Task-sharing spinal anaesthesia care in three rural Indian hospitals: a non-inferiority randomised controlled clinical trial.

BACKGROUND: Task-sharing of spinal anaesthesia care by non-specialist graduate physicians, termed medical officers (MOs), is commonly practised in rural Indian healthcare facilities to mitigate workforce constraints. We sought to assess whether spinal anaesthesia failure rates of MOs were non-inferior to those of consultant anaesthesiologists (CA) following a standardised educational curriculum. METHODS: We performed a randomised, non-inferiority trial in three rural hospitals in Tamil Nadu and Chhattisgarh, India. Patients aged over 18 years with low perioperative risk (ASA I & II) were randomised to receive MO or CA care. Prior to the trial, MOs underwent task-based anaesthesia training, inclusive of remotely accessed lectures, simulation-based training and directly observed anaesthetic procedures and intraoperative care. The primary outcome measure was spinal anaesthesia failure with a non-inferiority margin of 5%. Secondary outcome measures consisted of incidence of perioperative and postoperative complications. FINDINGS: Between 12 July 2019 and 8 June 2020, a total of 422 patients undergoing surgical procedures amenable to spinal anaesthesia care were randomised to receive either MO (231, 54.7%) or CA care (191, 45.2%). Spinal anaesthesia failure rate for MOs (7, 3.0%) was non-inferior to those of CA (5, 2.6%); difference in success rate of 0.4% (95% CI=0.36-0.43%; p=0.80). Additionally, there were no statistically significant differences observed between the two groups for intraoperative or postoperative complications, or patients' experience of pain during the procedure. INTERPRETATION: This study demonstrates that failure rates of spinal anaesthesia care provided by trained MOs are non-inferior to care provided by CAs in low-risk surgical patients. This may support policy measures that use task-sharing as a means of expanding anaesthesia care capacity in rural Indian hospitals. TRIAL REGISTRATION NUMBER: NCT04438811.

Exploring the perioperative infection control practices & incidence of surgical site infections in rural India.

BACKGROUND: Surgical site infections (SSIs) affect around a third of patients undergoing surgeries worldwide, annually. It is heterogeneously distributed with a higher burden in low and middle-income countries. Although rural and semi-urban hospitals cater to 60-70% of the Indian population, scarce data regarding SSI rates are available from such hospitals. The study aimed to determine the prevalent SSI prevention practices and existing SSI rates in the smaller rural and semi-urban hospitals in India. METHODS: This is a prospective study performed in two phases involving surgeons and their hospitals from Indian rural and semi-urban regions. In the first phase, a questionnaire was administered to surgeons enquiring into the perioperative SSI prevention practices and five interested hospitals were recruited for phase two which documented the rate of SSIs and factors affecting them. RESULTS: There was full compliance towards appropriate perioperative sterilisation practices and postoperative mop count practice at the represented hospitals. But prophylactic antimicrobials were continued in the postoperative period in more than 80% of the hospitals. The second phase of our study documented an overall SSI rate of 7.0%. The SSI rates were influenced by the surgical wound class with dirty wounds recording six times higher rate of infection than clean cases. CONCLUSIONS: SSI prevention practices and protocols were in place in all the less-resourced hospitals surveyed. The SSI rates are comparable or lower than other LMIC settings. However, this is accompanied by poor implementation of the antimicrobial stewardship guidelines.

Non-oncologic incidental uptake on FAPI PET/CT imaging.

