: 1.7 to 4.8; p < 0.01). CONCLUSIONS: In lung sbrt patients, nlr and mlr are independently associated with os and disease-unrelated death. If validated, nlr and mlr could help to identify patients who would benefit most from sbrt.

Influence of temperament score and handling facility on stress, reproductive hormone concentrations, and fixed time AI pregnancy rates in beef heifers.

The objectives were (i) to evaluate the effect of temperament, determined by modified 2-point chute exit and gait score, on artificial insemination (AI) pregnancy rates in beef heifers following fixed time AI and (ii) to determine the effect of temperament on cortisol, substance-P, prolactin and progesterone at initiation of synchronization and at the time of AI. Angus beef heifers (n = 967) at eight locations were included in this study. At the initiation of synchronization (Day 0 = initiation of synchronization), all heifers received a body condition score (BCS), and temperament score (0 = calm; slow exit and walk or 1 = excitable; fast exit or jump or trot or run). Blood samples were collected from a sub-population of heifers (n = 86) at both synchronization initiation and the time of AI to determine the differences in serum progesterone, cortisol, prolactin and substance-P concentrations between temperament groups. Heifers were synchronized with 5-day CO-Synch+ controlled internal drug release (CIDR) protocol and were inseminated at 56 h after CIDR removal. Heifers were examined for pregnancy by ultrasound 70 days after AI to determine AI pregnancy. Controlling for synchronization treatment (p = 0.03), facility design (p = 0.05), and cattle handling facility design by temperament score interaction (p = 0.02), the AI pregnancy differed between heifers with excitable and calm temperament (51.9% vs 60.3%; p = 0.01). The alley-way with acute bends and turns, and long straight alley-way had lower AI pregnancy rate than did the semicircular alley-way (53.5%, 56.3% and 67.0% respectively; p = 0.05). The serum hormone concentrations differed significantly between different types of cattle handling facility (p < 0.05). The cattle handling facility design by temperament group interactions significantly influenced progesterone (p = 0.01), cortisol (p = 0.01), prolactin (p = 0.02) and substance-P (p = 0.04) both at the initiation of synchronization and at the time of AI. Inter- and intra-rater agreement for temperament scoring were moderate and good (Kappa = 0.596 ± 0.07 and 0.797 ± 0.11) respectively. The predictive value for calm and pregnant to AI was 0.87, and excited and non-pregnant to AI was 0.76. In conclusion, the modified 2-point temperament scoring method can be used to identify heifers with excitable temperament. Heifers with excitable temperament had lower AI pregnancy. Further, cattle handling facility design influenced the temperament and AI pregnancy.

Effect of the first GnRH and two doses of PGF2α in a 5-day progesterone-based CO-Synch protocol on heifer pregnancy.

The objectives were (1) to determine the effects of gonadorelin hydrochloride (GnRH) injection at controlled internal drug release (CIDR) insertion on Day 0 and the number of PGF2α doses at CIDR removal on Day 5 in a 5-day CO-Synch + CIDR program on pregnancy rate (PR) to artificial insemination (AI) in heifers; (2) to examine how the effect of systemic concentration of progesterone and size of follicles influenced treatment outcome. Angus cross beef heifers (n = 1018) at eight locations and Holstein dairy heifers (n = 1137) at 15 locations were included in this study. On Day 0, heifers were body condition scored (BCS), and received a CIDR. Within farms, heifers were randomly divided into two groups: at the time of CIDR insertion, the GnRH group received 100 µg of GnRH and No-GnRH group received none. On Day 5, all heifers received 25 mg of PGF2α at the time of CIDR insert removal. The GnRH and No-GnRH groups were further divided into 1PGF and 2PGF groups. The heifers in 2PGF group received a second dose of PGF2α 6 hours after the administration of the first dose. Beef heifers underwent AI at 56 hours and dairy heifers at 72 hours after CIDR removal and received 100 µg of GnRH at the time of AI. Pregnancy was determined approximately at 35 and/or 70 days after AI. Controlling for herd effect (P < 0.06), the treatments had significant effect on AI pregnancy in beef heifers (P = 0.03). The AI-PRs were 50.3%, 50.2%, 59.7%, and 58.3% for No-GnRH + PGF + GnRH, No-GnRH + 2PGF + GnRH, GnRH + PGF + GnRH, and GnRH + 2PGF + GnRH groups, respectively. The AI-PRs were ranged from 50% to 62.4% between herds. Controlling for herd effects (P < 0.01) and for BCS (P < 0.05), the AI pregnancy was not different among the treatment groups in dairy heifers (P > 0.05). The AI-PRs were 51.2%, 51.9%, 53.9%, and 54.5% for No-GnRH + PGF + GnRH, No-GnRH + 2PGF + GnRH, GnRH + PGF + GnRH, and GnRH + 2PGF + GnRH groups, respectively. The AI-PR varied among locations from 48.3% to 75.0%. The AI-PR was 43.5%, 50.4%, and 64.2% for 2.5 or less, 2.75 to 3.5, and greater than 3.5 BCS categories. Numerically higher AI-PRs were observed in beef and dairy heifers that exhibited high progesterone concentrations at the time of CIDR insertion (>1 ng/mL, with a CL). In addition, numerically higher AI-PRs were also observed in heifers receiving CIDR + GnRH with both high and low progesterone concentration (<1 ng/mL) initially compared with heifers receiving a CIDR only with low progesterone. In dairy heifers, there were no differences in the pregnancy loss between 35 and 70 days post-AI among the treatment groups (P > 0.1). In conclusion, GnRH administration at the time of CIDR insertion is advantageous in beef heifers, but not in dairy heifers, to improve AI-PR in the 5-day CIDR + CO-Synch protocol. In addition, in this study, both dairy heifers that received either one or two PGF2α doses at CIDR removal resulted in similar AI-PR in this study regardless of whether they received GnRH at CIDR insertion.

