A Comparative Study of Secondary Procedures after Subpectoral and Prepectoral Single-Stage Implant-Based Breast Reconstruction.

BACKGROUND: Implant-based breast reconstruction (IBR) is the most commonly used procedure to reconstruct the breast after mastectomy. The advantages and disadvantages of subpectoral versus prepectoral implant placement remain a matter of debate. This study compares the need for secondary aesthetic procedures between prepectoral and subpectoral IBR. METHODS: This is a retrospective cohort study of consecutive patients who underwent subpectoral or prepectoral IBR between 2015 and 2018 under a single surgeon at a tertiary breast unit. The primary endpoint was the number of secondary procedures performed to improve the aesthetic outcome. Secondary endpoints included the number of secondary procedures during the first year. RESULTS: A total of 271 one-stage IBRs were performed (subpectoral, n = 128 in 74 patients; prepectoral, n = 143 in 84 patients). Overall, more patients required secondary procedures in the subpectoral group (36.5% versus 19%; P = 0.014), although through longer follow-up. The most common procedures were pocket revision and implant exchange [11.7% versus 3.5% ( P = 0.010); 11.7% versus 4.2% ( P = 0.021)], whereas fat grafting was similar between the two groups (46% versus 40.5%; P = 0.777). When adjusted for follow-up time, there was no significant difference in the number of secondary procedures undertaken in the subpectoral versus the prepectoral group (21% versus 16%, respectively; P = 0.288) at 1 year. CONCLUSIONS: The requirement for secondary procedures at 1 year was not different between groups. The need for fat grafting was not increased following prepectoral IBR. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Three-dimensional contrast-enhanced ultrasound improves endoleak detection and classification after endovascular aneurysm repair.

BACKGROUND: Three-dimensional contrast-enhanced ultrasound (3D-CEUS) is a novel technology allowing surgeons to view duplex ultrasound images in three dimensions with ultrasound contrast highlighting blood flow in endoleaks after endovascular aneurysm repair (EVAR). It potentially reduces the need for computed tomography angiography (CTA) and catheter angiography. This study compares 3D-CEUS with both CTA and the final vascular multidisciplinary team (MDT) diagnosis using all available imaging. Interoperator variability for detection of endoleak and the influence of 3D-CEUS on patient management were studied. METHODS: A consecutive 100 patients undergoing CTA for EVAR surveillance were invited to undergo standard CEUS and 3D-CEUS on the same day, with 3D-CEUS reported independently by two blinded vascular scientists. Presence and type of endoleak were compared between CTA, standard CEUS, 3D-CEUS, and the final diagnostic decision made in the vascular MDT meeting. Interoperator reliability of 3D-CEUS was analyzed using the κ statistic. RESULTS: The 100 paired CTA, CEUS, and 3D-CEUS studies were analyzed. Compared with CTA, the sensitivity, specificity, positive predictive value, and negative predictive value of 3D-CEUS to endoleak were 96%, 91%, 90%, and 96%, respectively. Compared with the MDT decision with access to all imaging modalities, the sensitivity, specificity, positive predictive value, and negative predictive value of 3D-CEUS were 96%, 100%, 100%, and 96%. The κ statistic for interoperator agreement was 0.89. CONCLUSIONS: 3D-CEUS was more sensitive and accurate than CTA for endoleak detection and classification after EVAR. 3D-CEUS is now our initial investigation of choice in cases of sac expansion during duplex ultrasound follow-up or if there is diagnostic uncertainty on standard duplex ultrasound or CTA.

Thoracic but not abdominal phase contrast magnetic resonance-derived aortic pulse wave velocity is elevated in patients with abdominal aortic aneurysm.

OBJECTIVES: Increased stiffening of the aortic wall could contribute to the development of abdominal aortic aneurysm (AAA). We investigated regional aortic wall pulse wave velocity (PWV) in patients with AAA. METHODS: Forty-six men diagnosed with a small AAA and 42 control men were recruited from the AAA surveillance and screening programmes at Guy's and St Thomas' Hospital. Phase-contrast cardiovascular MRI was performed to determine regional PWV along the thoracic (PWVTHOR) and abdominal aorta (PWVABD). PWV over the total aorta (PWVTOTAL) was calculated from the combined regions. RESULTS: PWVTOTAL was significantly higher in patients with AAA compared to controls (10.0 ±â€Š2.1 versus 8.4 ±â€Š1.6 m/s, respectively; P < 0.0001). The difference in total aortic PWV between groups was explained by increased thoracic PWV in patients with AAA compared to controls (PWVTHOR 9.9 ±â€Š2.8 versus 8.1 ±â€Š2.5 m/s, respectively; P < 0.01). In contrast, there was no difference in PWV measured over the abdominal region in AAA patients compared with controls (PWVABD 10.7 ±â€Š3.3 and 10.1 ±â€Š3.3 m/s, in AAA and control groups, respectively; P = 0.40). In multiple regression analysis, including the whole cohort, abdominal aortic diameter remained significantly associated with PWVTOTAL and PWVTHOR (standardized regression coefficients 0.22 and 0.19, respectively; each P < 0.05 after adjustment for age and mean arterial pressure), but not with PWVABD. CONCLUSION: AAA patients have a greater PWV in the thoracic but not abdominal aorta compared to control individuals. Greater abdominal aortic diameter in patients with AAA is likely to offset effects of intrinsic stiffening of the abdominal aorta on PWV.

Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review.

Chronic pelvic pain (CPP) affects 24% of women worldwide; the cause cannot be identified in 40% despite invasive investigations. Dilated, refluxing pelvic veins may be a cause of CPP and treatment by trans-venous occlusion is increasingly performed when gynecological causes are excluded, but is it effective? A systematic review of the literature published between 1966 and July 2014 was conducted. Two authors independently reviewed potential studies according to a set of eligibility criteria, with a third assessor available as an arbiter. Thirteen studies including 866 women undergoing trans-venous occlusion of pelvic veins for CPP were identified (Level of evidence: one study grade 2b, 12 studies grade four). Statistical significant improvements in pelvic pain were reported in nine of the 13 studies. Technical success was reported in 865 of 866 (99.8%) with low complication rates: coil migration in 14 women (1.6%), abdominal pain in ten women (1.2%) and vein perforation in five (0.6%). In a study on varicose veins of the legs, recurrence was seen in 13% of 179 women 5-years following coil embolization. Subjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion. All 13 studies were of poor methodological quality. Complication rates were low and no fatalities occurred. Well-designed studies are essential to determine whether pelvic vein incompetence (PVI) is associated with CPP, and to explore whether trans-venous occlusion of PVI improves quality of life for these women.

Role of miR-195 in aortic aneurysmal disease.

RATIONALE: Abdominal aortic aneurysms constitute a degenerative process in the aortic wall. Both the miR-29 and miR-15 families have been implicated in regulating the vascular extracellular matrix. OBJECTIVE: Our aim was to assess the effect of the miR-15 family on aortic aneurysm development. METHODS AND RESULTS: Among the miR-15 family members, miR-195 was differentially expressed in aortas of apolipoprotein E-deficient mice on angiotensin II infusion. Proteomics analysis of the secretome of murine aortic smooth muscle cells, after miR-195 manipulation, revealed that miR-195 targets a cadre of extracellular matrix proteins, including collagens, proteoglycans, elastin, and proteins associated with elastic microfibrils, albeit miR-29b showed a stronger effect, particularly in regulating collagens. Systemic and local administration of cholesterol-conjugated antagomiRs revealed better inhibition of miR-195 compared with miR-29b in the uninjured aorta. However, in apolipoprotein E-deficient mice receiving angiotensin II, silencing of miR-29b, but not miR-195, led to an attenuation of aortic dilation. Higher aortic elastin expression was accompanied by an increase of matrix metalloproteinases 2 and 9 in mice treated with antagomiR-195. In human plasma, an inverse correlation of miR-195 was observed with the presence of abdominal aortic aneurysms and aortic diameter. CONCLUSIONS: We provide the first evidence that miR-195 may contribute to the pathogenesis of aortic aneurysmal disease. Although inhibition of miR-29b proved more effective in preventing aneurysm formation in a preclinical model, miR-195 represents a potent regulator of the aortic extracellular matrix. Notably, plasma levels of miR-195 were reduced in patients with abdominal aortic aneurysms suggesting that microRNAs might serve as a noninvasive biomarker of abdominal aortic aneurysms.

Accelerated aortic imaging using small field of view imaging and electrocardiogram-triggered quadruple inversion recovery magnetization preparation.

PURPOSE: To accelerate and optimize black blood properties of the quadruple inversion recovery (QIR) technique for imaging the abdominal aortic wall. MATERIALS AND METHODS: QIR inversion delays were optimized for different heart rates in simulations and phantom studies by minimizing the steady state magnetization of blood for T(1) = 100-1400 ms. To accelerate and improve black blood properties of aortic vessel wall imaging, the QIR prepulse was combined with zoom imaging and (a) "traditional" and (b) "trailing" electrocardiogram (ECG) triggering. Ten volunteers were imaged pre- and post-contrast administration using a conventional ECG-triggered double inversion recovery (DIR) and the two QIR implementations in combination with a zoom-TSE readout. RESULTS: The QIR implemented with "trailing" ECG-triggering resulted in consistently good blood suppression as the second inversion delay was timed during maximum systolic flow in the aorta. The blood signal-to-noise ratio and vessel wall to blood contrast-to-noise ratio, vessel wall sharpness, and image quality scores showed a statistically significant improvement compared with the traditional QIR implementation with and without ECG-triggering. CONCLUSION: We demonstrate that aortic vessel wall imaging can be accelerated with zoom imaging and that "trailing" ECG-triggering improves black blood properties of the aorta which is subject to motion and variable blood flow during the cardiac cycle.