Efficacy and Complication Rates of Percutaneous Vertebroplasty and Kyphoplasty in the Treatment of Vertebral Compression Fractures: A Retrospective Analysis of 280 Patients.

Background: Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) are established methods in the treatment of vertebral compression fractures (VCFs). In our manuscript, the target was to evaluate the efficacy of PVPs/PKPs and to determine the implications of potential periprocedural complications. Methods: 280 patients, specifically 194 women (69.3%) and 86 men (30.7%), were enrolled. We used the AO spine fractures classification and the Yeom classification to determine the subtype of cement leakage. Only single-level VCFs of the thoracic or lumbar spine were included. Visual analogue scale (VAS) was assessed preoperatively and regularly after the surgery. Vertebral compression ratio (VBCR) was used to determine postoperative vertebral body collapse. Results: We recorded 54 cases (19.3%) of cement leakage. There was a significant decrease in mean VAS scores (6.82-0.76 in PVPs, 7.15-0.81 in PKPs). The decrease in VBCR was greater in the VP group (4.39%; 84.21-79.82) compared to the KP group (1.95%; 74.36-72.41). Conclusions: No significant difference in the risk of cement leakage when comparing KPs and VPs was found. VPs and KPs provide rapid and significant pain relief in patients with VCFs. Clinically relevant complications of VPs and KPs are rare. Kyphoplasties prevent further vertebral body collapse more effectively compared to vertebroplasties.

Autologous Alternative Vein Grafts for Infrainguinal Bypass in the Absence of Single-Segment Great Saphenous Vein: A Single-Center Study.

BACKGROUND: Alternative autologous veins can be used as a conduit when adequate great saphenous vein is unavailable. We analyzed the results of our infrainguinal bypasses after adopting upper extremity veins in our practice. METHODS: This is a single-center observational study involving all patients whose infrainguinal bypass involved the use of upper extremity veins between April 2019, when we began using arm veins, and February 2023. RESULTS: During the study period, 49 bypasses were done in 48 patients; mean age 68.1 ± 9.8; men 32 (66.7%); body mass index 28.0 ± 4.8; indications for surgery: chronic limb threatening ischemia 41 (83.7%); acute limb ischemia 3 (6.1%); complications of previous prosthetic 3 (6.1%), or autologous 2 (4.1%) bypass grafts. Vein splicing was used in 43 (87.8%) bypasses with 3-segment grafts being the most common (26; 53.1%). There were 24 (49.0%) femorotibial, 11 (22.4%) femoropopliteal, 9 (18.4%) femoropedal, and 5 (10.2%) extension jump bypass procedures. Eighteen (36.7%) operations were redo surgeries. Twenty-one (42.9%) bypasses were formed using only arm veins. The median follow-up was 12.9 months (4.5-24.2). Two bypasses occluded during the first 30 postoperative days (2/49; 4.1%). Overall 30-day, 1-year, and 2-year primary patency rates were 93.7% ± 3.5%, 84.8% ± 5.9%, and 80.6% ± 6.9%, and secondary patency (SP) rates were 95.8% ± 2.9%, 89.2% ± 5.3%, and 89.2% ± 5.3%. One-segment grafts had better patencies than 2-, 3-, and 4-segment grafts (1-year SP 100% ± 0% vs 87.6% ± 6.0%). Two-year amputation-free survival was 86.8% ± 6.5%; 2-year overall survival was 88.2% ± 6.6%. CONCLUSIONS: Integration of arm vein grafts in infrainguinal bypass practice can be done safely with low incidences of perioperative graft failure. One-segment grafts had better patencies than spliced vein grafts. The achieved early patency and amputation-free survival rates strongly encourage their use. In the absence of a single-segment great saphenous vein, upper extremity vein grafts should be the preferred conduit choice.

Procalcitonin kinetics following abdominal aortic surgery and its value for postoperative intestinal ischaemia detection.

