Technique optimization of orbital atherectomy in calcified peripheral lesions of the lower extremities: the CONFIRM series, a prospective multicenter registry.

OBJECTIVES: The purpose of CONFIRM registry series was to evaluate the use of orbital atherectomy (OA) in peripheral lesions of the lower extremities, as well as optimize the technique of OA. BACKGROUND: Methods of treating calcified arteries (historically a strong predictor of treatment failure) have improved significantly over the past decade and now include minimally invasive endovascular treatments, such as OA with unique versatility in modifying calcific lesions above and below-the-knee. METHODS: Patients (3135) undergoing OA by more than 350 physicians at over 200 US institutions were enrolled on an "all-comers" basis, resulting in registries that provided site-reported patient demographics, ABI, Rutherford classification, co-morbidities, lesion characteristics, plaque morphology, device usage parameters, and procedural outcomes. RESULTS: Treatment with OA reduced pre-procedural stenosis from an average of 88-35%. Final residual stenosis after adjunctive treatments, typically low-pressure percutaneous transluminal angioplasty (PTA), averaged 10%. Plaque removal was most effective for severely calcified lesions and least effective for soft plaque. Shorter spin times and smaller crown sizes significantly lowered procedural complications which included slow flow (4.4%), embolism (2.2%), and spasm (6.3%), emphasizing the importance of treatment regimens that focus on plaque modification over maximizing luminal gain. CONCLUSION: The OA technique optimization, which resulted in a change of device usage across the CONFIRM registry series, corresponded to a lower incidence of adverse events irrespective of calcium burden or co-morbidities.

Senior surgical residents can accurately interpret trauma radiographs.

Surgical residents routinely interpret radiographic studies during the evaluation of trauma patients, which directs further evaluation and invasive procedures. Official interpretations--"post-reading"--of radiographs by radiologists may be delayed by hours or even days. Trauma surgeons frequently act on their impressions before "official" readings are available. It has been demonstrated that surgical residents can accurately perform and interpret trauma ultrasound examinations. The purpose of this study was to evaluate the ability of senior surgery residents to interpret basic trauma radiographs. Interpretations of trauma radiographs (cervical spine, chest, pelvis, and CT of the brain) were recorded prospectively by the senior surgery resident present during trauma evaluations. These interpretations were compared with the findings of the radiologist as obtained from the official radiology report. Differing results were divided into clinically significant and clinically nonsignificant findings using defined criteria. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were determined. Interpretations of trauma radiographs by senior residents achieved an accuracy of 100 per cent for cervical spine radiographs, 95.9 per cent for chest radiographs, 98.0 per cent for pelvis radiographs, and 97.9 per cent for CT of the head. In aggregate senior residents interpreted trauma radiographs with 97.9 per cent accuracy. Differences that were considered clinically significant according to preset criteria occurred in 2.1 per cent of observations. We conclude that senior general surgical residents can accurately interpret trauma radiology, including CT of the brain. These results suggest that institutional policies for post-reading of trauma radiology should be reassessed.

Blunt abdominal trauma with ruptured 16-week cornual ectopic pregnancy.

Trauma is the leading cause of nonobstetric morbidity and mortality in pregnancy. Care of the pregnant trauma patient is well documented in the medical literature; however, little has been written about the management of trauma patients with ectopic or cornual pregnancy. Herein, we report the previously undocumented occurrence of a traumatic rupture of a cornual ectopic pregnancy. The use of trauma ultrasound, computerized tomography, as well as obstetrical evaluation prevented an imminent life-threatening complication of this patient's pregnancy.

The midterm results of stent graft treatment of thoracic aortic injuries.

INTRODUCTION AND OBJECTIVES: Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS: A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS: From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS: Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.