Fibroblast-activation protein (FAP) is a serine protease classified in the dipeptidyl peptidase 4 (DPP4) family. FAP is predominantly expressed in activated fibroblasts such as the cancer-associated fibroblasts (CAFs). FAP expression in CAFs is associated with tumor progression and poor prognosis in solid cancers. Recently, radiolabeled FAP inhibitors (FAPI) has been developed, which enables positron emission tomography (PET) imaging of FAP. FAPI PET/CT can provide a higher tumor-to-background ratio (TBR) than 18F-fludeoxyglucose PET/CT in various cancers, and thus has attracted substantial attention. As studies on FAPI PET grow in number and size, incidental findings related to non-oncologic conditions have been increasingly reported. FAPI PET uptake has been reported in various conditions such as benign tumors, fibrotic, granulomatosis, scarring/wound, degenerative diseases, and inflammatory diseases.The knowledge of physiological and non-oncologic causes of FAPI uptake is indispensable for accurate FAPI PET/CT interpretation and can help appropriate management of incidental findings on FAPI PET/CT in patients referred for cancer staging indications. In this review article, we describe for each organ system (Brain, Oral mucosa, Salivary Glands, Thyroid, Lung, Myocardium, Breast, Esophagus, Stomach, Intestine, Liver, Gallbladder, Pancreas, Spleen, Kidney, , Uterus, Bone marrow, Joints, Muscle, Vessels, Lymph nodes), the patterns of physiological FAPI uptake and the main causes of non-oncological uptake reported from the literature with FAPI-02, FAPI-04 and FAPI-46. We also illustrate some examples from our institutional database at UCLA.

Obstetric neonatal emergency simulation workshops in remote and regional South India: a qualitative evaluation.

BACKGROUND: Healthcare facilities in remote locations with poor access to a referral centre have a high likelihood of health workers needing to manage emergencies with limited support. Obstetric and neonatal clinical training opportunities to manage childbirth emergencies are scant in these locations, especially in low- and middle-income countries. OBJECTIVES: This study aimed to explore the factors, which influenced healthcare worker experience of attending birth emergencies in remote and regional areas of South India, and the perceived impact of attending the Obstetric and Neonatal Emergency Simulation (ONE-Sim) workshop on these factors. DESIGN: Qualitative descriptive study using pre- and post-workshop qualitative surveys. SETTINGS: Primary healthcare facilities in remote/regional settings in three states of South India. PARTICIPANTS: A total of 125 healthcare workers attended the workshops, with 85 participants completing the pre- and post-workshop surveys included in this study. Participants consisted of medical and nursing staff and other health professionals involved in care at childbirth. METHODS: ONE-Sim workshops (with a learner-centred approach) were conducted across three different locations for interprofessional teams caring for birthing women and their newborns, using simulation equipment and immersive scenarios. Thematic analysis was employed to the free-text responses obtained from the surveys consisting of open-ended questions. RESULTS: Participants identified their relationship with the patient, the support provided by other health professionals, identifying their gaps in knowledge and experience, and the scarcity of resources as factors that influenced their experience of birth emergencies. Following the workshops, participant learning centred on improving team and personal performance and approaching future emergencies with greater confidence. CONCLUSIONS: Challenges experienced by healthcare workers across sites in remote and regional South India were generally around patient experience, senior health professional support and resources. The technical and interpersonal skills introduced through the ONE-Sim workshop may help to address some of these factors in practice.

The Impact of Nurse Navigator-Led Preoperative Education on Hospital Outcomes Following Posterolateral Lumbar Fusion Surgery.

Beyond the spine-specific pathology, patient factors such as associated medical and psychosocial conditions, understanding of the treatment process, and the degree of patient activation-defined as the ability of the individual to utilize the available information and actively engage in making their healthcare decisions-can influence outcomes after posterolateral lumbar fusion (PLF) surgery. A retrospective observational cohort study of 177 patients undergoing PLF at a single institution was conducted. Patient demographics, medical and psychosocial risk factors, and outcomes were compared between patients who attended a nurse navigator-led group preoperative education course and those who did not. Patients attending the course were younger, more likely to undergo one-level fusion, less likely to undergo 5- or more-level fusion, and had less comorbidity burden as measured by the hierarchical condition categories score. No differences in psychosocial risk factors were observed between groups. Course attendees had a significantly shorter length of stay (2.12 vs. 2.60 days, p = .042) and decreased average hospital cost (U.S. $10,149 vs. U.S. $14,792, p < .001) than those who did not attend; no differences in other outcomes were observed. After controlling for differences in risk factors, patients enrolled in a preoperative education course demonstrated a statistically significant reduction in hospital cost (ß=-4,143, p < .001). Preoperative education prior to PLF surgery may reduce hospital cost, possibly through increased patient activation. Given the relatively high prevalence of psychosocial risk factors in this and similar patient populations, optimizing patient activation and engagement is important to achieve high value care. Based on our findings, nurse navigator-led preoperative education appears to be valuable in this patient population and should be included in enhanced recovery protocols.

