Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms.

Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.

The addition of a leaded arm sleeve to leaded aprons further decreases operator upper outer quadrant chest wall radiation dose during fluoroscopically guided interventions.

OBJECTIVE: Breast cancer most commonly occurs in the upper outer quadrant (UOQ) chest wall (CW). The effectiveness of routine leaded aprons to protect this region of the body in interventionalists during fluoroscopically guided interventions (FGIs) is unknown. Given the high lifetime attributable risks of prolonged occupational exposure to ionizing radiation and the increasing number of practicing female vascular surgeons and interventionalists, we sought to determine if the use of a leaded arm shield would offer additional protection to the lateral CW and axilla in operators compared with routine leaded aprons. METHODS: Effectiveness of leaded sleeves in attenuating radiation dose to the axilla and UOQ was evaluated in clinical practice and simulated scenarios. In the clinical setting, optically stimulated luminescence nanoDot detectors were placed at the UOQ lateral CW position, both over and under a standard leaded apron vest with and without the addition of an antimony/bismuth Enviro-Lite sleeve on two vascular surgeons performing FGIs. In the simulation, nanoDots were similarly placed on an anthropomorphic phantom positioned to represent a primary operator performing right femoral access. Fluorography was performed on 12-inch-thick acrylic scatter phantom at 80 kVp for an exposure of 3 Gy reference air kerma. Experiments were done with and without the sleeve. Paired Wilcoxon and χ2 tests were performed to identify the statistical significance of radiation attenuation. RESULTS: Operator UOQ CW dose was measured during 61 FGIs: 33 cases (54%) with and 28 cases (46%) without the sleeve. Median procedure reference air kerma and fluoroscopy time was 180 mGy (interquartile range [IQR], 85-447 mGy) and 21 minutes (IQR, 11-39 minutes) when the sleeve was worn vs 100 mGy (IQR, 67-270 mGy) and 11 minutes (IQR, 6.3-25 minutes) without the sleeve. Radiation dose to the operator's UOQ was reduced by 96% (IQR, 85%-96%) when the sleeve was present and by 62% (IQR, 44%-82%; P < .001) without the sleeve. In the simulated setting, the sleeve reduced the radiation dose to the UOQ compared with the apron alone (96% vs 67%; P < .001). CONCLUSIONS: Routine leaded aprons do attenuate the majority of UOQ chest wall radiation dose; however, the addition of a lead-equivalent sleeve further significantly reduces this dose. Because this area of the body has a high incidence of cancer formation, additional protection, especially to female interventionalists, seems prudent. Vascular surgeons should consider using a protective sleeve with their personal protective equipment when performing complex fluoroscopically guided procedures.

Hemorrhage Occluder™ Pin to control life-threatening bleeding during the removal of an infected sacrocolpopexy mesh: A case report.

Vaginal mesh exposures and infections are recognized complications of open and laparoscopic sacrocolpopexy performed for vault prolapse. In severe cases, complete sacrocolpopexy mesh removal may be necessary. This case report presents a 72-year-old woman with previous mesh sacrocolpopexy who presented with infected mesh and recurrent vaginal bleeding despite multiple attempts at surgical transvaginal mesh excision. A life-threatening massive hemorrhage occurred intra-operatively. After several failed attempts to control bleeding, hemorrhage Occluder™ Pins were successfully placed by vascular surgery to control presacral veins. Although an exceedingly rare complication, anticipation and rapid management of life-threatening bleeding are critical to save life during complicated mesh removals.

Operator Lower Leg Radiation Dose during Fluoroscopically Guided Interventions is Effectively Reduced by Wearing Lead-Equivalent Leg Wraps.

BACKGROUND: The intensity of radiation scatter that emanates from the X-ray beam during fluoroscopically guided interventions is greater below the fluoroscopy table than above. Yet interventionalists' lower legs are typically unshielded and table skirts are often positioned incorrectly. We sought to characterize the efficacy of the leg protector wraps (Leg Wraps, Burlington Medical Inc.) in reducing the radiation dose to the operator's lower leg during fenestrated and branched endovascular aneurysm repair (F-BEVAR). METHODS: A prospective cohort study was performed evaluating the lower leg radiation dose reduction of one vascular surgeon during F/BEVAR using antimony/bismuth Enviro-Lite leg wraps (0.35 mm lead equivalency, 99.7% attenuation at 50 kVp; Burlington Medical, Hampton Roads, Virginia). Optically Stimulated Luminescence nanoDot detectors (microSTARii System, LANDAUER, Inc., Glenwood, Illinois) were placed over and under the left leg wrap at the anterior tibial tuberosity position to compare operator leg dose with and without this additional protection. The table-mounted lead skirt was used consistently in all cases. The nanoDot detectors were cross-calibrated with a survey meter (RaySafe X2 survey sensor, Fluke Biomedical, Cleveland, Ohio) by measuring scattered radiation at a position equivalent to an operator's mid-tibia while performing digital acquisitions of a 25-cm thick, 30 cm × 30 cm acrylic phantom with a Philips FD20 fluoroscope (Philips Healthcare, Best, The Netherlands) with the table skirt removed. The measured radiation doses were converted to a Hp (0.07) skin dose, assuming an RQR6 beam spectrum (IEC-61267). Paired Wilcoxon test was performed to identify significant attenuation of radiation exposure. RESULTS: Leg dose measurements from 40 F-BEVARs were analyzed. The patients had a median (interquartile range) body mass index of 27 (24-32) kg/m2. Median procedure reference air kerma was 1,100 (728-1,601) mGy, kerma-area product was 127 (73-184) Gycm2, and fluoroscopy time was 69 (54-86) min. The median skin dose Hp (0.07) over the leg wraps (n = 40) was 54.2 (24-100) µSv and under the leg wraps (n = 40) was 2.7 µSv (1.0-5.8). The leg wraps attenuated the radiation dose by 95% (89-98%) (P < 0.001). The unprotected, Hp (0.07) per kerma-area product was determined to be 0.38 (0.30-0.55) µSv/Gycm2. CONCLUSIONS: The 0.35-mm lead-equivalent leg wraps significantly decreased scattered radiation to the lower leg during F-BEVAR. Protective leg wraps should be recommended to operators performing complex fluoroscopically guided procedures.

