A systematic review of differences in outcome between one and two stage palate repair in cleft lip and palate.

The aim of this systematic review was to determine whether one-stage palatoplasty for children born with cleft lip and palate shows overall advantages in outcome compared with two-stage palatoplasty. The included studies were controlled studies of syndromic and non-syndromic children born with unilateral cleft lip and palate, bilateral cleft lip and palate, or isolated cleft palate. The interventions studied were one-stage palatoplasty and two-stage palatoplasty starting with the soft palate. The outcomes were facial growth, speech, hearing, presence of fistulae, other complications related to surgery, health-related quality of life, and health economics. In total, 14 original studies were included. Results were dichotomized into showing advantage for one- or two-stage palatoplasty for the respective outcome and compared with the results from six included systematic reviews. No overall advantage for either surgical strategy was found for any of the outcome measures. The certainty of evidence was highest for the presence of fistulae, followed by facial growth and speech. For several outcomes, the quality of the existing evidence was too low to allow for any conclusions to be drawn. Neither one- nor two-stage palatoplasty showed significant advantages in clinical outcomes compared with the other. Other aspects such as ethics, economics, or surgeon's preference might hence be of more importance. Homogenous choices of outcome measures and defined minimal clinically important differences would facilitate further research.

Evaluation of Processed Nerve Allograft in Peripheral Nerve Surgery: A Systematic Review and Critical Appraisal.

Peripheral nerve injuries cause substantial problems when not treated properly. A specific problem is reconstruction of nerve defects, which can be treated in different ways. This study aimed to systematically review whether processed nerve allograft (PNA) is justified in reconstruction of a nerve defect in patients after posttraumatic or iatrogenic peripheral nerve injury and to compare PNA with other established methods. Methods: A systematic review with a focused question, PICO (patient, intervention, comparison, outcome) and constraints, was performed. A structured literature search, including several databases, was done to evaluate the existing evidence for outcomes and postoperative complications related to PNA. The certainty of evidence was classified according to Grading of Recommendations, Assessment, Development and Evaluations. Results: No conclusions, concerning differences in outcome of nerve reconstruction using PNA compared with the use of nerve autograft or conduits, could be drawn. The level of certainty for all evaluated outcomes was very low (⊕◯◯◯). Most published studies lack a control group to patients treated with PNA; being only descriptive, making it difficult to compare PNA with established methods without substantial risk of bias. For studies including a control group, the scientific evidence was of very low certainty, due to a low number of included patients, and large, undefined loss of patients during follow-up, rendering a high risk of bias. Finally, the authors often had financial disclosures. Conclusion: Properly conducted randomized controlled trial studies on the use of PNA in reconstruction of peripheral nerve injuries are needed to establish recommendations in clinical practice.

Abdominal aortic aneurysm growth rates are not correlated to body surface area in screened men.

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) in 65-year-old males reduces aneurysm related mortality. Infrarenal aortic diameter (IAD) has been shown to correlate to body surface area (BSA) which could influence diagnostic criteria for AAA. This study investigates whether AAA growth rates are also dependent on BSA, as that might have potential effects on surveillance of small AAAs. METHODS: We conducted a retrospective, single center cohort study of 301 men with screening detected AAA between 2010-2017 with surveillance to 2021. AAA growth rates were analyzed in relation to the subject's BSA, smoking habits, and diabetic disease using a linear mixed-effects model. All men were offered smoking cessation program, optimized medical treatment, and advice on physical activity. RESULTS: The screening program included 28,784 men. Of the 22,819 (79%) attending the examinations, 374 men (1.6%) were found to have an AAA out of which 301 men had undergone two or more examinations during surveillance and were included with a median follow-up of 1846 days (IQR: 1 399). Mean unadjusted AAA growth rate was 1.60 mm/year (95% CI: 1.41-1.80). Diabetes mellitus had a statistically significant negative impact, smoking had a statistically significant positive impact on AAA growth rates whereas no correlation between AAA growth rate and BSA could be found. CONCLUSIONS: Body surface area could not be found to have a statistically significant correlation to AAA growth rates. The impact of smoking and diabetes on AAA growth rates remains similar to previously reported.

Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies.