OBJECTIVE: The purpose of our study was to describe perioperative kinetics of procalcitonin (PCT) in patients undergoing aortic surgery, to compare the kinetics in the open abdominal aortic aneurysm (AAA) repair and aortobifemoral bypass for aortoiliac occlusive disease (AIOD), and to evaluate the ability of PCT to detect intestinal ischaemia. METHODS: A prospective non-randomized observational cohort study in 80 patients (62 men and 18 women) undergoing elective aortic surgery was performed. Serum PCT was measured at baseline and defined intraoperative and postoperative timepoints up to postoperative day 7. MRI contrast-enhanced imaging was used to detect intestinal ischaemia. RESULTS: The comparison of the AAA and AIOD cohort did not show any significant difference in PCT levels. Patients with intestinal ischaemia had higher serum PCT at multiple timepoints postoperatively. The most accurate timepoints for early diagnosis were postoperative day 3, followed by 24 h after declamping of the vascular reconstruction, and postoperative day 7. The sensitivity and negative predictive values were 100% in all mentioned timepoints. However, event at the best timepoint the specificity was 89% and the positive predictive value 43%. CONCLUSIONS: Procalcitonin levels in the postoperative period at proper timepoints might help to detect postoperative intestinal ischaemia. The limitation of this marker is its low specificity for intestinal ischaemia and low positive predictive value. The highest value of this marker is that it can rule out this complication because normal PCT levels mean that intestinal ischaemia is very unlikely.

Treatment of knee cartilage by cultured stem cells and three dimensional scaffold: a phase I/IIa clinical trial.

PURPOSE: Damage of the knee cartilage is a common condition manifesting itself mainly by pain and/or swelling that may substantially reduce the quality of life while ultimately leading to osteoarthritis in affected patients. Here, we aimed to evaluate the safety and efficacy of cultured autologous bone marrow mesenchymal stem cells (BM-MSCs) attached to the 3D Chondrotissue® scaffold by autologous blood plasma coagulation (BiCure® ortho MSCp) in the treatment of knee cartilage defects. METHODS: The primary endpoint of this phase I/IIa clinical trial was to evaluate the safety of the treatment. The secondary objective was to determine the short-to-medium-term therapeutic outcomes by standardized scoring questionnaires including Lysholm Knee Scoring Scale (Lysholm score), Knee Injury and Osteoarthritis Outcome Score (KOOS), and pain Visual Analogue Scale (VAS) systems and imaging (X-ray and magnetic resonance imaging, MRI). A total of six patients were included and followed for 12 months after the surgery. RESULTS: BiCure® ortho MSCp was well tolerated with no adverse events associated with the investigational medicinal product. Significant improvements were observed in Lysholm scores and KOOS while X-ray showed no deterioration of the arthritis and MRI revealed a persistent filling of the chondral defects by the implant. CONCLUSION: Overall, our data demonstrate the safety of the tested investigational medicinal product. The function of the treated knee improved within one year after surgery in all enrolled patients. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: EudraCT No.: 2018-004,067-31; October 18 2018.

Kinetics of d-lactate and ischemia-modified albumin after abdominal aortic surgery and their ability to predict intestinal ischemia.

OBJECTIVES: Acute intestinal ischemia is a severe complication of abdominal aortic surgery that is difficult to diagnose early and therefore to treat adequately and timely. In this study the perioperative kinetics of d-lactate and ischemia-modified albumin (IMA) are described and the predictive value of these markers for the early diagnosis of acute intestinal ischemia is assessed. DESIGN & METHODS: This non-randomised, single-centre cohort study enrolled 50 patients with abdominal aortic aneurysm (AAA) and 30 patients with aortoiliac occlusive disease (AOID). Serum d-lactate and IMA were assessed pre-, intra-, and postoperatively at eight defined time points. RESULTS: The highest serum d-lactate was at 6 h after complete declamping of the vascular graft. The highest predictive power of d-lactate was at 3 h after complete declamping (AUC 0.857). IMA was found to be higher in the AAA group in ischemic patients 10 min after complete declamping than in the AOID group. The highest predictive values of IMA were at 1 h after aortic cross-clamping (AUC 0.758) and 3 and 6 h after complete declamping (0.745 and 0.721, respectively). Moreover, the multivariate model with both markers at 3 h after complete declamping improved the detection of intestinal ischemia (AUC 0.894). CONCLUSIONS: Serum levels of IMA and d-lactate seem to be influential predictive markers for postoperative intestinal ischemia, especially after 3 h from complete declamping of vascular reconstruction.

Current Approaches to Osteoid Osteoma and Minimally Invasive Surgery-A Minireview and a Case Report.

