Influence of the concentrate inclusion level in a grass silage-based diet on hepatic transcriptomic profiles in Holstein-Friesian dairy cows in early lactation.

Excessive negative energy balance in early lactation is linked to an increased disease risk but may be mitigated by appropriate nutrition. The liver plays central roles in both metabolism and immunity. Hepatic transcriptomic profiles were compared between 3 dietary groups in each of 40 multiparous and 18 primiparous Holstein-Friesian cows offered isonitrogenous grass silage-based diets with different proportions of concentrates: (1) low concentrate (LC, 30% concentrate + 70% grass silage); (2) medium concentrate (MC, 50% concentrate + 50% grass silage), or (3) high concentrate (HC, 70% concentrate + 30% grass silage). Liver biopsies were taken from all cows at around 14 d in milk for RNA sequencing, and blood metabolites were measured. The sequencing data were analyzed separately for primiparous and multiparous cows using CLC Genomics Workbench V21 (Qiagen Digital Insights), focusing on comparisons between HC and LC groups. More differentially expressed genes (DEG) were seen between the primiparous cows receiving HC versus LC diets than for multiparous cows (597 vs. 497), with only 73 in common, indicating differential dietary responses. Multiparous cows receiving the HC diet had significantly higher circulating glucose and insulin-like growth factor-1 and lower urea than those receiving the LC diet. In response to HC, only the multiparous cows produced more milk. In these animals, bioinformatic analysis indicated expression changes in genes regulating fatty acid metabolism and biosynthesis (e.g., ACACA, ELOVL6, FADS2), increased cholesterol biosynthesis (e.g., CYP7A1, FDPS, HMGCR), downregulation in hepatic AA synthesis (e.g., GPT, GCLC, PSPH, SHMT2), and decreased expression of acute phase proteins (e.g., HP, LBP, SAA2). The primiparous cows on the HC diet also downregulated genes controlling AA metabolism and synthesis (e.g., CTH, GCLC, GOT1, ODC1, SHMT2) but showed higher expression of genes indicative of inflammation (e.g., CCDC80, IL1B, S100A8) and fibrosis (e.g., LOX, LUM, PLOD2). This potentially adverse response to a HC diet in physically immature animals warrants further investigation.

Musculoskeletal Embolotherapy.

Painful articular musculoskeletal (MSK) conditions are common, debilitating and sometimes difficult to treat. Transcatheter embolisation may offer an alternative way to manage the pain associated with these conditions, but the field is still in its infancy. To date, the most commonly studied indication is knee osteoarthritis, but the technique has been trailed in multiple other tissue beds, including for adhesive capsulitis and tendinopathies. Whilst early results appear promising, the existing studies are mostly open-labelled and non-randomised; there is a need for high-quality evidence to robustly assess the procedures efficacy. In this review, we set out to evaluate the current evidence underlying the pathophysiology and mechanism of action of embolisation; discuss the technical aspects of the procedure including embolic selection, and appraise the published clinical outcomes and adverse effects. Finally, we discuss the future directions and research priorities in this rapidly developing field.

Genicular artEry embolizatioN in patiEnts with oSteoarthrItiS of the Knee (GENESIS) Using Permanent Microspheres: Interim Analysis.

PURPOSE: Planned interim analysis of GENESIS; a prospective pilot study investigating the role of genicular artery embolization (GAE) in patients with mild to moderate osteoarthritis of the knee using permanent microspheres. METHODS: Thirty-eight patients, median age = 60 (45-83), attended for GAE using 100-300 µm permanent microspheres. All patients had mild to moderate knee OA, resistant to conservative treatments over 6 months. Knee MRI was performed at baseline, and 12 months, enabling semi-quantitative analysis using Whole-Organ Magnetic Resonance Imaging Score (WORMS). Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS) (0-100 mm) were completed at baseline, 6 weeks, 3 months (n = 32), and 1-year (n = 16). Adverse events were recorded prospectively. RESULTS: Technical success of accessing and embolizing the target genicular arteries was 84%. Six patients were not embolized: four due to a presumed risk of non-target embolization, and two due to a lack of hyperaemic target. Mean VAS improved from 60 (SD = 20, 95% CI 53-66) at baseline to 36 (SD = 24, 95% CI 28-44) at 3 months (p < 0.001) and 45 (SD = 30, 95% CI 30-60) at 1-year (p < 0.05). All KOOS subscales showed a significant improvement at 6-weeks, 3-months, and 1-year follow-up, except function in daily living, which reached borderline significance (p = 0.06) at 1-year. Four patients experienced mild self-limiting skin discoloration over the embolized territory. One patient experienced a small self-limiting groin haematoma. WORMS scores at 1-year follow-up showed significant improvement in synovitis (p < 0.05). There were no cases of osteonecrosis. CONCLUSION: GAE using permanent microspheres in patients with mild to moderate knee OA is safe, with potential efficacy at early follow-up.

