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.

Glaucoma e óleo de silicone / Glaucoma and silicone oils

RESUMO O óleo de silicone é um importante tampão utilizado na retinopexia cirúrgica de casos graves de descolamento de retina. O aumento da pressão intraocular e o desenvolvimento de glaucoma secundário são frequentes complicações da sua utilização. A depender do período de aparecimento, diversos mecanismos justificam a ocorrência de tais complicações. Compreender os fatores de riscos e a patogênese do aumento da pressão intraocular associada a aplicação de óleo de silicone em cirurgia retiniana ajuda a orientar o tratamento adequado para cada paciente. O objetivo deste artigo é revisar a literatura sobre a patogenia, a incidência, os fatores de risco e o tratamento desta condição clínica.

ABSTRACT Silicone oil has been an important intraocular tamponade in retinopexy in cases of complicated retinal detachment surgery. The increase of intraocular pressure and development of secondary glaucoma are a known complication of its use. A variety of mechanisms have been proposed for the pathogenesis, depending on the onset. This article aims to review the literature about pathogenesis, the incidence and risk factors, as well as the treatment of this pathology.

Damage control surgery in lung trauma.

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.

Las técnicas de control de daños aplicadas al manejo de lesiones torácicas han evolucionado en los últimos 15 años. A pesar de que el número de publicaciones es limitado, la información es suficiente para desvirtuar algunos temores y establecer los principios de manejo. La severidad del compromiso anatómico justifica el procedimiento de control de daños solamente en algunos casos. En la mayoría, la magnitud del deterioro fisiológico y la presencia de otras fuentes de sangrado dentro del tórax o en otros compartimientos corporales constituyen la indicación del procedimiento abreviado. La clasificación de la lesión pulmonar como periférica, transfixiante y central o múltiple, proporciona una pauta para el control transitorio del sangrado y para el manejo definitivo de la lesión: neumorrafía, resección en cuña, tractotomía o resecciones anatómicas, respectivamente. La identificación de ciertos patrones como la necesidad de toracotomía de reanimación o de oclusión aórtica, la existencia de un hemotórax masivo, de una lesión pulmonar central, una lesión traqueobronquial o una lesión vascular mayor, así como el reconocimiento de hipotermia, acidosis o coagulopatía, constituyen la indicación de una toracotomía de control de daños. En estos casos, el cirujano concluye de manera abreviada los procedimientos con empaquetamiento de las superficies sangrantes, el manejo primario con empaquetamiento de algunas lesiones pulmonares periféricas o transfixiante seleccionadas y el aplazamiento de la resección pulmonar, pinzando el hilio de la manera más selectiva posible. La abreviación del cierre de la toracotomía se logra con la sutura de la piel sobre el empaquetamiento de la herida, o mediante la instalación de un sistema de presión negativa. El manejo del paciente en cuidados intensivos permitirá identificar aquellos que requieren reintervención urgente y corregir la alteración fisiológica de los restantes para su reoperación programada y manejo definitivo.

Cuantificación digital de integración de injertos de piel de espesor parcial ocluidos con sistema de presión negativa / Digital quantification of integration in occluded partial-thickness skin grafts with negative pressure system