Osteoid osteoma is a benign bone tumor typically affecting the long bones of the lower limbs in young male patients. The lesion can be asymptomatic but, in most cases, patients present with characteristic nocturnal pain that is very responsive to the administration of non-steroidal anti-inflammatory drugs. Although osteoid osteomas can regress spontaneously over time, surgical therapy is often indicated in cases of long-lasting resistant pain. Apart from a traditional open resection, the modalities of minimally invasive surgery, such as radiofrequency ablation or cryoablation, have gradually become the option of choice in most cases. The first part of this manuscript is a minireview of the contemporary literature on the pathogenesis, diagnosis, and current trends in the treatment of osteoid osteoma. The second part is a case report of our own experience with a conventional C-arm-guided radiofrequency ablation of an osteoid osteoma located in the femoral neck in an adolescent patient. The aim was to prove that, even when more sophisticated guiding devices (CT, O-arm, etc.) are not available, the safe and reliable ablation of the lesion using a C-arm is still possible even in hard-to-reach areas. The case was a success, with no perioperative or postoperative complications.

l-lactate kinetics after abdominal aortic surgery and intestinal ischemia - An observational cohort study.

BACKGROUND: Postoperative intestinal ischemia is a severe complication in abdominal aortic surgery. Early diagnosis is needed for adequate and timely treatment. We studied the postoperative kinetics of l-lactate in vascular patients to assess its value as a marker for early postoperative intestinal ischemia detection. MATERIAL AND METHODS: We performed a prospective non-randomized single-center observational cohort study in eighty elective patients, fifty operated on for abdominal aortic aneurysm (AAA) and thirty for aortoiliac occlusive disease (AIOD). Serum l-lactate was measured preoperatively, intraoperatively, and postoperatively at defined timepoints up to postoperative day 7. Intestinal ischemia was detected using MRI enterocolography. We have used univariate logistic regression and receiver operating characteristics curves for the evaluation of marker accuracy. RESULTS: We recorded 6 cases of postoperative intestinal ischemia (7.5%), five non-transmural and one transmural. Two patients died because of this complication (mortality 33%). The comparison of AAA and AIOD cohorts showed a significant difference in l-lactate levels at one intraoperative timepoint, which was attributable to procedure differences. The only preoperative factor associated with higher l-lactate levels at some timepoints was chronic kidney disease. Patients suffering postoperative intestinal ischemia had elevated serum l-lactate levels at multiple timepoints. The most accurate timepoint for diagnosis was 24 h after the declamping of the vascular reconstruction (DC24H), the second was 10 min after declamping. Sensitivity, specificity, positive and negative predictive values at timepoint DC24H were 100%, 82%, 32%, and 100%, respectively. CONCLUSION: Serum l-lactate levels might help in the early detection of postoperative intestinal ischemia after aortic surgery if proper timepoints are used. Cutoff values need to be established in large-scale prospective studies.

Toxocariasis as a Rare Parasitic Complication of a Transthoracic Spine Surgery Procedure.

Human toxocariasis is a helminthozoonosis caused by the migration of Toxocara species larvae through an organism. The infection in humans is transmitted either by direct ingestion of the eggs of the parasite, or by consuming undercooked meat infested with Toxocara larvae. This parasitosis can be found worldwide, but there are significant differences in seroprevalence in different areas, depending mainly on hot climate conditions and on low social status. However, the literature estimates of seroprevalence are inconsistent. Infected patients commonly present a range of symptoms, e.g., abdominal pain, decreased appetite, restlessness, fever, and coughing. This manuscript presents a case report of a polytraumatic patient who underwent a two-phase spinal procedure for a thoracolumbar fracture. After the second procedure, which was a vertebral body replacement via thoracotomy, the patient developed a pathologic pleural effusion. A microscopic cytology examination of this effusion revealed the presence of Toxocara species larvae. Although the patient presented no specific clinical symptoms, and the serological exams (Enzyme-linked immunosorbent assay (ELISA), Western blot) were negative, the microscopic evaluation enabled a timely diagnosis. The patient was successfully treated with albendazole, with no permanent sequelae of the infection.

Increased Microvessel and Arteriole Density in the Contracted Side of the Relapsed Clubfoot.

BACKGROUND: Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process. METHODS: We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression. RESULTS: An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, ß catenin and active ß catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis. CONCLUSIONS: Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot. LEVEL OF EVIDENCE: Level II-analytical and prospective.

First experience in the Czech Republic with perirectal hydrogel injection before radiotherapy for prostate cancer.

