Perinatal outcomes after selective feticide via umbilical cord occlusion in complicated monochorionic pregnancies: A systematic review and meta-analysis.

OBJECTIVE: We aimed to compare perinatal outcomes between umbilical cord occlusion techniques in monochorionic pregnancies, including umbilical cord ligation, fetoscopic laser coagulation, interstitial laser coagulation, bipolar cord occlusion, radiofrequency ablation, and microwave ablation. METHODS: This study was registered with PROSPERO (CRD42020158861). PubMed, Web of Science, Cochrane Library, and Embase were searched for studies published up to May 2020. The DerSimonian-Laird random-effects model was used for the meta-analysis. Subgroup analyses were performed to compare the outcomes among the six techniques. Meta-regression was used to adjust for confounders. RESULTS: Thirty-four studies with 1646 participants were included. The overall survival was 76.5% after umbilical cord ligation, 78.8% after fetoscopic laser coagulation, 60.3% after interstitial laser coagulation, 79.2% after bipolar cord occlusion, 77.5% after radiofrequency ablation, and 75.0% after microwave ablation. Subgroup comparison showed the rates of overall survival and preterm premature rupture of membranes were not significant different among six techniques. However, rates of fetal loss, premature birth, live birth, and neonatal death differed significantly among the six groups. CONCLUSIONS: The choice of umbilical cord occlusion techniques will affect perinatal outcomes. We suggested that the choice of umbilical cord occlusion techniques should fully consider these differences among techniques.

Isquemia mesentérica: algoritmos diagnósticos y terapéuticos / Mesenteric ischaemia: Diagnosis and therapeutic algorithms

La isquemia mesentérica se caracteriza por una reducción del flujo sanguíneo a nivel intestinal, de forma brusca o de forma progresiva, con unas consecuencias potencialmente letales, sobre todo en los casos agudos. La falta de evidencia científica ante una enfermedad poco frecuente, con una clínica y pruebas diagnósticas en ocasiones inespecíficas, y la gran heterogeneidad en los procedimientos de revascularización hacen difícil la toma de decisiones. Las sociedades científicas deben estimular el desarrollo de algoritmos diagnósticos y terapéuticos con el fin de mejorar el manejo y la supervivencia de estos pacientes y, por otro lado, avalar la actividad de sus miembros. Es, en este marco, donde la SOciedad Castellano Leonesa de Angiología y CIrugía VAScular (SOCLACIVAS) se propuso establecer un algoritmo diagnóstico y terapéutico en la isquemia mesentérica

Mesenteric ischaemia is characterised by a sudden or gradual reduction in blood flow at intestinal level, with some potentially fatal consequences, particularly in acute cases. The lack of scientific evidence of a rare disease, with a clinical picture and diagnostic tests that are occasionally non-specific, as well as a wide variation in revascularisation procedures, make it difficult to make decisions. The scientific societies must stimulate the development of diagnostic and therapeutic algorithms, with the aim of improving the management and survival of these patients, as well as to endorse the activities of their members. It is within this framework that the Angiology and Vascular Surgery Society of Castile and Leon (Sociedad Castellano Leonesa de Angiología y Cirugía Vascular) (SOCLACIVAS) proposes to establish a diagnostic and therapeutic algorithm for mesenteric ischaemia

Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: The PREVAIL trial.