INTRODUCCIÓN Y OBJETIVO: El éxito en la integración de los injertos de piel de espesor parcial no depende de un solo factor, siendo uno de los más importantes el método de curación que se le realiza al injerto. Por tal razón, el objetivo de nuestro estudio es demostrar, a través de un programa digital informático, el porcentaje de integración que tienen los injertos de piel de espesor parcial a los que se realizó curación oclusiva con sistema de presión negativa. MATERIAL Y MÉTODO: Estudio descriptivo retrospectivo que toma como muestra todos los pacientes con defectos de cobertura y lecho receptor con tejido de granulación óptimo para realizar injerto de piel de espesor parcial, del Servicio de Cirugía Plástica de la Clínica Reina Catalina sede Barranquilla y Baranoa, en Colombia, desde el 1 de enero de 2019 hasta 31 de diciembre del mismo año. Empleamos el sistema de presión negativa WoundPro(R) (Ї#x00a9;2020 Pensar Medical, LLC) y posteriormente cuantificamos la integración de los injertos de forma digital a través de un programa de procesamiento de imágenes (ImageJ(R)), complementado con un desarrollo informático del Área de Sistemas de la Clínica para obtener un resultado matemático que permitiera, de manera más objetiva, evaluar la integración del injerto. RESULTADOS: Revisamos 70 pacientes, de los que 42 eran varones, con una edad promedio de 41.8 años. La etiología más común fue la quemadura (34%), el área anatómica de mayor incidencia fue la pierna (27.7%) y el porcentaje promedio de integración fue del 98.4%. Aplicamos el sistema de presión negativa durante 6 días para luego retirarlo y proceder a la toma de imagen fotográfica que usamos como insumo para el cálculo de la integración; tras la primera cura, el paciente es egresado y realizamos seguimiento ambulatorio, con una media de curación del área injertada de 17 días. CONCLUSIONES: En nuestra experiencia, el uso del sistema de presión negativa como método de curación oclusiva en los injertos de piel parcial, presenta tasas de éxito superiores al 98% en la integración de los injertos, lo cual se traduce en un tratamiento coste - efectivo ya que reduce las complicaciones inherentes al procedimiento. Así mismo, el cálculo matemático de la integración del injerto permite evaluar y definir de forma específica la conducta en cada caso

BACKGROUND AND OBJECTIVE: Success in the integration of partial thickness skin grafts does not depend on a single factor; one of the most important factors is the healing method performed on the skin graft. For this reason, the objective of our study is to demonstrate the percentage of integration through a digital computer program of the partial thickness skin grafts that underwent occlusive healing with the use of the negative pressure system. METHODS: Retrospective descriptive study. All patients with coverage defects, who had a wound with optimal granulation tissue to perform the partial thickness skin graft, were taken as a sample in the Plastic Surgery Service of the Reina Catalina Clinic in Barranquilla and Baranoa in Colombia, from January 1, 2019 to December 31 of the same year. For this, the WoundPro(R) negative pressure system (Ї#x00a9;2020 Pensar Medical, LLC) was used and the integration of the grafts was digitally quantified throug an image processing program (ImageJ(R)) complemented with a computerized developer of the Systems Area of the Clinic to obtain a mathematical result that would allow, more objectively, to evaluate the integration of the graft. RESULTS: Seventy patients were part of the study, the male gender was the most affected with 42 cases, the average age was 41.8 years. The most common etiology was burn (34%), the anatomical area with the highest incidence was the leg (27.7%) and the percentage integration average was 98.4%. The negative pressure system was applied for 6 days, then it was removed and the photographic record was made; that image was used to calculate the integration. After the first cure, the patient was discharged and follow-up was performed on an outpatient basis, with a healing average of the grafted area of 17 days. CONCLUSIONS: In our experience, the use of the negative pressure system as an occlusive healing method in partial skin grafts has represented success rates greater than 98% in the integration of the grafts, which translates into a cost-effective treatment since it reduces the complications inherent to this procedure. Likewise, the mathematical calculation of the graft integration makes possible the specific evaluation and definition of the behavior in each case

Vascular function in continuous-flow left ventricular assist device recipients: effect of a single pulsatility treatment session.

Vascular function is further attenuated in patients with chronic heart failure implanted with a continuous-flow left ventricular assist device (LVAD), likely due to decreased arterial pulsatility, and this may contribute to LVAD-associated cardiovascular complications. However, the impact of increasing pulsatility on vascular function in this population is unknown. Therefore, 15 LVAD recipients and 15 well-matched controls underwent a 45-min, unilateral, arm pulsatility treatment, evoked by intermittent cuff inflation/deflation (2-s duty cycle), distal to the elbow. Vascular function was assessed by percent brachial artery flow-mediated dilation (%FMD) and reactive hyperemia (RH) (Doppler ultrasound). Pretreatment, %FMD (LVAD: 4.0 ± 1.7; controls: 4.2 ± 1.4%) and RH (LVAD: 340 ± 101; controls: 308 ± 94 mL) were not different between LVAD recipients and controls; however, %FMD/shear rate was attenuated (LVAD: 0.10 ± 0.04; controls: 0.17 ± 0.06%/s-1, P < 0.05). The LVAD recipients exhibited a significantly attenuated pulsatility index (PI) compared with controls prior to treatment (LVAD: 2 ± 2; controls: 15 ± 7 AU, P < 0.05); however, during the treatment, PI was no longer different (LVAD: 37 ± 38; controls: 36 ± 14 AU). Although time to peak dilation and RH were not altered by the pulsatility treatment, %FMD (LVAD: 7.0 ± 1.8; controls: 7.4 ± 2.6%) and %FMD/shear rate (LVAD: 0.19 ± 0.07; controls: 0.33 ± 0.15%/s-1) increased significantly in both groups, with, importantly, %FMD/shear rate in the LVAD recipients being restored to that of the controls pretreatment. This study documents that a localized pulsatility treatment in LVAD recipients and controls can recover local vascular function, an important precursor to the development of approaches to increase systemic pulsatility and reduce systemic vascular complications in LVAD recipients.