PURPOSE: SpaceOAR® is a Food and Drug Administration approved hydrogel injection used to create space between the prostate and rectum before prostate radiotherapy (RT). This bio-degradable hydrogel was not available in the Czech Republic until 2019. We present our first experience as a new established SpaceOAR® centre. We namely focused on technical difficulties with a new procedure and possible medical complications. METHODS: We injected SpaceOAR® to 58 patients indicated for prostate RT due to prostate cancer. Prospectively and retrospectively, we monitored the learning curve and complication rate and we assessed the feasibility as an out-patient procedure in the Czech medical environment. RESULTS: The procedure is technically feasible as an out-patient procedure in a urological office. The learning curve with reasonable ultrasound experience and adequate equipment is acceptably short. The number of complications which might be associated with hydrogel injection was very low, with one exception in our centre - ulceration of the rectum. CONCLUSION: SpaceOAR® injection is a minimally invasive out-patient procedure with expected minimum complications and it is easy to learn.

Impaired Adrenergic/Protein Kinase A Response of Slow Delayed Rectifier Potassium Channels as a Long QT Syndrome Motif: Importance and Unknowns.

The slow delayed rectifier potassium current (IKs) significantly contributes to cardiac repolarization under specific conditions, particularly at stimulation by the protein kinase A (PKA) during increased sympathetic tone. Impaired PKA-mediated stimulation of IKs channels may considerably aggravate dysfunction of the channels induced by mutations in the KCNQ1 gene that encodes the structure of the α-subunit of IKs channels. These mutations are associated with several subtypes of inherited arrhythmias, mainly long QT syndrome type 1, less commonly short QT syndrome type 2, and atrial fibrillation. The impaired PKA reactivity of IKs channels may significantly increase the risk of arrhythmia in these patients. Unfortunately, only approximately 2.7% of the KCNQ1 variants identified as putatively clinically significant have been studied with respect to this problem. This review summarizes the current knowledge in the field to stress the importance of the PKA-mediated regulation of IKs channels, and to appeal for further analysis of this regulation in KCNQ1 mutations associated with inherited arrhythmogenic syndromes. On the basis of the facts summarized in our review, we suggest several new regions of the α-subunit of the IKs channels as potential contributors to PKA stimulation, namely the S4 and S5 segments, and the S2-S3 and S4-S5 linkers. Deeper knowledge of mechanisms of the impaired PKA response in mutated IKs channels may help to better understand this regulation, and may improve risk stratification and management of patients suffering from related pathologies.

Novel contribution to clubfoot pathogenesis: The possible role of extracellular matrix proteins.

Idiopathic pes equinovarus (clubfoot) is a congenital deformity of the feet and lower legs. Clubfoot belongs to a group of fibro-proliferative disorders but its origin remains unknown. Our study aimed to achieve the first complex proteomic comparison of clubfoot contracted tissue of the foot (medial side; n = 16), with non-contracted tissue (lateral side; n = 13). We used label-free mass spectrometry quantification and immunohistochemistry. Seven proteins were observed to be significantly upregulated in the medial side (asporin, collagen type III, V, and VI, versican, tenascin-C, and transforming growth factor beta induced protein) and four in the lateral side (collagen types XII and XIV, fibromodulin, and cartilage intermediate layer protein 2) of the clubfoot. Comparison of control samples from cadavers brought only two different protein concentrations (collagen types I and VI). We also revealed pathological calcification and intracellular positivity of transforming growth factor beta only in the contracted tissue of clubfoot. Most of the 11 differently expressed proteins are strongly related to the extracellular matrix architecture and we assume that they may play specific roles in the pathogenesis of this deformity. These proteins seem to be promising targets for future investigations and treatment of this disease. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Expression of CD44, EGFR, p16, and their mutual combinations in patients with head and neck cancer: Impact on outcomes of intensity-modulated radiation therapy.

BACKGROUND: Progress in radiation treatment of head and neck squamous cell carcinoma (HNSCC) deserves the studies focused on molecular predictors that would help to enhance individually tailored treatment. METHODS: p16/epidermal growth factor receptor (EGFR)/cluster of differentiation-44 (CD44) was immunohistochemically analyzed in 165 HNSCC patients. RESULTS: In the entire group and the p16 negative cohort, better 3-year overall survival and locoregional control correlated with p16 positivity, CD44, and EGFR negativity were observed. Combined analysis revealed the worst results in the CD44+/p16-, EGFR+/p16-, and EGFR+/CD44+ groups and in the EGFR+/CD44+ within p16 negative cohort. Multivariate analysis found tumor stage, Karnofsky index, p16, and CD44 as prognostic factors of overall survival and clinical stage, and p16 as a prognostic factor for locoregional control. Clinical stage and Karnofsky index affected overall survival and tumor stage. EGFR affected locoregional control in the p16 negative subgroup. CONCLUSION: Our study confirmed the negative effect of CD44 and EGFR and the positive effect of p16 on radiotherapy results.