Diagnostic contribution from pulmonary biopsies in hematology patients with acute respiratory failure from undetermined etiology.

BACKGROUND: In about 20% of patients with malignancies with acute respiratory failure (ARF), no etiology can be determined, whatever the diagnostic strategy used. Lung biopsy could then be a precious diagnostic tool leading to therapeutic adaptations and increasing chances for cure. The aim of this study was to assess the diagnostic contribution of lung biopsy in patients for whom a complete diagnosis strategy failed to identify ARF etiology. METHODS: All hematology patients admitted for ARF to our ICU between 1995 and 2011, and for whom lung biopsy was performed were included in the study. Lung biopsies were surgical, CT guided, or post-mortem. Histological findings were compared to prebiopsy diagnosis and classified into specific or non-specific diagnosis. Therapeutic impact (or Goldman-class in post-mortem biopsies) was also recorded. RESULTS: Among the 1440 hematology patients with ARF managed during the study period, 21 (1%) biopsies were performed, including 10 post-mortem biopsies. Histological diagnoses were specific in 10 biopsies, non specific in 8 biopsies and lung parenchyma was normal in three patients. In 8/11 (72.7%) alive patients, lung biopsy had lead to therapeutic modifications, including treatment implementation in 5 patients and treatment withdrawal in 3 patients. One out of 10 (10%) patients had minor complications. For the 10 dead patients, only one Goldman-type 1 error was found. CONCLUSION: Diagnostic lung biopsy is rarely needed in hematology patients with ARF. But, it has a 73% therapeutic impact and has overall no major complications. Contribution from post-mortem biopsies seems less relevant.

ShearWave™ Elastography BE1 multinational breast study: additional SWE™ features support potential to downgrade BI-RADS®-3 lesions.

PURPOSE: To determine the benefit of ShearWave™ Elastography (SWE™) in the ultrasound characterization of BI-RADS® 3 breast lesions in a diagnostic population. MATERIALS AND METHODS: 303 BI-RADS® 3 lesions (mean size: 13.2 mm, SD: 7.5 mm) from the multicenter BE1 prospective study population were analyzed: 201 (66%) had cytology or core biopsy, and the remaining 102 had a minimum follow-up of one year; 8 (2.6%) were malignant. 7 SWE features were evaluated with regard to their ability to downgrade benign BI-RADS® 3 masses. The performance of each SWE feature was assessed by evaluating the number of lesions correctly reclassified and the impact on cancer rates within the new BI-RADS® 3' lesion group. RESULTS: No malignancies were found with an E-color "black to dark blue", which allowed the downgrading of 110/303 benign masses (p < 0.0001), with a non-significant increase in BI-RADS® 3' malignancy rate from 2.6% to 4.1%. E-max ≤ 20 kPa (2.6 m/s) was able to downgrade 48/303 (p < 0.0001) lesions with a lower increase in BI-RADS® 3' malignancy rate (3.1%). No other SWE features were useful for reclassifying benign BI-RADS® 3 lesions. CONCLUSION: Applying simple reclassification rules, SWE assessment of the maximum stiffness of lesions allowed the downgrading of a sub-group of benign BI-RADS® 3 lesions. This was accompanied by a non-significant increase in the malignancy rate in the new BI-RADS® 3 class.