A Rapid Recovery Protocol Applied to Total Joint Arthroplasty Reduced Readmissions for Surgical but Not Medical Reasons Over a 5-Year Period.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed procedures that are expected to continue increasing in demand. Although they are proven to be safe and effective, emergency room (ER) visits or hospital readmissions within 90 days after these procedures account for more than one-third of the total cost of postacute care. Purpose: We sought to identify changes in reasons for 90-day ER visits and readmissions after total joint arthroplasty (TJA) during a 5-year period over which rapid recovery protocols evolved. Methods: We conducted a retrospective cohort study comparing 1980 patients who had undergone TJA from July 2017 to June 2018 with a previously published cohort of 7466 patients who had undergone TJA from July 2013 to June 2017. All procedures were performed at a single institution. Changes in the proportion of patients returning for medical and surgical reasons were compared using univariate analysis. Results: For patients discharged home, the 2017-2018 cohort showed a significant reduction in the proportion of ER visits due to pain and swelling and wound infection and an increase in visits for medical reasons. This cohort had a higher proportion of readmissions for medical reasons. In patients discharged to a skilled nursing facility (SNF), similar reasons for ER visits were observed across time periods, and a decrease in the proportion of readmissions for wound infections was observed in the 2017-2018 cohort. Falls and nausea, vomiting, or diarrhea increased significantly to account for 9.5% of readmissions each in 2017-2018. Conclusion: The results of a comparison of 2 cohorts demonstrate the heterogeneous and dynamic nature of unplanned return-to-hospital events and the importance of patient support throughout the surgical episode. As we strive toward minimizing ER visits and readmissions after TJA, rapid recovery protocols must continue to evolve to address the complexity of this patient population.

Polynomial modeling of emergency department arrivals: An analysis of local and national utilization patterns.

Emergency department (ED) overcrowding is a national problem that is associated with ambulance diversion, decreased patient and provider satisfaction and poor patient outcomes. This study presents a novel approach to modeling the relationship between time of day, day of week, and ED arrivals using a hierarchical polynomial regression model. A series of hierarchical regression models were created to determine polynomial effects and capture the covariability (defined as R2) of the relationships from the 2009 to 2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department Public Use Data File and institutional data from a regional medical center from 2018 to 2019. The following hierarchical regression models were constructed: cubic main effects, cubic interaction effects, quartic main effects, quartic interaction effects, quintic main effects, and quintic interaction effects. Based on maximal improvement in R2 and significance of each of the four effects in both the national and institutional data sets, the quartic main effects model was determined to be optimal for describing ED arrival patterns. In alignment with prior studies, significantly higher ED arrival volumes were observed on Mondays in comparison to all other weekdays.

Bilateral mammary hibernoma mimicking breast carcinoma: a diagnostic challenge.

We describe a 68-year-old postmenopausal woman who presented with a history of rapidly enlarging lumps in both breasts. Though the breast lumps appeared suspicious on ultrasonography, the core biopsy was reported to be benign. In view of the clinical and radiological suspicion of malignancy, she underwent a diagnostic excision of both the lumps, the histopathology was consistent with mammary hibernoma. To the best of the authors' knowledge, this is the first report of a bilateral mammary hibernoma in an elderly postmenopausal woman. Given the clinical presentation, it is important to differentiate mammary hibernoma from carcinoma breast, which is a more common condition in this age group. However, preoperative diagnosis is challenging in view of the lack of definitive radiological and histological features. Although benign, hibernoma may have a propensity for local recurrence and, therefore, complete surgical excision remains the mainstay of treatment.

Preoperative Predictors of Same-Day Discharge After Total Knee Arthroplasty.