Pseudoaneurysm of the Dorsalis Pedis Artery: Case Report and Literature Review.

Aneurysms and pseudoaneurysms of the dorsalis pedis artery are rare vascular entities usually caused by traumatic injury or iatrogenic intervention, producing a focal soft pulsatile tissue mass in the dorsal foot. Gradual expansion of the fibrous capsule can produce secondary physical signs through the pressure exerted on surrounding structures. We report the case of a 57-year-old male with an idiopathic pseudoaneurysm of the dorsalis pedis artery. A focused history found a low-grade blunt trauma to the dorsal foot that had occurred 2 years previously. The diagnosis of a pseudoaneurysm was confirmed by ultrasound examinations and computed tomography angiograms. The pseudoaneurysm was treated with resection, and a short reversed great saphenous vein interposition graft was placed. He recovered well after surgery and remained free of symptoms 18 months postoperatively. The literature review of this uncommon vascular pathologic entity and the diagnosis and management are discussed.

Clinical characteristics of 30 Czech families with long QT syndrome and KCNQ1 and KCNH2 gene mutations: importance of exercise testing.

BACKGROUND: Classic symptoms of long QT syndrome (LQTS) include prolongation of QT interval on electrocardiograph, syncope, and cardiac arrest due to a distinctive form of polymorphic ventricular tachycardia, known as Torsade de Pointes. We assessed occurrence of LQTS signs in individuals from 30 Czech families with mutations in KCNQ1 and KCNH2 genes. METHODS AND RESULTS: One hundred five individuals from 30 Czech families with LQTS were genotyped for KCNQ1 and KCNH2. The occurrence of typical LQTS signs (pathologic prolongation of QT interval; syncope; cardiac arrest; Torsade de Pointes) was clinically assessed by exercise test with QT interval analysis. Family history of sudden cardiac death was taken. Statistical analysis was performed to determine correlation of clinical results and mutation status. KCNQ1 gene mutations were found in 23 families, and KCNH2 gene mutations in eight families. Only 46 (70%) of the 66 mutation carriers had at least two of the typical LQTS signs. The others were minimally or asymptomatic. From 39 noncarrier individuals, only 1 fulfilled the clinical criteria of LQTS diagnosis, another 4 had an intermediate probability of diagnosis. The exercise test had 92% sensitivity and 93% specificity for LQTS diagnosis. CONCLUSIONS: Incidence of classical signs of LQTS was not high in Czech carriers of KCNQ1 and KCNH2 mutations. Therefore, proper diagnosis relies on detection of symptoms at presentation. The exercise test may be beneficial owing to its high sensitivity and specificity for LQTS diagnosis.

Evaluation of a knitted polytetrafluoroethylene mesh placed intraperitoneally in a New Zealand white rabbit model.

BACKGROUND: The intraperitoneal application of surgical mesh remains a controversial issue because of possible complications, especially adhesion and fistula formation. This study aimed to assess the potential of a knitted polytetrafluoroethylene (PTFE) mesh for intraabdominal implantation. METHODS: Twenty-eight 5 × 5 cm samples of knitted macroporous PTFE mesh and light-weight polypropylene mesh (LW-PP) were implanted intraperitoneally in 14 New Zealand white rabbits in a randomized manner and fixed using eight polypropylene stitches. After 90 days, the adhesion formation, adhesion score, shrinkage, strength of fixation to the abdominal wall, and histologic biocompatibility were assessed. RESULTS: No intraoperative or anesthesia-related complications or mesh infection were recorded. The average area covered by adhesions was 4.7 ± 7.2% for the PTFE and 36.4 ± 36.1% for the LW-PP. The median adhesion score was 0 for the PTFE and 8 for the LW-PP. Shrinkage was 36.9 ± 12.9% for the PTFE mesh and 12.6 ± 8.72% for the LW-PP. The mesh-to-abdominal wall fixation strength was almost the same for both materials (PTFE 3.6 ± 1.9 vs. LW-PP 3.6 ± 2.9). The inflammatory cell count was almost the same for the two groups, with no statistically significant difference. The width of the inner granuloma was equal (PTFE 10.5 ± 0.9 vs. LW-PP 11.1 ± 0.9). The outer granuloma was reduced significantly in the PTFE group (PTFE 23.0 ± 2.1 vs. LW-PP 33.6 ± 7.9). One of the animals in the PTFE group died on postoperative day 12 because of ileus. The reason was an adhesion of the small intestine to the polypropylene fixation stitch, which caused small intestine strangulation. CONCLUSIONS: The knitted PTFE mesh induces fewer intraperitoneal adhesions of lower density than the light-weight polypropylene mesh. The strength of the knitted PTFE mesh fixation to the abdominal wall is comparable with that of the light-weight polypropylene mesh, but the shrinkage is greater. The biocompatibility of the knitted PTFE mesh is comparable with that of the light-weight polypropylene implant.