Thyroid disease awareness is associated with high rates of identifying subjects with previously undiagnosed thyroid dysfunction.

BACKGROUND: Conventional screening for hypothyroidism is controversial. Although hypothyroidism is underdiagnosed, many organizations do not recommend screening, citing low disease prevalence in unselected populations. We studied attendees at a thyroid health fair, hypothesizing that certain patient characteristics would enhance the yield of testing. METHODS: We carried out an observational study of participants at a Michigan health fair that focused on thyroid disease. We collected patient-reported symptoms and demographics by questionnaire, and correlated these with the TSH values obtained through the health fair. RESULTS: 794 of 858 health fair attendees participated. Most were women, and over 40% reported a family history of thyroid disease. We identified 97 (12.2%) participants with previously unknown thyroid dysfunction. No symptom or combination of symptoms discriminated between hypothyroid and euthyroid individuals. Hypothyroid and euthyroid participants in the health fair reported each symptom with a similar prevalence (p > 0.01), a prevalence which was very high. In fact, when compared with a previously published case-control study that reported symptoms, the euthyroid health fair participants reported a higher symptom prevalence (range 3.9% to 66.3%, mean 31.5%), than the euthyroid individuals from the case-control study (range 2% to 54%, mean 17.4%). CONCLUSIONS: A high proportion of previously undiagnosed thyroid disease was identified at this health fair. We initially hypothesized symptoms would distinguish between thyroid function states. However, this was not the case in this health fair screening population. The prevalence of reported symptoms was similar and high in both euthyroid and hypothyroid participants. Because attendees were self-selected, it is possible that this health fair that focused on thyroid disease attracted participants specifically concerned about thyroid health. Despite the lack of symptom discrimination, the much higher prevalence of hypothyroidism in this study (12%) compared with the general population (<2%) suggests that screening may be appropriate and effective in certain circumstances such as thyroid health fairs.

Vancomycin serum concentration during febrile neutropenia in patients with acute myeloid leukemia.

BACKGROUND: Adult leukemia patients with febrile neutropenia have a higher volume of distribution requiring increased drug doses. We performed a survey of vancomycin use in that population to assess the accuracy of our dosing guidelines. METHODS: We retrospectively reviewed the charts and laboratory results of vancomycin prescription and monitoring in adult acute myeloid leukemia patients with febrile neutropenia in a teaching hospital. RESULTS: Fifty-four patients received 67 vancomycin courses between January 2005 and April 2007. A loading dose was used in 97% of cases dosed at a mean 15.5±3.3mg/kg. It was followed by a continuous infusion of an average 35.4±6.9mg/kg per day maintenance dose. Serum monitoring yielded serum levels above the 20mg/L target in only 12% of cases. Despite higher dose, the target concentration was only reached in 32% of cases, after a mean 1.5 dose adjustment. The mean final maintenance dose was 42.1±9.4mg/kg per day. Vancomycin was well tolerated and induced only two temporary increases in serum creatinine. The treatment was microbiologically justified in only two cases. The mean length of therapy was 7.7±4.4 days and 41 over 65 (63%) non-documented infections were treated for more than five days despite local guidelines recommending a maximum 5-day course without bacterial documentation. Overall, only seven (10%) vancomycin courses complied with all defined criteria. CONCLUSIONS: Vancomycin use was not optimal. We updated our guidelines after the study to dramatically reduce vancomycin indications in leukemia patients. When it is indicated, following the loading dose, we more closely monitor vancomycin serum levels to allow for an earlier dose adjustment when necessary.

Accounting for pH heterogeneity and variability in modelling human health risks from cadmium in contaminated land.

The authors have previously published a methodology which combines quantitative probabilistic human health risk assessment and spatial statistical methods (geostatistics) to produce an assessment, incorporating uncertainty, of risks to human health from exposure to contaminated land. The model assumes a constant soil to plant concentration factor (CF(veg)) when calculating intake of contaminants. This model is modified here to enhance its use in a situation where CF(veg) varies according to soil pH, as is the case for cadmium. The original methodology uses sequential indicator simulation (SIS) to map soil concentration estimates for one contaminant across a site. A real, age-stratified population is mapped across the contaminated area, and intake of soil contaminants by individuals is calculated probabilistically using an adaptation of the Contaminated Land Exposure Assessment (CLEA) model. The proposed improvement involves not only the geostatistical estimation of the contaminant concentration, but also that of soil pH, which in turn leads to a variable CF(veg) estimate which influences the human intake results. The results presented demonstrate that taking pH into account can influence the outcome of the risk assessment greatly. It is proposed that a similar adaptation could be used for other combinations of soil variables which influence CF(veg).