OBJECTIVE: The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications. STUDY DESIGN: The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined. RESULTS: Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients. CONCLUSIONS: Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.

A significant correlation between body surface area and infrarenal aortic diameter is detected in a large screening population with possibly clinical implications.

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) in elderly men reduces aneurysm related mortality. AAA is commonly defined as an infrarenal aortic diameter (IAD) of ≥30 mm, which is based on the definition of an arterial aneurysm as a focal dilation of 150% or more compared to the expected diameter of about 20 mm. The IAD has been shown to correlate to body surface area (BSA). The aim of this study was to investigate the possibility to use an individualized AAA-criteria by using a BSA-based model to refine the screening for AAA. METHODS: We conducted an observational single center cohort study of 25 236 65-year old men invited to AAA screening in Malmö, Sweden 2010-2015. Out of the 19 738 (78.5%) attendees, 14 846 (58.8%) completed a health questionnaire including height, weight and smoking habits. Linear regression analysis was performed between BSA and IAD, taking smoking habits into account. This regression was used to calculate the predicted IAD for each individual according to their BSA. RESULTS: There was a significant correlation between BSA and aortic diameter, rho =0.26 (95% CI: 0.25, 0.28). AAA defined as an IAD≥30 mm was found in 226 men (1.5%) whereas AAA defined as ≥150% larger IAD than predicted according to the individual BSA was found in 299 men (1.9%), a relative difference in AAA detection rate of more than 30% (P<0.001). CONCLUSIONS: We have found a statistically significant correlation between BSA and IAD in a homogenous screening population that could have clinical implications. In men with low BSA, IAD <30 mm might still be ≥150% larger than predicted according to BSA, whereas in men with high BSA, IAD≥30 mm might not be ≥150% larger than predicted. Further follow-up of these subjects is planned to investigate if the first group have an "aneurysm-in-formation," challenging the diagnostic criteria for AAA.

Mid-term Outcomes of Endovascular Repair of Ruptured Thoraco-abdominal Aortic Aneurysms with Off the Shelf Branched Stent Grafts.

OBJECTIVE: To assess the mid-term outcomes and feasibility of branched endovascular repair (b-EVAR) of ruptured thoracoabdominal aortic aneurysms (rTAAAs). METHODS: All patients undergoing b-EVAR of rTAAAs between 2011 and 2016 were included. Pre-, intra and postoperative imaging was reviewed to assess technical success, outcomes, and feasibility of b-EVAR in the emergent setting. RESULTS: Eleven emergency b-EVAR of rTAAAs (10 aneurysms and 1 chronic dissection) were performed using off-the-shelf (OTS) branched stentgrafts. Only 18% of patients complied to the anatomical instruction-for-use of the OTS device; a small aortic lumen and occluded target vessels were the main violations. Median operative time was 430 (IQR 395-629) minutes. Technical failure was 36% including one intraoperative death, one target vessel catheterization failure, one type Ia and one type III endoleak. Thirty-day mortality was 27%. Only early re-intervention was for the type Ia endoleak. Spinal cord ischemia occurred in 4 patients (30%), of which 2 recovered completely. Median clinical follow-up were 15 (IQR 7-39) months respectively. The median clinical follow-up index (FUI) was 0.65 (0.32-0.95). Overall survival was 75 ± 21.7% at 18 months. Four branch occlusions occurred; one renal stent occlusion led to permanent hemodialysis. Branch patency was 87.5 ± 8.3% and 72.2 ± 12% at 1 and 2 years, respectively. One stentgraft migrated but no late major endoleak occurred. CONCLUSION: Emergency b-EVAR of rTAAA with OTS device is feasible despite a low anatomical suitability. With proper adjunctive procedures, it can be offered to most hemodynamically stable patients. These time-consuming complex procedures are not suitable for unstable patients. Often the procedure is done as life-saving in the emergency setting and reinterventions may be needed later. Consequently, the success rates are lower than in the elective setting. These results need to be confirmed by larger studies and longer follow-up.

Psychosocial consequences in men taking part in a national screening program for abdominal aortic aneurysm.