Mutation analysis ion channel genes ventricular fibrillation survivors with coronary artery disease.

BACKGROUND: Observations from population-based studies demonstrated a strong genetic component of sudden cardiac death. The aim of this study was to test the hypothesis that ion channel genes mutations are more common in ventricular fibrillation (VF) survivors with coronary artery disease (CAD) compared to controls. METHODS: The entire coding sequence of KCNQ1, KCNH2, SCN5A, KCNE1, and KCNE2 genes was analyzed in 45 (five females) CAD individuals-survivors of documented VF and in 90 matched healthy controls. In another control group of 141 matched patients with CAD without malignant arrhythmias, the exons containing rare coding variants found in the VF survivors were sequenced. RESULTS: The carrier frequency of all the rare sequence variants was significantly higher in the VF survivors (8/45, 17.8%) than in CAD controls (3/141, 2.2%, P = 0.001). In VF survivors, four coding variants in eight individuals were found. Three in KCNH2 gene: R148W and GAG186del are novel; P347S was previously related to long QT syndrome. In SCN5A gene, P2006A variant was found in five unrelated males. This variant has been demonstrated previously to have small effect on sodium channel kinetics. No rare coding variants were found in the healthy controls. The P2006A variant was found in three CAD controls. CONCLUSION: The prevalence of selected, rare coding variants in five long QT genes was significantly higher in cases versus controls, confirming a mechanistic role for these genes among a subgroup of patients with coronary disease and VF.

The learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease.

BACKGROUND: Since the end of the 20th century, robot-assisted surgery has been finding its role among other minimally invasive methods. Vascular surgery seems to be another specialty in which the benefits of this technology can be expected. Our objective was to assess the learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease in a group of 40 patients. METHODS: Between May 2006 and January 2010, 40 patients (32 men, 8 women), who were a median age of 58 years (range, 48-75 years), underwent 40 robot-assisted laparoscopic aortofemoral reconstructions. Learning curve estimations were used for anastomosis, clamping, and operative time assessment. For conversion rate evaluation, the cumulative summation (CUSUM) technique was used. Statistical analysis comparing the first and second half of our group, and unilateral-to-bilateral reconstructions were performed. RESULTS: We created 21 aortofemoral and 19 aortobifemoral bypasses. The median proximal anastomosis time was 23 minutes (range, 18-50 minutes), median clamping time was 60 minutes (range, 40-95 minutes), and median operative time was 295 minutes (range, 180-475 minutes). The 30-day mortality rate was 0%, and no graft or wound infection or cardiopulmonary or hepatorenal complications were observed. During the median 18-month follow-up (range, 2-48 months), three early graft occlusions occurred (7%). After reoperations, the secondary patency of reconstructions was 100%. Data showed a typical short learning curve for robotic proximal anastomosis creation with anastomosis and clamping time reduction. The operative time learning curve was flat, confirming the procedure's complexity. There were two conversions to open surgery. CUSUM analysis confirmed that an acceptable conversion rate set at 5% was achieved. Comparing the first and second half of our group, all recorded times showed statistically significant improvements. Differences between unilateral and bilateral reconstructions were not statistically significant. CONCLUSIONS: Our results show that the success rate of robot-assisted laparoscopic aortofemoral bypass grafting is high and the complication rate is low. Anastomosis creation, one of the main difficulties of laparoscopic bypass grafting, has been overcome using the robotic operating system and its learning curve is short. However, the endoscopic dissection of the aortoiliac segment remains the most difficult part of the operation and should be addressed in further development of the method to reduce the operative times. Long-term results and potential benefits of this minimally invasive method have to be verified by randomized controlled clinical trials.