Transcatheter Closure of Patent Ductus Arteriosus under Echocardiography Guidance: A Randomized Controlled Noninferiority Trial.

BACKGROUND: Percutaneous occlusion under fluoroscopy guidance has become the preferred method for the treatment of patent ductus arteriosus (PDA). To avoid radiation exposure and contrast agent use, PDA occlusion under transthoracic echocardiography (TTE) guidance was conducted. OBJECTIVES: We assessed the hypothesis that the success rate of percutaneous PDA occlusion under TTE was noninferior to that under fluoroscopy guidance. METHODS: In this single-center trial, 100 patients were randomly assigned in a 1 : 1 ratio to the TTE group (n = 50) or to the fluoroscopy group (n = 50). The primary endpoint was the success rate of occlusion, with the noninferiority margin set at 8% for the between-group difference in intention-to-treat analysis. Secondary endpoints were hospitalization duration, cost, procedure time, and rate of adverse events including occluder migration, hemolysis, peripheral vascular complications, and residual shunt at 1-month and 12-month follow-up. RESULTS: Patient, defect, and device characteristics were similarly distributed between groups. The success rate of occlusion was 98% for the TTE group and 100% for the fluoroscopy group (absolute difference: -2%; 95% confidence interval: -5.9% to 1.9%). Cost and procedure duration were significantly lower in the TTE group, without adverse events in either group at a median of 12.0 months (range, 10.0-15.5 months) of follow-up. CONCLUSION: Percutaneous PDA occlusion can be performed via TTE guidance safely and effectively, and the success rate of the TTE-guided procedure was noninferior to that under fluoroscopy guidance, with reduced cost and procedure time. The trial is registered with http://www.chictr.org.cn (ChiCTR-ICR-15006334).

Anaesthetic management and complications of transvascular patent ductus arteriosus occlusion in dogs.

OBJECTIVE: To retrospectively analyse the anaesthetic management, complications and haemodynamic changes in a cohort of dogs undergoing transvascular patent ductus arteriosus (PDA) occlusion in a tertiary referral centre (from January 2017 to August 2018). STUDY DESIGN: Retrospective study. ANIMALS: A total of 49 client-owned dogs. METHODS: Anaesthetic records of dogs with PDA that underwent transvascular occlusion of the ductus were reviewed. Anaesthetic complications evaluated included tachycardia [heart rate (HR) > 160 beats minute-1], bradycardia (HR < 50 beats minute-1), hypertension [systolic arterial pressure (SAP) > 150 mmHg], hypotension [mean arterial pressure (MAP) < 60 mmHg], hypothermia (<37 °C) and the presence of arrhythmias. Cardiovascular variables [HR and invasive SAP, MAP and diastolic arterial pressure (DAP)] at the time of occlusion device deployment (time 0) were compared with variables at 5 and 10 minutes after deployment. Descriptive statistics, Shapiro-Wilk test and repeated measures analysis of variance followed by a Dunnett's post hoc test were used to analyse the data (p < 0.05). RESULTS: Crossbreed dogs were the most commonly represented followed by the Cavalier King Charles Spaniel. The median age was 8 (2-108) months, and female dogs were over-represented (65.3%). The most common American Society of Anesthesiologists score was III. Mean duration of anaesthesia was 96 ± 26 minutes and mean surgery time was 58 ± 21 minutes. Acepromazine with methadone was the most commonly used premedication combination (77.6%). Propofol was the most common induction agent (73.5%). General anaesthesia was maintained with isoflurane in oxygen in all dogs. Complications included hypotension (63%), hypothermia (34%), bradycardia (28%), arrhythmias (16%), hypertension (16%) and haemorrhage (2%). MAP and DAP increased significantly 10 minutes after device deployment compared with time 0. CONCLUSIONS: and clinical relevance: Hypotension was the most common complication reported in dogs undergoing transvascular PDA occlusion. No major adverse events were documented.