Screening for abdominal aortic aneurysm (AAA) has proven to reduce AAA-related mortality, but how the knowledge of having an untreated AAA affects health and daily life requires further clarification. The aim was to investigate the psychosocial consequences and sense of coherence (SOC) in 65-year-old men diagnosed with AAA and participating in a national screening program during a 6-month follow-up compared with men with no AAA. The single-center cohort study included 52 men with AAA and 118 men without AAA. A questionnaire including the Short Form 36 Health Survey, Hospital Anxiety and Depression Scale, SOC, questions concerning stress, and questions related to AAA were answered at baseline and after 6 months. Men with AAA reported more problems with physical functioning, pain, and general health than men with a normal aorta at baseline. After 6 months, men with AAA still reported more problems with physical functioning and stress in relation to disease than men with normal aortic diameter. No differences were observed between groups in SOC, anxiety, and depression. A significantly higher satisfaction with information from the physician and desire to learn about the AAA diagnosis was reported at baseline compared with that at follow-up. Having knowledge about the AAA diagnosis may moderately impact physical health and perceived stress, and in combination with the increased prevalence of other cardiovascular diseases, may lead to impaired perceived health for men diagnosed with AAA.

Aortic diameter at age 65 in men with newly diagnosed type 2 diabetes.

OBJECTIVES: Type 2 diabetes mellitus has been linked to a decreased risk for abdominal aortic aneurysm (aortic diameter ≥30 mm, AAA) development in men. The aim of this study was to evaluate if such an effect is detectable already around the time of diabetes diagnosis. DESIGN: We cross-sectionally compared aortic diameter at ultrasound screening for AAA in 691 men aged 65 years with incipient or newly diagnosed type 2 diabetes (group A) with 18,262 65-year old control men without diabetes (group B). RESULTS: Aortic diameter did not differ between groups (18.8[17.4-20.8] vs. 19.0[17.5-28.7] mm; p = 0.43). AAA prevalence was 2.5% in group A and 1.5% in group B (p = .010). In logistic regression taking group differences in body mass index (BMI), smoking, presence of atherosclerotic disease and hypertension into account, the difference in AAA prevalence was no longer significant (p = .15). Among men in group A, C-peptide (r = .093; p = .034), but not HbA1c (r = .060; p = .24) correlated with aortic diameter. CONCLUSION: Among 65 year old men aortic diameter and AAA prevalence do not differ between those with newly diagnosed type 2 diabetes and those without diabetes. Putative protective effects of type 2 diabetes mellitus against aortic dilatation and AAA development therefore probably occur later after diagnosis of diabetes.

No relation between biomarkers at age 47-49 and aortic diameter after 14-19 years of follow-up - a population-based study.

BACKGROUND: Biomarkers reflecting diverse pathophysiological pathways may play an important role in the pathogenesis of abdominal aortic aneurysm (aortic diameter ≥30 mm, AAA), levels of many biomarkers are elevated and correlated to aortic diameter among 65-year-old men undergoing ultrasound (US) screening for AAA. PROBANDS AND METHODS: To evaluate potential relationships between biomarkers and aortic dilatation after long-term follow-up, levels of C-reactive protein (CRP), proneurotensin (PNT), copeptin (CPT), lipoprotein-associated phospholipase 2 (Lp-PLA2), cystatin C (Cyst C), midregional proatrial natriuretic peptide (MR-proANP), and midregional proadrenomedullin (MR-proADM) were measured in 117 subjects (114 [97 %] men) aged 47-49 in a prospective population-based cohort study, and related to aortic diameter at US examination of the aorta after 14-19 years of follow-up. RESULTS: Biomarker levels at baseline did not correlate with aortic diameter after 14-19 years of follow up (CRP [r = 0.153], PNT [r = 0.070], CPT [r = -.156], Lp-PLA2 [r = .024], Cyst C [r = -.015], MR-proANP [r = 0.014], MR-proADM [r = -.117]). Adjusting for age and smoking at baseline in a linear regression model did not reveal any significant correlations. CONCLUSIONS: Tested biomarker levels at age 47-49 were not associated with aortic diameter at ultrasound examination after 14-19 years of follow-up. If there are relationships between these biomarkers and aortic dilatation, they are not relevant until closer to AAA diagnosis.