ABCB1-1Delta polymorphism can predict hematologic toxicity in dogs treated with vincristine.

BACKGROUND: Dogs that harbor the naturally occurring ABCB1-1Delta polymorphism experience increased susceptibility to avermectin-induced neurological toxicosis as a result of deficient P-glycoprotein function. Whether or not the ABCB1-1Delta polymorphism affects susceptibility to toxicity of other P-glycoprotein substrate drugs has not been studied. HYPOTHESIS: Dogs that possess the ABCB1-1Delta mutation are more likely to develop hematologic toxicity associated with vincristine than ABCB1 wild-type dogs. ANIMALS: Thirty-four dogs diagnosed with lymphoma were included in this study. METHODS: Cheek swab samples were obtained from dogs diagnosed with lymphoma that were to be treated with vincristine. DNA was extracted from cheek swabs and the ABCB1 genotype was determined. Hematologic adverse drug reactions were recorded for each dog and graded according to the Veterinary Comparative Oncology Group's criteria for adverse event reporting (Consensus Document). In order to avoid possible bias, ABCB1 genotype results for a particular patient were not disclosed to oncologists until an initial adverse event report had been submitted. RESULTS: Dogs heterozygous or homozygous for the ABCB1-1Delta mutation were significantly more likely to develop hematologic toxicity, specifically neutropenia (P= .0005) and thrombocytopenia (P= .0001), after treatment with vincristine than ABCB1 wild-type dogs. CONCLUSIONS AND CLINICAL IMPLICATIONS: At currently recommended dosages (0.5-0.7 mg/M(2)), vincristine is likely to cause hematologic toxicity in dogs with the ABCB1-1Delta mutation, resulting in treatment delays and unacceptable morbidity and mortality. Assessing the ABCB1-1Delta genotype before vincristine administration and decreasing the dosage may prevent toxicity and treatment delays resulting from neutropenia or thrombocytopenia.

Setting up of a multicentric European registry dealing with type B dissections in chronic and acute phases with thoracic EndoFit devices.

AIM: This registry aims at evaluating the use and efficacy of the EndoFit stent graft (LeMaitre Vascular, Burlington MA, USA) for the treatment of acute and chronic aortic type B dissections. METHODS: Indications for treatment are: recurrent pain, persistent hypertension, serious organ malperfusion in patients with acute or subacute type B aortic dissection and progression of aneurysm size despite maximal medical therapy in patient with chronic type B dissection. Exclusion criteria are: age under 18 years old, pregnancy, coagulopathy or bleeding disorders, connective tissue disease. Straight or tapered EndoFit stent graft will be used in acute or chronical dissection respectively. RESULTS: The primary endpoint is the assessment of the safety and the efficacy of the EndoFit Thoracic Endoluminal Stent Graft in the exclusion of the thoracic aortic false lumen in acute and chronic type B aortic dissections. The assessment includes: technical success, thrombosis of the thoracic false lumen at 6 months, rate of aorto-enteric, aorto-esophageal and aorto-bronchial fistula, serious adverse events including death, stroke, paraplegia, myocardial infarction, multi-organ failure and renal insufficiency. Secondary endpoints are: the technical feasibility of device implantation in 2 different shapes (straight for acute dissection and tapered for chronic dissection), the technical feasibility of endovascular placement of tapered grafts in vessels of different size and shape, the integrity of the device fabric and wire structure, the occurrence of device migration, the patient's neurological, cardiac and cardiovascular status, the blood flow supply to abdominal and visceral organs arteries and any secondary intervention including stentgraft extension, coiling or surgical conversion. One hundred patients enrolled have been defined to allow reliable findings and results. CONCLUSION: The DEDICATED is the first prospective data collection registry focusing on the role of tapered stentgrafts in chronic aortic dissection and their efficacy in excluding the dissected thoracic false lumen.

Identification of proximal landing zone limit for proper deployment of aortic arch stentgraft after supra-aortic great vessels transposition.