BACKGROUND: In January 2020, The Centers for Medicare and Medicaid Services approved total knee arthroplasty (TKA) to be performed in ambulatory surgery centers (ASCs). This study aims to develop a predictive model for targeting appropriate patients for ASC-based TKA. METHODS: A retrospective review of 2266 patients (205 same-day discharge [SDD; 9.0%] and 2061 one-day length of stay [91.0%]) undergoing TKA at a regional medical center between July 2016 and September 2020 was conducted. Multiple logistic regression was used to evaluate predictors of SDD, as these patients represent those most likely to safely undergo TKA in an ASC. RESULTS: Controlling for other demographics and comorbidities, patients with the following characteristics were at reduced odds of SDD: increased age (odds ratio [OR] = 0.935, P < .001), body mass index ≥35 (OR = 0.491, P = .002), female (OR = 0.535, P < .001), nonwhite race (OR = 0.456, P = .003), primary hypertension (OR = 0.710, P = .032), ≥3 comorbidities (OR = 0.507, P = .002), American Society of Anesthesiologists score ≥3 (OR = 0.378, P < .001). The model was deemed to be of adequate fit using the Hosmer and Lemeshow test (χ2 = 12.437, P = .112), and the area under the curve was found to be 0.773 indicating acceptable discrimination. CONCLUSION: For patients undergoing primary TKA, increased age, body mass index ≥35, female gender, nonwhite race, primary hypertension, ≥3 comorbidities, and American Society of Anesthesiologists score ≥3 decrease the likelihood of SDD. A predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in identifying patients that are candidates for SDD or ASC-based TKA.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis.

Introduction: The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals. Methods: Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children's Hospital's (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues. Results: Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios. Conclusion: An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Structural Allograft Versus Synthetic Interbody Cage for Anterior Cervical Discectomy and Fusion: A Comparison of 1-Year Outcomes From a National Database.

STUDY DESIGN: Observational cohort study. OBJECTIVE: To compare 1-year perioperative complications between structural allograft (SA) and synthetic cage (SC) for anterior cervical discectomy and fusion (ACDF) using a national database. METHODS: The TriNetX Research Network was retrospectively queried. Patients undergoing initial single or multilevel ACDF surgery between October 1, 2015 and April 30, 2019 were propensity score matched based on age and comorbidities. The rates of 1-year revision ACDF surgery and reported diagnoses of pseudoarthrosis, surgical site infection (SSI), and dysphagia were compared between structural allograft and synthetic cage techniques. RESULTS: A comparison of 1-year outcomes between propensity score matched cohorts was conducted on 3056 patients undergoing single-level ACDF and 3510 patients undergoing multilevel ACDF. In single-level ACDF patients, there was no difference in 1-year revision ACDF surgery (P = .573), reported diagnoses of pseudoarthrosis (P = .413), SSI (P = .620), or dysphagia (P = .529) between SA and SC groups. In multilevel ACDF patients, there was a higher rate of revision surgery (SA 3.8% vs SC 7.3%, odds ratio = 1.982, P < .001) in the SC group, and a higher rate of dysphagia in the SA group (SA 15.9% vs SC 12.9%). CONCLUSION: While the overall revision and complication rate for single-level ACDF remains low despite interbody graft selection, SC implant selection may result in higher rates of revision surgery in multilevel procedures despite yielding lower rates of dysphagia. Further prospective study is warranted.

Mortality in sickle cell disease: A population-based study in an aboriginal community in the Gudalur Valley, Nilgiris, Tamil Nadu, India.

BACKGROUND: Sickle cell disease (SCD), the most common monogenic disorder, affects more than 300 000 births annually, with 44  000 in India. Although the clinical phenotype of SCD is considered to be milder in aboriginal populations in India, there is a paucity of data on outcomes. To determine the severity of SCD in this population, we studied mortality rates and causes of mortality in a longitudinal cohort of patients with SCD in a remote aboriginal community in India receiving community-based comprehensive care. PROCEDURES: Causes of death were analyzed in this cohort from January 2008 to December 2018. Details were collected from hospital records and in case of deaths at home by utilizing the WHO verbal autopsy questionnaire. RESULTS: The cohort consisted of 157 patients belonging to the Paniya, Betta Kurumba, Kattunyakan, and Mullu Kurumba tribes. During the study period, there were 22 deaths, all from the Paniya tribe. Twelve deaths (54.5%) occurred in the hospital and the remaining at home (45.5%), reflecting a crude mortality rate of 140 per 1000 population. Twenty-five percent of deaths occurred in the 6-18 age group. There were no deaths in the 0-5 age group. The median age of death was 25 years, which was 30 years less than in the non-SCD aboriginal population. The leading causes of death were acute chest syndrome, anemia, and sepsis among the SCD patients and stroke and suicides in the non-SCD aboriginal population. CONCLUSION: SCD is a severe disease among the Gudalur Valley's aboriginal population with a significant risk of premature mortality.