Reversal of the Anticoagulation Effects of Dabigatran Etexilate by Idarucizumab in Three Patients Needing Urgent Surgical Intervention and One Case of Intravenous Thrombolysis in Ischaemic Stroke.

OBJECTIVE: To describe the benefits of reversal of the anticoagulation effects of dabigatran etexilate in patients requiring urgent surgery or thrombolysis for ischaemic stroke. MATERIALS AND METHODS: Four patients, treated with dabigatran etexilate and presenting with cholecystitis, tibial fracture, lower limb ischaemia and ischaemic stroke, respectively. RESULTS: Administration of idarucizumab normalized bleeding parameters and provided safe conditions for surgery and, in one case, successful thrombolysis of an ischaemic stroke. CONCLUSION: The introduction of an effective reversal agent for dabigatran etexilate allows physicians perform surgery under conditions of normal coagulation and permits thrombolysis in patients with ischaemic stroke despite being treated with dabigatran etexilate. LEARNING POINTS: Novel oral anticoagulants (NOACs) are a safe alternative to warfarin to prevent ischaemic stroke.Ability to reverse the anticoagulant effects of NOACs could increase adherence to anticoagulation therapy, thereby decreasing the risk of ischaemic stroke.Reversal of the anticoagulant effect of dabigatran etexilate can improve the outcome in patients needing urgent surgery, intervention and thrombolysis.

On the complexity of screening detected abdominal aortic aneurysms: a retrospective observational multicenter cohort study.

BACKGROUND: Ultrasound screening for abdominal aortic aneurysms (AAA) has been shown to decrease aneurysm related mortality. Likely by providing an opportunity to intervene while the aneurysm is still intact, but possibly also when and the anatomy still relatively uncomplicated which would provide a less complex procedure. Our aim was to retrospectively investigate the complexity of repair for screening-detected AAAs in a cohort of 65-year-old men. METHODS: All screening detected AAA cases that underwent repair between Sept 2010 and June 2014 in the most southern region of Sweden were included. Procedures were classified as either standard or complex. A standard procedure was defined as either standard EVAR (endovascular aneurysm repair) within the manufacturers Instructions For Use (IFU) or open repair with infrarenal clamping followed by a tube graft repair. All other types of procedures were defined as complex. The prevalence rate of AAA, screening compliance, short- and midterm outcome of the operations were reported. RESULTS: From the 35513 men invited to screening, 27 951 (78.7%) attended screening with ultrasound. AAA≥30 mm was found in 561 cases, yielding a prevalence rate of 2.0%. Forty-eight patients underwent AAA repair. A percentage of 43.8% of these were classified as complex procedures. These consisted mostly of branched/fenestrated EVAR or EVAR with simultaneous exclusion of common iliac aneurysm. CONCLUSIONS: Our study confirms contemporary prevalence rates of AAA. Almost half (43.8%) of screening-detected AAA required complex operations, a significant proportion. The complex aneurysms were, on average, larger than the non-complex cases and they were more likely to be cases that required surgery immediately after screening detection. Our data suggests that the nature of AAA is heterogenous, even in the screening-detected group requiring operation. This should spur interest in more studies to investigate this issue.

Inflammatory markers associated with abdominal aortic aneurysm.