Immunological effects of altering the concentrate inclusion level in a grass silage-based diet for early lactation Holstein Friesian cows.

Concentrate inclusion levels in dairy cow diets are often adjusted so that the milk yield responses remain economic. While changes in concentrate level on performance is well known, their impact on other biological parameters, including immune function, is less well understood. The objective of this study was to evaluate the effect of concentrate inclusion level in a grass silage-based mixed ration on immune function. Following calving 63 (45 multiparous and 18 primiparous) Holstein Friesian dairy cows were allocated to one of three isonitrogenous diets for the first 70 days of lactation. Diets comprised of a mixture of concentrates and grass silage, with concentrates comprising either a low (30%, LC), medium (50%, MC) or high (70%, HC) proportion of the diet on a dry matter (DM) basis. Daily DM intakes, milk yields and BW were recorded, along with weekly body condition score, milk composition and vaginal mucus scores. Blood biochemistry was measured using a chemistry analyzer, neutrophil phagocytic and oxidative burst assessed using commercial kits and flow cytometry, and interferon-γ production evaluated by ELISA after whole blood stimulation. Over the study period cows on HC had a higher total DM intake, milk yield, fat yield, protein yield, fat+protein yield, protein content, mean BW and mean daily energy balance, and a lower BW loss than cows on MC, whose respective values were higher than cows on LC. Cows on HC and MC had a lower serum non-esterified fatty acid concentration than cows on LC (0.37, 0.37 and 0.50 mmol/l, respectively, P=0.005, SED=0.032), while cows on HC had a lower serum ß-hydroxybutyrate concentration than cows on MC and LC (0.42, 0.55 and 0.55 mmol/l, respectively, P=0.002, SED=0.03). Concentrate inclusion level had no effect on vaginal mucus scores. At week 3 postpartum, cows on HC tended to have a higher percentage of oxidative burst positive neutrophils than cows on LC (43.2% and 35.3%, respectively, P=0.078, SED=3.11), although at all other times concentrate inclusion level in the total mixed ration had no effect on neutrophil phagocytic or oxidative burst characteristics, or on interferon-γ production by pokeweed mitogen stimulated whole blood culture. This study demonstrates that for high yielding Holstein Friesian cows managed on a grass silage-based diet, concentrate inclusion levels in early lactation affects performance but has no effect on neutrophil or lymphocyte immune parameters.

Rectal Venous Malformation Treated by Superior Rectal Artery Embolization.

A 25-year-old female was referred to the Interventional Radiology Department for investigation and treatment of a rectal venous malformation (RVM) causing large recurrent episodes of rectal bleeding and chronic anaemia. Magnetic resonance imaging (MRI) demonstrated a large venous malformation affecting the rectum, lower pelvis and left thigh. After three failed attempts at injection foam sclerotherapy using fluoroscopic colonoscopy, a multidisciplinary team proposed an embolization procedure of the arterial inflow to the venous malformation. Following discussion with the patient, embolization of the superior rectal arteries was undertaken with immediate on-table fluoroscopic improvement in the RVM. Post-treatment, a significant reduction in bleeding, was reported by day 10 with subsequent return to activities of daily living and full employment. Follow-up MRI at 1 year demonstrated significant reduction in bowel-wall thickening.

Local control, safety, and survival following image-guided percutaneous microwave thermal ablation in primary lung malignancy.