The proper identification of the proximal landing zone prior to aortic stentgraft deployment is a key step that impacts the global outcome of the procedure. We report an intraoperative technique during total aortic arch transposition that facilitates subsequent endovascular arch exclusion thanks to a reliable radio-opaque marker. In patients who require an endovascular exclusion of the aortic arch, a total arch transposition can be performed through a median sternotomy prior to stentgraft deployment. During the surgical stage, a radio-opaque thread is pull out of a surgical sponge pad, looped around the ascending aorta just distal to the ostium of the aorto-innominate bypass and fixed in place by means of metal clips. The technique we describe increases the accuracy of stentgraft deployment in the ascending aorta after total arch transposition. It will potentially improve the outcome.

Novel technique: staged hybrid surgical and endovascular treatment of acute Type A aortic dissections with aortic arch involvement.

AIM: The standard approach for treating acute Type A aortic dissections (TAD) is replacement of the ascending aorta utilizing hypothermic circulatory arrest (HCA), which is associated with significant morbidity and frequently leaves a residual aortic arch dissection. We describe a staged surgical and endovascular technique of ascending aorta replacement and simultaneous aorto-innominate artery bypass without HCA, followed 4 weeks later by carotid-carotid bypass and endovascular exclusion of the remaining arch dissection with a thoracic endograft. METHODS: From December 2004 to December 2005, 5 consecutive patients (mean age 58 +/- 6.9 years) with TADs underwent the staged procedure. All patients underwent replacement of the ascending aorta and aorto-innominate bypass. Two patients subsequently underwent the second endovascular stage. In one patient the aortic false lumen completely thrombosed following the first surgical stage and two patients are currently awaiting the endovascular stage. RESULTS: There were no major adverse events (death, cerebrovascular accident or paraplegia) following the first surgical stage. One patient suffered a transient minor stroke. The 2 patients who underwent the second endovascular stage showed no immediate adverse events. Postoperative CT scans have demonstrated that the false channel was excluded from the aortic arch down to the distal end of the endograft in the descending aorta in each case, but became patent further downstream. CONCLUSIONS: This procedure appears safe and feasible. It may allow for a more definitive treatment of TADs than the standard surgical approach. It can be adapted by low volume centers, surgeons untrained in aortic arch repair, and in high risk patients.

Can carotid stenting registries help in determining predictors of neurological outcome?

AIM: Carotid stenting (CS) has proved to be a safe alternative to carotid endarterectomy, and subsets of patients who may benefit from carotid stents rather than surgery still need to be defined. Randomized trials and individual series are looking at predicting factors of early outcome after carotid angioplasty and stenting (CAS) that can hardly be applied to all series. We analyzed early results of the Eurocast registry and discussed the potential role of multicentric registries in determining such outcome predictors. METHODS: The Eurocast registry is an online prospective registry on CAS that collected 897 procedures from February 2000 to December 2005 across 20 centers. Statistical analyses were performed with the univariate Fisher's exact test on CS procedures, excluding sole balloon angioplasty. Risk factors reported were hypertension, hyperlipidemia, past or current history of smoking, diabetes mellitus, obesity, cardiac disease, other vascular disease, pulmonary disease, hostile neck and renal failure. Half of patients (50.2%) had symptomatic carotid lesions. Local anesthesia (91.8%) and retrograde femoral access (95.6%) were the preferred method. Overall procedures were achieved in 98.2%, of which 84.5% were performed under cerebral protection. RESULTS: Intraoperative neurological complications occurred in 26 (3.1%) of 824 procedures achieved. No immediate deaths were reported. The intraoperative ipsilateral stroke/death rate was 1.7%. The overall in-hospital stroke/death rate was 3.5%. Significant predictors of early neurological complications were infarctions on preoperative cerebral CT scanning, a deficient circle of Willis, a too short preoperative length of medication (7 days or less), any additional intervention (stenting and/or balloon dilatation), bradycardia and hypotension. Less reliable predictors were: age >70 years, renal failure, preoperative speech or motor deficit, postradiation stenosis, lesion on the left carotid axis and lesion on the common carotid artery. CONCLUSIONS: This analysis confirmed that CS is a feasible and secure technique to treat carotid stenosis. However, the determination of neurological outcome predictors remains subject to further confirmation. Other patient subgroups identified in other studies (female sex, diabetics, coronary disease) should be investigated more precisely. Finally, the Eurocast analysis showed that the setting up of risk scores would be dependent on local practices, physicians' experience and would not be reproducible.