PURPOSE: Inflammation with leukocytic infiltration, degradation of extracellular matrix (ECM), and depletion of vascular smooth muscle cells (VSMC) are pathological hallmarks of abdominal aortic aneurysm (AAA). The aim of this study was to further evaluate relationships between AAA and inflammatory biomarkers, interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α), endothelin-1 (ET-1) and soluble urokinase-type plasminogen activator receptor (suPAR), by comparing levels in 65-year-old men with and without AAA at ultrasound screening. We also evaluated whether any biomarker can independently predict AAA at screening, and clarified potential correlations between aortic diameter and blood levels of these biomarkers. RESULTS: There were significant (p ≤ 0.05) differences between subjects with and without AAA for the following variables: p-leukocyte count (TLC) (p<0.001), p-homocysteine (p<0.001), p-TNF-α (p = 0.023), p-IL-6 (p<0.001), p-ET-1 (p = 0.002), p-suPAR (p<0.001), ankle brachial index (ABI) (p<0.001), plasma (p)-creatinine (p = 0.049), p-total cholesterol (p<0.001), p-high density lipoprotein (HDL) (p<0.001) and low density lipoprotein (LDL) cholesterol (p = 0.001), smoking habits (p<0.001), and use of antihypertensive (p<0.001) and lipid-lowering (p = 0.001) drugs. When the above variables were stepwise excluded in a logistic regression model, only p-IL-6 (p = 0.002), p-homocysteine (p = 0.015), p-HDL (p = 0.004), ABI in the right (p = 0.005) and left (p = 0.094) leg, smoking habits (p = 0.003), and antihypertensive drug use (p = 0.045), differed between groups. Significant correlations with aortic diameter existed for p-TNF-α (p = 0.028), p-IL-6 (p<0.001), p-ET-1 (p = 0.002) and p-suPAR (p<0.001) in the entire study population, and for p-TNF-α (p = 0.023), p-ET-1 (p = 0.009) and p-suPAR (p = 0.001) among men with AAA. CONCLUSIONS: Several inflammatory biomarkers were significantly elevated and correlated with aortic diameter among 65-year old men with AAA at ultrasound screening. IL-6, homocysteine and use of antihypertensive medication remained elevated in the logistic regression model, together with known risk markers for AAA such as smoking and signs of atherosclerosis.

Outcome of the Swedish Nationwide Abdominal Aortic Aneurysm Screening Program.

BACKGROUND: A general abdominal aortic aneurysm (AAA) screening program, targeting 65-year-old men, has gradually been introduced in Sweden since 2006 and reached nationwide coverage in 2015. The aim of this study was to determine the outcome of this program. METHODS: Data on the number of invited and examined men, screening-detected AAAs, AAAs operated on, and surgical outcome were retrieved from all 21 Swedish counties for the years 2006 through 2014. AAA-specific mortality data were retrieved from the Swedish Cause of Death Registry. A linear regression analysis was used to estimate the effect on AAA-specific mortality among all men ≥65 years of age for the observed time period. The long-term effects were projected by using a validated Markov model. RESULTS: Of 302 957 men aged 65 years invited, 84% attended. The prevalence of screening-detected AAA was 1.5%. After a mean of 4.5 years, 29% of patients with AAA had been operated on, with a 30-day mortality rate of 0.9% (1.3% after open repair and 0.3% after endovascular repair, P<0.001). The introduction of screening was associated with a significant reduction in AAA-specific mortality (mean, 4.0% per year of screening, P=0.020). The number needed to screen and the number needed to operate on to prevent 1 premature death were 667 and 1.5, respectively. With a total population of 9.5 million, the Swedish national AAA-screening program was predicted to annually prevent 90 premature deaths from AAA and to gain 577 quality-adjusted life-years. The incremental cost-efficiency ratio was estimated to be €7770 per quality-adjusted life-years. CONCLUSIONS: Screening 65-year-old men for AAA is an effective preventive health measure and is highly cost-effective in a contemporary setting. These findings confirm the results from earlier randomized controlled trials and model studies in a large population-based setting of the importance for future healthcare decision making.

The importance of socioeconomic factors for compliance and outcome at screening for abdominal aortic aneurysm in 65-year-old men.