AIM: To determine local control, safety, and survival following percutaneous computed tomography (CT)-guided high-power microwave ablation (MWA) in the treatment of primary lung malignancy at a single institution. MATERIAL AND METHODS: From July 2010 to June 2016, 52 patients (mean age 76.3 years, range 55-91 years) with 61 unresectable primary lung cancers of mean diameter 23.8 mm (range 26-55 mm) underwent MWA in 55 ablation sessions. Tumours were diagnosed at biopsy, or positron-emission tomography (PET) avidity (mean SUV max = 10.51) and interval growth. Statistical analysis was performed by Kaplan-Meier modelling and Cox and logistic regression. RESULTS: Local tumour progression (LTP) was diagnosed in six lesions (10%). Median time to local recurrence was 3 months (range 2-14 months). There was a near 12-fold increased odds of local recurrence if the lesion size was >3 cm (95% confidence interval [CI]: 1.84-75.14; p=0.009). The median inpatient stay was 1 day, with no intra-procedural deaths and a 0% 30-day post-ablation mortality rate. Pneumothorax requiring drain was the most serious complication, occurring in 22% (n=12) of patients. Presence of severe emphysema and predicted forced expiratory volume in 1 second (FEV1) of <50% were found to predict future requirement of a drain (odds ratio [OR] 8.17, 95% CI: 1.62-41.37, p=0.01 and OR: 5.14, 95% CI: 1.28-20.68, p=0.02 respectively), when adjusted for age and gender. Tumour size >3 cm had a hazard ratio of 4.37 compared with tumour size ≤3 cm (95% CI: 1.45-13.17, p=0.009) of risk of cancer death at any time, by Cox regression. CONCLUSION: MWA for primary lung malignancy is a safe and effective treatment for primary lung tumours with outcomes that may be comparable to stereotactic body radiation therapy.

Concentrate supplementation of a diet based on medium-quality grass silage for 4 weeks prepartum: Effects on cow performance, health, metabolic status, and immune function.

Because negative energy balance (EB) contributes to transition-period immune dysfunction in dairy cows, dietary management strategies should aim to minimize negative EB during this time. Prepartum diets that oversupply energy may exacerbate negative EB in early lactation, with detrimental effects on immune function. However, with lower body condition score (BCS) cows, it has been shown that offering concentrates in addition to a grass silage-based diet when confined during an 8-wk dry period resulted in increased neutrophil function in early lactation. The aim of this study was to examine if similar benefits occur when concentrate feeding was restricted to a 4-wk period prepartum. Twenty-six multiparous and 22 primiparous Holstein-Friesian cows were offered ad libitum access to medium-quality grass silage until 28 d before their predicted calving dates (actual mean of 32 d prepartum; standard deviation = 6.4). At this time multiparous cows had a mean BCS of 2.9 (standard deviation = 0.12) and primiparous cows a mean BCS of 3.0 (standard deviation = 0.14) on a 1 to 5 scale. Cows were then allocated in a balanced manner to 1 of 2 treatments (13 multiparous cows and 11 primiparous cows on each treatment): silage only (SO) or silage plus concentrates (S+C) until calving. Cows on SO were offered the same grass silage ad libitum. Cows on S+C were offered an ad libitum mixed ration of the same grass silage and additional concentrates in a 60:40 dry matter (DM) ratio, which provided a mean concentrate DM intake (DMI) of 4.5 kg/cow per d. After calving, all cows were offered a common mixed ration (grass silage and concentrates, 40:60 DM ratio) for 70 d postpartum. Offering concentrates in addition to grass silage during the 4 wk prepartum increased prepartum DMI (12.0 versus 10.1 kg/cow per d), EB (+40.0 versus +10.6 MJ/cow per d), and body weight (BW; 640 versus 628 kg), and tended to increase BCS (3.02 versus 2.97). However, postpartum DMI, milk yield, milk composition, BW change, BCS change, serum nonesterified fatty acid, and ß-hydroxybutryrate concentrations, health, and corpus luteum measures were unaffected by treatment. The in vitro assays of neutrophil phagocytosis, neutrophil oxidative burst, and interferon gamma production, conducted on blood samples obtained at d 14 prepartum and d 3, 7, 14, and 21 postpartum, were unaffected by treatment. Primiparous cows had higher phagocytic fluorescence intensity at d 14 prepartum and d 3 and 7 postpartum; a higher percentage of neutrophils undergoing oxidative burst at d 3, 7, and 21 postpartum; and a higher oxidative burst fluorescence intensity at d 14 prepartum and d 7, 14, and 21 postpartum compared with multiparous cows. This suggests that neutrophil function of primiparous cows was less sensitive to the changes occurring during the transition period than that of multiparous cows. In conclusion, offering concentrates during the 4-wk period prepartum had no effect on postpartum DMI, milk yield, body tissue mobilization, EB, measures of neutrophil or lymphocyte function, health, or corpus luteum activity.

Adenomatous-Dominant Benign Prostatic Hyperplasia (AdBPH) as a Predictor for Clinical Success Following Prostate Artery Embolization: An Age-Matched Case-Control Study.