Risk factors for severe illness in hospitalized Covid-19 patients at a regional hospital.

BACKGROUND: The Covid-19 pandemic threatens to overwhelm scarce clinical resources. Risk factors for severe illness must be identified to make efficient resource allocations. OBJECTIVE: To evaluate risk factors for severe illness. DESIGN: Retrospective, observational case series. SETTING: Single-institution. PARTICIPANTS: First 117 consecutive patients hospitalized for Covid-19 from March 1 to April 12, 2020. EXPOSURE: None. MAIN OUTCOMES AND MEASURES: Intensive care unit admission or death. RESULTS: In-hospital mortality was 24.8% and average total length of stay was 11.82 days (95% CI: 10.01 to 13.63 days). 30.8% of patients required intensive care unit admission and 29.1% required mechanical ventilation. Multivariate regression identified the amount of supplemental oxygen required at admission (OR: 1.208, 95% CI: 1.011-1.443, p = .037), sputum production (OR: 6.734, 95% CI: 1.630-27.812, p = .008), insulin dependent diabetes mellitus (OR: 11.873, 95% CI: 2.218-63.555, p = .004) and chronic kidney disease (OR: 4.793, 95% CI: 1.528-15.037, p = .007) as significant risk factors for intensive care unit admission or death. Of the 48 patients who were admitted to the intensive care unit or died, this occurred within 3 days of arrival in 42%, within 6 days in 71%, and within 9 days in 88% of patients. CONCLUSIONS: At our regional medical center, patients with Covid-19 had an average length of stay just under 12 days, required ICU care in 31% of cases, and had a 25% mortality rate. Patients with increased sputum production and higher supplemental oxygen requirements at admission, and insulin dependent diabetes or chronic kidney disease may be at increased risk for severe illness. A model for predicting intensive care unit admission or death with excellent discrimination was created that may aid in treatment decisions and resource allocation. Early identification of patients at increased risk for severe illness may lead to improved outcomes in patients hospitalized with Covid-19.

Cortical bone trajectory instrumentation provides favorable perioperative outcomes compared to pedicle screws for single-level lumbar spinal stenosis and degenerative spondylolisthesis.

OBJECTIVE: To compare perioperative outcomes between cortical bone trajectory (CBT) instrumentation with pedicle screws (PS) in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis. METHODS: A consecutive series of 91 patients from a single institution between January 2017 and July 2019 were retrospectively reviewed. RESULTS: Patients in CBT group had significantly shorter operative time, lower blood loss and shorter length of stay. CONCLUSION: CBT instrumentation demonstrated favorable perioperative outcomes that may enhance the overall value in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis.

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List.

BACKGROUND: The Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data. METHODS: This is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities. RESULTS: Controlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value. CONCLUSION: For patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty.

BACKGROUND: Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program. METHODS: A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status. RESULTS: In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m2, P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent. CONCLUSION: OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

Transcervical Carotid Artery Stenting Using a Prosthetic Arterial Conduit: Case Series of a Novel Surgical Technique.

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.

Flow Reduction-Aided Thrombin Injection for Complex Femoral Pseudoaneurysms: Case Series and Review of the Literature.

BACKGROUND: Peripheral pseudoaneurysms are a known complication of vascular access procedures. Complex lesions-those with short, wide necks or other complex arrangements-would conventionally require open repair, but we believe that even these lesions could be managed with an endovascular approach. METHODS: Four patients with complex pseudoaneurysms were offered an open repair or thrombin injection with the use of flow-reducing balloons. RESULTS: In our series of 4 patients with complex pseudoaneurysms, all were safely treated with percutaneous thrombin injection in conjunction with endovascular flow reduction. All patients recovered from their procedures without incident and are free from recurrence at follow-up. CONCLUSIONS: Flow reduction-aided thrombin injection may have particular utility in complex femoral pseudoaneurysms, especially in a patient population that may not tolerate open repair. High-risk lesions may merit special consideration for this technique, and further study is warranted.