OBJECTIVE: To evaluate compliance with screening and prevalence of abdominal aortic aneurysm (AAA) in relation to background data regarding area-based socioeconomic status. METHODS: Our department annually invites 4300 65-year-old men from the city of Malmö and 15 neighboring municipalities to ultrasound AAA screening. In a cross-sectional cohort study, compliance and AAA prevalence among 8269 men were related to background socioeconomic data such as mean income, proportion of immigrants, percentage of subjects on welfare, smoking habits, and unemployment rate in the different municipalities. The 10 different administrative areas in Malmö were evaluated separately. RESULTS: Compliance with screening in the entire area was 6630/8269 (80.2%) but varied between 64.4% and 89.3% in different municipalities (P < .001). In univariate analysis, compliance increased with increasing mean income (r = 0.873; P < .001) but decreased with increasing proportion of immigrants (r = -0.685; P =.005) and subjects on welfare (r = -0.698; P = .004). Compliance in 10 different administrative parts of Malmö (P = .002) also increased with increasing mean income (r = 0.948; P < .001), and decreased with increasing proportion of immigrants (r = -0.650; P = .042) and increasing unemployment rate (r = -0.796; P = .006). Altogether, 117 (1.8%) AAAs were found, the prevalence differing between both different municipalities (P =.003) and the 10 different administrative parts of Malmö (P =.02). The prevalence of AAA in the 10 administrative parts of Malmö increased with increasing percentage of smokers (r = 0.784; P = .007), percentage of immigrants (r = 0.644; P = .044), and unemployment rate (r = 0.783; P =.007) but decreased with increasing mean income (r = -0.754; P = .012). CONCLUSIONS: Compliance with ultrasound screening for AAA differed between different geographical areas. In areas with low socioeconomic status, compliance rates were lower, whereas AAA prevalence was higher. The identification of contextual factors associated with low compliance is important to be able to allow targeted actions to increase efficacy of ultrasound screening for AAA. Targeted actions to increase compliance in those areas are being scientifically investigated and implemented.

In vitro and in vivo evaluation of chemically modified degradable starch microspheres for topical haemostasis.

Degradable starch microspheres (DSMs) are starch chains cross-linked with epichlorhydrin, forming glycerol-ether links. DSMs have been used for many years for temporary vascular occlusion and drug delivery in treatment of malignancies. They are also approved and used for topical haemostasis by absorbing excess fluid from the blood and concentrating endogenous coagulation factors, thereby facilitating haemostasis. This mechanism of action is not sufficient for larger bleedings in current chemical formulations of DSMs, and modification of DSMs to trigger activation of platelets or coagulation would be required for use in such applications. Chemical modifications of DSMs with N-octenyl succinic anhydride, chloroacetic acid, acetic anhydride, diethylaminoethyl chloride and ellagic acid were performed and evaluated in vitro with thrombin generation and platelet adhesion tests, and in vivo using an experimental renal bleeding model in rat. DSMs modified to activate platelets in vitro were superior in haemostatic capacity in vivo. Further studies with non-toxic substances are warranted to confirm these results and develop the DSM as a more effective topical haemostatic agent.

Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.

In situ bending of thoracic stent grafts: clinical application of a novel technique to improve conformance to the aortic arch.

PURPOSE: A straight thoracic stent graft often complies poorly with the curvature of the aortic arch. We have previously reported an in vitro model of a modified stent graft that can be bent in situ after deployment to improve conformance to the aortic arch. We now report the first clinical experience with this technique in three consecutive patients. METHODS: Between September 2007 and August 2008, three patients were treated for different pathologies of the aortic arch with a modified thoracic stent graft that was fitted with a sliding self-locking knot and a detachable Bowden cable. Transfemoral traction on the Bowden cable enables controlled shortening of the proximal part of the stent graft at the inner curve after deployment. The stent graft is thereby directed to allow for better apposition to the aortic wall. RESULTS: The modified thoracic stent grafts were correctly orientated and deployed in all patients. Transfemoral traction on the Bowden cable successfully bent all stent grafts and improved vessel wall apposition without a residual gap on the inner curve. The Bowden cable was successfully released and withdrawn in all patients. CONCLUSION: In situ bending of thoracic stent grafts with a sliding self-locking knot is feasible and improves proximal apposition of the device at the inner curve of the aortic arch. More data and longer follow-up are required to confirm the applicability of this technique.

Carotid artery entrapment by the hyoid bone.

We report a patient with a transient ischemic attack presumably caused by an entrapment of the internal carotid artery by the hyoid bone and without a significant carotid artery stenosis. The patient was operated on, with a release of the right internal and external carotid artery and resection of the right greater cornu of the hyoid bone. One year after treatment, the patient has not experienced any further neurologic symptoms, and a color duplex scan showed no stenosis of the right carotid artery. The hyoid bone is a potential cause of damage to the carotid vessels, depending on the individual's anatomy. Provocative maneuvers can be performed in patients with cerebrovascular symptoms who are not demonstrated to have significant anatomic stenosis with carotid imaging.