PURPOSE: To investigate the clinical impact of performing prostate artery embolization (PAE) on patients with adenomatous-dominant benign prostatic hyperplasia (AdBPH). MATERIALS AND METHODS: Twelve patients from the ongoing proSTatic aRtery EmbolizAtion for the treatMent of benign prostatic hyperplasia (STREAM) trial were identified as having AdBPH; defined as two or more adenomas within the central gland of ≥1 cm diameter on multi-parametric MRI (MP-MRI). These patients were age-matched with patients from the STREAM cohort, without AdBPH. Patients were followed up with repeat MP-MRI at 3 months and 1 year. International prostate symptom score (IPSS), international index for erectile function (IIEF), and quality of life assessment from the IPSS and EQ-5D-5S questionnaires were recorded pre-PAE and at 6 weeks, 3 months, and 1 year. RESULTS: The mean age of patients was 68 (61-76). All patients had PAE as a day-case procedure. The technical success in the cohort was 23/24 (96%). There was a significant reduction in prostate volume following embolization with a median reduction of 34% (30-55) in the AdBPH group, compared to a mean volume reduction of 22% (9-44) in the non-AdBPH group (p = 0.04). There was a significant reduction in IPSS in the AdBPH group following PAE when compared with the control group [AdBPH median IPSS 8 (3-15) vs. non-AdBPH median IPSS 13 (8-18), p = 0.01]. IPSS QOL scores significantly improved in the AdBPH group (p = 0.007). There was no deterioration in sexual function in either group post-PAE. CONCLUSIONS: This is the first time that AdBPH has been identified as being a predictor of clinical success following PAE.

Does perfusion CT play a role in the evaluation of percutaneous microwave-ablated lung tumours?

AIM: To assess the clinical utility of perfusion computed tomography (pCT) parameters in microwave ablation (MWA) of lung tumours. MATERIALS AND METHODS: Patients were included who had primary or metastatic lung tumours and underwent pCT studies immediately pre- and post-MWA. Perfusion maps of the tumours were constructed using CT perfusion software (GE, Milwaukee, WI, USA). Regions of interest were drawn on sequential axial sections to extract the pCT parameters, blood volume (BV), average blood flow (BF), and mean transit time (MTT) from the entire tumour volume. Direct visualisation of perfusion maps were performed by two experienced readers blinded to outcome. Data were analysed using the Mann-Whitney test. RESULTS: Thirty-one patients with 34 lung tumours had follow-up data at 12 months. The median tumour diameter was 19 mm (10-52 mm). Seven patients developed local tumour progression (LTP) at 12 months. There was no statistical difference between patients with LTP and complete treatment based on quantitative pCT parameters. Using radiologist visualisation of perfusion maps, there was moderate agreement between the two readers (kappa coefficient 0.53) with a combined 96% sensitivity, 62% specificity, 91% positive predictive value, and 80% negative predictive value. CONCLUSION: Quantitative pCT parameters do not help differentiate between LTP and complete treatment, but subjective analysis of perfusion maps may be a useful assessment tool for identifying treatment adequacy potentially enabling identification of areas requiring further treatment at the time of the procedure.

Prepartum concentrate supplementation of a diet based on medium-quality grass silage: Effects on performance, health, fertility, metabolic function, and immune function of low body condition score cows.

When cows with a "higher" body condition score (BCS) are oversupplied with energy during the dry period, postpartum energy balance is normally reduced, which can have a detrimental effect on immune competence and increase the infectious disease risk. However, within grassland-based systems higher yielding cows frequently have a low BCS at drying off. The effects on performance, health, and metabolic and immune functions of providing additional energy to cows with low BCS during the dry period is less certain. To address this uncertainty, 53 multiparous Holstein-Friesian cows (mean BCS of 2.5; 1-5 scale) were allocated to 1 of 2 treatments at dry-off: silage only or silage plus concentrates. Cows on the silage-only treatment were offered ad libitum access to medium-quality grass silage. Cows on the silage-plus-concentrate treatment were offered ad libitum access to a mixed ration comprising the same grass silage plus concentrates [in a 75:25 dry matter (DM) ratio], which provided a mean concentrate DM intake of 3.0kg/cow per day. Postpartum, cows were offered a common mixed ration comprising grass silage and concentrates (in a 40:60 DM ratio) for a 70-d period. Offering concentrates during the dry period increased DM intake, tended to increase energy balance, and increased body weight (BW) and BCS gain prepartum. Offering concentrates during the dry period increased BW and BCS loss postpartum and tended to increase milk fat percentage and serum nonesterified fatty acid concentration, but it did not affect postpartum DM intake, energy balance, and milk yield. Although the percentage of phagocytosis-positive neutrophils did not differ, neutrophils from cows on the silage-plus-concentrate treatment had higher phagocytic fluorescence intensity at 1 and 2 wk postpartum and higher phagocytic index at 1 wk postpartum. Serum haptoglobin concentrations and IFN-γ production by pokeweed mitogen stimulated whole blood culture were unaffected by treatment, although haptoglobin concentrations increased and IFN-γ production decreased peripartum. Offering concentrates during the dry period increased the incidence of lameness postpartum, although other health and fertility parameters were unaffected. In conclusion, supplementing low BCS cows with concentrates during the dry period had no effect on performance and fertility and resulted in a higher neutrophil phagocytic index at 1 wk postpartum and an increased incidence of lameness compared with offering cows a grass silage-only diet prepartum.