OBJECTIVES: Assessing the safety and effectiveness of left atrial appendage (LAA) (pouch found in the upper chambers of the heart) occlusion, using the Watchman device compared to long term warfarin therapy (drug that reduces clot formation), in preventing the risk of stroke in patients with atrial fibrillation (most common type of irregular heart beat). 90% of strokes in atrial fibrillation arise from clots forming in this pouch. By mechanically blocking it using the device less clots are suggested to be formed. This is an alternative to taking warfarin especially in patients who cannot take it. SETTING AND PARTICIPANTS: 50 sites in the United States enrolled 407 participants. After being randomly allocated, the device group had 269 participants and warfarin group (comparator)had 138 participants. METHOD: Patients with atrial fibrillation and at high risk of stroke were randomly allocated a group after they were deemed eligible. Patients in the device group had to take warfarin and aspirin for 45days till the complete closure of the LAA. The oral anticoagulant was followed by dual antiplatelet therapy until 6months and then ASA. Patients in the warfarin group have to take it for life and were continually monitored. The study ran for 26months. MAIN OUTCOME MEASURES: The trial assessed the rate of adverse events using three endpoints: RESULTS: The PREVAIL trial was not designed to show superiority, but non-inferiority. It met the safety endpoint and one efficacy endpoint for the watchman device compared to long term warfarin for overall efficacy of the device. The results established that LAA occlusion is not worse than warfarin intake for the prevention of stroke more than 1week after randomization. Compared to previous trials, the safety of the device has also improved. CONCLUSION: LAA occlusion is a reasonable alternative to chronic warfarin therapy in stroke prevention for patients with atrial fibrillation.

Carotid sacrifice with a single Penumbra occlusion device: a feasibility study in a swine model.

INTRODUCTION: Carotid sacrifice is a valuable tool in the treatment of select vascular lesions. Traditional coil embolization as the primary means of carotid sacrifice can be expensive, with high radiation exposure. We investigated the feasibility of a novel hybrid coil, the Penumbra occlusion device (POD), for carotid sacrifice in a swine model. METHODS: A total of eight common carotid artery sacrifices were performed in fully heparinized pigs under fluoroscopic guidance. A single POD device was deployed within each vessel, and intermittent follow-up angiography was performed to assess flow. RESULTS: Complete carotid occlusion was achieved in all cases with a single POD (time range 2-15 min) without any coil migration or intraprocedural complications. Once the anchor zone was stable, no distal migrations were observed during either proximal soft coil packing or during hand injected angiography. Complete occlusion was verified between 2 and 15 min following POD deployment. CONCLUSIONS: Carotid artery sacrifice using a novel POD device is safe and effective, allowing for reduced radiation and material costs compared with any other described endovascular technique.

Is long-term follow-up of adequately coil-occluded ruptured cerebral aneurysms always necessary? A single-center study of recurrences after endovascular treatment.

PURPOSE: Aneurysm recurrence following coil occlusion is well recognized. However, there is controversy as to how long these patients should be followed up after coiling to detect reopening. We aimed to identify the rate of late reopening and the risk factors for reopening in a large single-center cohort of ruptured aneurysms that appeared adequately occluded at 6 months. We also aimed to assess whether rates of recurrence have altered over time with improving coil and angiographic technology. METHODS: Patients treated between 1996 and 2010 were assessed and those with both 6-month initial and subsequent long-term follow-up with either digital subtraction angiography or magnetic resonance angiography were included. Aneurysms were stratified by features such as size, neck width, anatomical location and time of treatment: 1996-2005 (cohort 1) and 2006-2010 (cohort 2). ORs for risk of recurrence were calculated for aneurysm features and rates of recurrence in each cohort were compared using a χ(2) test. RESULTS: 437 patients with 458 adequately occluded aneurysms at 6 months had mean long-term follow-up of 31 months; 57 (12.4%) were large (≥ 10 mm) and 104 (22.7%) were wide-necked (>4 mm). Nine aneurysms (2%) showed significant late anatomical deterioration whereby retreatment was considered or undertaken. The risk was greater for large aneurysms (≥ 10 mm) (OR 15.61, 95% CI 3.79 to 64.33, p=0.0001) or wide-necked aneurysms (>4 mm) (OR 12.70, 95% CI 2.60 to 62.13, p=0.0017). The frequency of significant late anatomical deterioration and retreatment was also less common in those treated in cohort 2 (p<0.05). No completely occluded aneurysm at 6 months demonstrated significant late recurrence. CONCLUSIONS: Most aneurysms adequately occluded at 6 months did not show evidence of late recurrence. Large and wide-neck aneurysms are, however, at greater risk of later recurrence.