New imaging technology system reduces patient radiation dose during peripheral arterial endovascular interventions.

BACKGROUND: Radiation exposure and imaging quality are among the main concerns in endovascular procedures. The Clear VD11 PURE platform technology system (Siemens Healthineers, Erlangen, Germany) has been reported to lower the radiation dose and improve image quality. In the present study, we evaluated whether the radiation dose during peripheral arterial endovascular procedures had decreased after implementation of this new imaging system. METHODS: The patient characteristics (age, gender, body mass index [BMI]), procedure type (diagnostic, balloon angioplasty, atherectomy, stenting), body location (aortoiliac, superficial femoral artery, tibial artery), reference air kerma (RAK), kerma area product (KAP), and fluoroscopy time (FT) were recorded during peripheral artery interventions performed 1 year before (group A) and 1 year after (group B) the CLEAR system upgrade. The procedures were performed in an Artis zeego hybrid room (Siemens Healthineers) with the same providers. A general linear model was used to estimate the average difference between groups adjusted by procedure type and patient age, gender, and BMI. Additionally, to control for variations in case complexity, groups A and B were matched by age, gender, BMI, lesion location, and intervention type. Propensity score matching and a paired t test were used to compare the KAP, RAK, and FT stratified by single intervention procedures. RESULTS: A total of 487 endovascular procedures were performed: 209 in group A and 278 in group B. A total of 111 single intervention procedures from each group were matched (1:1), with a mean age of 61 ± 8 years and a BMI of 26.5 ± 4 kg/m2. The median KAP, RAK, and FT for group A were 28.8 Gy · cm2 (interquartile range [IQR], 24-34 Gy · cm2), 146 mGy (IQR, 123-173 mGy), and 12 minutes (IQR, 10-14 minutes), respectively. The median KAP, RAK, and FT for group B were 18.3 Gy · cm2 (IQR, 16-22 Gy · cm2), 71.2 mGy (IQR, 60-85 mGy), and 10.4 minutes (IQR, 9-12 minutes), respectively. The KAP, RAK, and FT were significantly decreased in group B by 24% (P = .005), 41% (P < .001), and 22% (P = .002), respectively, compared with the values for group A. Stratified by single intervention procedures, the KAP and RAK had decreased significantly in group B (36% [P = .002] and 51% [P < .001], respectively) compared with group A. The FT decrease of 13% in group B was not statistically significant (P = .20). CONCLUSIONS: Use of the Clear VD11 PURE platform system (Siemens Healthineers) reduced the patient radiation dose by 51% during endovascular peripheral interventions. The similar FTs for the matched single intervention procedures before and after the upgrade indicated consistent case complexity and surgeon practice. This platform appears to be an effective system for lowering the radiation dose.

Disposable, lightweight shield decreases operator eye and brain radiation dose when attached to safety eyewear during fluoroscopically guided interventions.

OBJECTIVE: Long-term radiation exposure from fluoroscopically guided interventions (FGIs) can cause cataracts and brain tumors in the operator. We have previously demonstrated that leaded eyewear does not decrease the operator eye radiation dose unless lead shielding has been added to the lateral and inferior portions. Therefore, we have developed a disposable, lightweight, lead-equivalent shield that can be attached to the operator's eyewear that conforms to the face and adheres to the surgical mask. In the present study, we evaluated the efficacy of our new prototype in lowering the operator brain and eye radiation dose when added to both leaded and nonleaded eyewear. METHODS: The attenuating efficacy of leaded eyewear alone, leaded eyewear plus the prototype, and nonleaded eyewear plus the prototype were compared with no eyewear protection in both a simulated setting and clinical practice. In the simulation, optically stimulated, luminescent nanoDot detectors (Landauer, Inc, Glenwood, Ill) were placed inside the ocular, temporal lobe, and midbrain spaces of a head phantom (ATOM model-701; CIRS, Norfolk, Va). The phantom was positioned to represent a primary operator performing right femoral access. Fluorography was performed on a plastic scatter phantom at 80 kVp for an exposure of 3 Gy reference air kerma. In the clinical setting, nanoDots were placed below the operator's eye both inside and outside the prototype during the FGIs. The median and interquartile ranges were calculated for the dose at each nanoDot location for the phantom and clinical studies. The average dose reduction was also recorded. RESULTS: Wearing standard leaded eyewear alone did not decrease the operator ocular or brain radiation dose. In the phantom experiment, the leaded glasses plus the prototype reduced the radiation dose to the lens, temporal lobe, and midbrain by 83% (P < .001), 78% (P < .001), and 75% (P < .001), respectively. The nonleaded glasses plus the prototype also reduced the dose to the lens, temporal lobe, and midbrain by 85% (P < .001), 81% (P < .001), and 71% (P < .001), respectively. A total of 15 FGIs were included in the clinical setting, with a median reference air kerma of 98.4 mGy. The use of our prototype led to an average operator eye dose reduction of 89% (P < .001). CONCLUSIONS: Attaching our prototype to both leaded and nonleaded glasses significantly decreased the eye and brain radiation dose to the operator. This face shield attachment provided meaningful radiation protection and should be considered as either a replacement or an adjunct to routine eyewear.