Therapeutic Ureteral Occlusion with Use of Occlusion Stents for Urinary Leakage or Fistula: A Bicentric Study.

PURPOSE: To evaluate the safety and efficacy of ureteral occlusion stents for urinary diversion in patients with inoperable urinary leakage or fistula or intractable bladder bleeding. MATERIALS AND METHODS: A total of 13 ureters in 12 patients (M:F = 4:8) who underwent ureteral occlusion stenting were included in this study. The internally silicone membrane-coated occlusion stent was a self-expanding stent with constriction at the middle (M-type) or distal end (D-type) of the stent. RESULTS: The reasons for ureteral occlusion were surgery infeasibility for urinary leakage (n = 6), temporary ureteral occlusion for urinary leakage before surgical reconstruction (n = 2), urinary fistula (n = 3), or control of bleeding from bladder cancer (n = 1). Technical success defined as successful deployment of the occlusion stent with no contrast agent passing beyond the occlusion stent was achieved in 92.3% (12/13 ureters); in one ureter with contrast passage beyond the occlusion stent, additional n-butyl cyanoacrylate (NBCA) embolization was performed immediately so that there was no further leakage. There were no procedure-related complications. During the mean follow-up of 11.6 months, recurrence of urinary leakage was observed in two ureters (15.4%, 2/13) where a D-type occlusion stent was used on the 3-day follow-up antegrade ureterogram; the contrast agent passed through the widened constricted portion of the occlusion stent and repeat occlusion with microcoils, and NBCA was subsequently performed inside the occlusion stent and with no further urinary leakage until the last follow-up. CONCLUSION: The ureteral occlusion stent is safe and effective for ureteral occlusion. Recurrence of leakage can be managed with additional microcoil and NBCA embolization.

Plasma nitrite as an indicator of cerebral ischemia during extracranial/intracranial bypass surgery in moyamoya patients.

BACKGROUND AND PURPOSE: Nitric oxide (NO) plays a key role in ischemia and shows potential as a biomarker for ischemia. We measured mixed venous nitrite (NO2-) as a proxy for NO, during controlled cerebral ischemia in patients with moyamoya disease (MMD) during direct extracranial/intracranial (EC/IC) bypass surgery with temporary occlusion of the M4 branch of the middle cerebral artery (MCA) to permit anastomosis with the superficial temporal artery (STA). This small, focal ischemic event is not reliably detected using cerebral oximetry, somatosensory evoked potentials (SSEPs) or electroencephalography (EEG). METHODS: We enrolled nine adult MMD patients (n=8 female, n=1 male) undergoing direct EC/IC bypass surgery. Nitrite was measured at least one hour prior to MCA occlusion, and before, during and after anastomosis. Cortical function was monitored using either multi-lead EEG and SSEPs, or frontal EEG activity. RESULTS: Mixed venous NO2- was significantly elevated (p<0.05) within 12 min following arterial occlusion vs. baseline. An M4 branch of the MCA was cross clamped for a median duration of 18 (IQR = 5) minutes during anastomosis. One patient with elevated NO2- showed a transient neurologic deficit that resolved 3 days post-operatively. CONCLUSIONS: Mixed venous NO2- was significantly elevated shortly following cerebral artery occlusion vs. baseline in a majority of the study subjects, suggesting that NO2- is a potential biomarker for ischemia. Since all patients received identical burst suppression anesthesia and vasopressors, the fact that NO2- was not elevated during cross-clamp in all patients supports the conclusion that the NO2- elevation is likely due to ischemia.

Aortopulmonary Collaterals in Single Ventricle Physiology: Variation in Understanding Occlusion Practice Among Interventional Cardiologists.