Technical and Clinical Outcomes Following Colonic Stenting: A Seven-Year Analysis of 268 Procedures.

AIMS: To assess the factors contributing to the technical and clinical success of colorectal stenting for large bowel obstruction. METHODOLOGY: 268 cases of colonic stenting for large bowel obstruction were performed in 249 patients of mean age of 72 years (28-98) between 2006 and 2013. The majority of strictures were due to malignant disease, 244/268 (91 %). Diverticular strictures accounted for 24/268 (9 %). RESULTS: Overall technical success rate was 81 % (217/268), with a clinical success rate of 65 % (174/268). Duration of symptoms ranged from 0 to 180 days (mean 8 days). Technical success rate was seen to decrease with increasing symptom duration. For symptom duration of less than 1 week, technical success was 85.4 % (181/212) versus 69.6 % (39/56) for those with symptoms of greater than a week (p < 0.05). Clinical success rates fell from 71.3 % (107/150) to 59.3 % (70/118) (p < 0.05) when attempting to stent lesions of greater than 5 cm. There was also a significant reduction in clinical success when stenting lesions on a bend rather than a straight segment of colon 75.7 % (109/144) versus 59.7 % (74/124) (p < 0.05). A total of 20 (7.46 %) perforations were identified during the study. Stent migration occurred in 6.6 % of cases. In-stent stenosis occurred in 3.3 %. The overall 30-day all cause mortality rate was 9 %. CONCLUSION: Lesion size, location and duration of obstructive symptoms are statistically significant determinants of patient outcome. These factors could be used to advise patient selection for colonic stenting or direct progression to surgical intervention.

A comparison of individual cow versus group concentrate allocation strategies on dry matter intake, milk production, tissue changes, and fertility of Holstein-Friesian cows offered a grass silage diet.

A diverse range of concentrate allocation strategies are adopted on dairy farms. The objectives of this study were to examine the effects on cow performance [dry matter (DM) intake (DMI), milk yield and composition, body tissue changes, and fertility] of adopting 2 contrasting concentrate allocation strategies over the first 140 d of lactation. Seventy-seven Holstein-Friesian dairy cows were allocated to 1 of 2 concentrate allocation strategies at calving, namely group or individual cow. Cows on the group strategy were offered a mixed ration comprising grass silage and concentrates in a 50:50 ratio on a DM basis. Cows on the individual cow strategy were offered a basal mixed ration comprising grass silage and concentrates (the latter included in the mix to achieve a mean intake of 6kg/cow per day), which was formulated to meet the cow's energy requirements for maintenance plus 24kg of milk/cow per day. Additional concentrates were offered via an out-of-parlor feeding system, with the amount offered adjusted weekly based on each individual cow's milk yield during the previous week. In addition, all cows received a small quantity of straw in the mixed ration part of the diet (approximately 0.3kg/cow per day), plus 0.5kg of concentrate twice daily in the milking parlor. Mean concentrate intakes over the study period were similar with each of the 2 allocation strategies (11.5 and 11.7kg of DM/cow per day for group and individual cow, respectively), although the pattern of intake with each treatment differed over time. Concentrate allocation strategy had no effect on either milk yield (39.3 and 38.0kg/d for group and individual cow, respectively), milk composition, or milk constituent yield. The milk yield response curves with each treatment were largely aligned with the concentrate DMI curves. Cows on the individual cow treatment had a greater range of concentrate DMI and milk yields than those on the group treatment. With the exception of a tendency for cows on the individual cow treatment to lose more body weight to nadir than cows on the group treatment, concentrate allocation strategy had little effect on either body weight or body condition score over the experimental period. Cows on the individual cow treatment had a higher pregnancy rate to first and second service and tended to have a higher 100-d in calf rate than cows on the group treatment. This study demonstrates that concentrate allocation strategy had little effect on overall production performance.

Antibiotics in interventional radiology.

The range and number of interventional procedures is rapidly increasing each year. A major complication associated with many procedures is infection, which can result in serious adverse outcomes for the patient. Consequently, antibiotics are amongst the most common pharmaceuticals used by the interventionist, particularly for non-vascular procedures, yet almost no randomized controlled trial data exist to inform our decision when formulating appropriate antibiotic prophylaxis regimens. The purpose of this review is to provide an update on the utilization of antibiotics for common interventional radiology procedures, focusing on timing and duration of antibiotic prophylaxis.

The differential effects of statins on the risk of developing pancreatic cancer: a case-control study in two centres in the United Kingdom.

INTRODUCTION: There are plausible biological mechanisms for how statins may prevent pancreatic cancer, although the evidence from epidemiological studies in the general population is conflicting. This study aims to clarify whether statins exert their effects in specific sub-groups, namely, gender, smoking status and diabetes. METHODS: A matched case-control study was conducted in patients diagnosed with pancreatic cancer, and a group of dermatology patients of similar ages and gender, diagnosed with basal cell carcinoma. Participants' medical records were reviewed for information on statin use prior to diagnosis. Odds ratios and 95 % CIs for the development of pancreatic cancer were estimated using conditional logistic regression. Subgroup analysis was performed in men, women, smokers and those with type 2 diabetes. RESULTS: Two hundred fifty-two cases (median age 71 years, range 48-73 years, 51 % women) and 504 controls were identified, of which 23 % of cases were regular statin users versus 21 % of controls. In the general study population there was no association between pancreatic cancer and regular statin use (OR 0.82, 95 % CI 0.53-1.23, p = 0.33). However, in male smokers, regular statin use was associated with significantly reduced odds of pancreatic cancer compared to male smokers not prescribed a statin (OR 0.11, 95 % CI 0.01-0.96, p = 0.05). In patients with type 2 diabetes statins use was not associated with reduced odds (OR 0.92, 95 % CI 0.35-2.45, p = 0.80), with no gender effects. CONCLUSIONS: In male smokers, statins may reduce the odds of pancreatic cancer. Statin use should be measured in aetiological studies of pancreatic cancer but analysed in specific sub-groups. Future work should investigate statins as chemopreventative agents in this high risk sub-group.

Percutaneous cholecystostomy: the radiologist's role in treating acute cholecystitis.

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patient's symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

Prospective study evaluating technical and clinical outcomes from the use of low profile angioplasty (LOPA) systems.

AIM: To compare the success and complication associated with 4 and 5 F access systems prospectively in the treatment of infra-inguinal vascular disease. MATERIALS AND METHODS: One hundred and twenty consecutive patients were treated for lower limb vascular disease via a 4 F (n = 60) or 5 F (n = 60) access sheath over a 12 month period. All common femoral arteries were punctured in an antegrade direction with ultrasound guidance. Seven minutes of manual compression was applied and the groin assessed with ultrasound to document complications. Repeated manual compression was applied until haemostasis was achieved in all cases. Time to haemostasis, equipment used, patient biochemical data, and demographics were recorded. Patients were followed-up at a mean of 12 weeks post-procedure. RESULTS: Antegrade access and sheath insertion was achieved in all cases. The technical success of the procedure was 56/60 (93%) cases using 4 F access and 57 (95%) cases using 5 F access. The time to haemostasis was reduced to a mean of 8.2 min (range 7-12 min) with a 4 F system compared to a mean of 12 min (range 7-30 minutes) with a 5 F system (p = 0.045). Overall there were 12 complications (10%; 11 <2 cm haematomas and one pseudoaneurysm) noted on ultrasound post-haemostasis, although there was no statistically significance difference between the two groups. Hypertension and renal dysfunction were associated with complications (p < 0.05). A 4 F system used an additional average of 5.1 (range 3-8) wires and catheters compared to an additional average of 3.5 (range 2-6) wires and catheters when using a 5 F system (p = 0.002). A 4 F technique cost three-times that of a 5 F technique. CONCLUSION: Four and 5 F access sheaths allow safe and successful infra-inguinal angioplasty with a low complication rate. Hypertensive patients and those with impaired renal function are at increased risk of complications. There are increasing costs using a 4 F system offset by a decrease in time to haemostasis following manual compression but no reduction in complication rate.