Although aortopulmonary collaterals (APCs) frequently develop in patients with single ventricle palliation, there is a lack of understanding of pathophysiology, natural history, and outcomes with no universal guidelines for management and interventional practice. We conducted a study to assess the views held by interventional congenital cardiologists regarding the hemodynamic impact of APCs in patients with single ventricle palliation, and their embolization practice. An electronic survey using the Pediatric Interventional Cardiology Symposium (PICS) mailing list was conducted between February and March 2019 with one reminder sent 2 weeks after initial invitation for participation. Of the 142 interventional cardiologist respondents, 95 (66.9%) reside in North America and 47 (33.1%) worldwide. We elected to exclude the data from interventionalists outside North America in this analysis as it was not representative of worldwide practice. Hypoxemia was considered to be the most common trigger for development of APCs by 56 (58.9%) respondents. After completion of total cavopulmonary connection, 30 (31.6%) respondents reported the APC burden stays the same while 31 (32.6%) feel it decreases. In evaluating the burden of APC flow, only 4 (4.2%) reported measuring oxygen saturation at different pulmonary artery segments, 21 (22.1%) perform segmental aortic angiograms, and 18 (19%) perform selective bilateral subclavian artery angiograms. A majority of respondents, 71 (74.7%), occlude the feeder vessel at different locations, while 10 (10.5%) occlude only the origin of the vessel. Our study demonstrates significant variation in the understanding of the cause and prognosis of APCs in patients with single ventricle palliation. Furthermore, there is variation in the approach for diagnosis and management among interventional cardiologists. Further studies are required to improve understanding of APCs and develop universal management guidelines.

Entrenamiento con restricción parcial de flujo sanguíneo en personas con enfermedades cardiovasculares: una revisión exploratoria / Blood flow restriction training for people with cardiovascular disease: an exploratory review

OBJETIVO: Analizar la evidencia sobre los efectos del entrenamiento con restricción parcial del flujo sanguíneo en personas con enfermedades cardiovasculares. MATERIALES Y MÉTODOS: Se realizó una búsqueda en las bases de datos de MEDLINE, EMBASE, SPORTDiscus, CINAHL, LILACS, SCOPUS y Wiley. Fueron incluidos estudios experimentales y no experimentales que investigaron sobre los efectos de la restricción parcial del flujo sanguíneo en sujetos con enfermedad cardiovascular. RESULTADOS: Seis ensayos clínicos y tres estudios no experimentales cumplieron los criterios de inclusión. Los estudios experimentales fueron realizados en sujetos con hipertensión arterial y enfermedad isquémica del corazón. Los estudios no experimentales describieron las adaptaciones hemodinámicas y los potenciales efectos secundarios de la terapia. El riesgo de sesgo de los ensayos clínicos incluidos fue de moderado a alto. El estrés hemodinámico inducido por el ejercicio aumenta significativamente durante el entrenamiento con restricción parcial del flujo sanguíneo en comparación al entrenamiento tradicional. La limitada cantidad de estudios disponibles se han centrado mayoritariamente en los efectos agudos, sin embargo, los efectos crónicos son desconocidos. CONCLUSIÓN: Actualmente no hay evidencia que recomiende el uso de la restricción parcial del flujo sanguíneo en personas con enfermedades cardiovasculares

OBJECTIVE: To analyse the evidence on the effects of blood flow restriction training in people with cardiovascular disease. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, SPORTDiscus, CINAHL, LILACS, SCOPUS and Wiley databases. Experimental and non-experimental studies investigating the effects of blood flow restriction in participants with cardiovascular disease were included. RESULTS: Six clinical trials and three non-experimental studies met the inclusion criteria. The experimental studies were conducted in participants with hypertension and ischaemic heart disease. Non-experimental studies described hemodynamic adaptations and potential adverse effects of therapy. The risk of bias of the included clinical trials was moderate to high. Exercise-induced hemodynamic stress increased significantly during training with blood flow restriction compared with traditional training. The small number of available studies have focused mostly on acute effects, but chronic effects are unknown. CONCLUSION: There is currently no evidence to recommend the use of blood flow restriction in people with cardiovascular disease

A Novel Technique for the Management of Massive Hemoptysis: The Customized Endobronchial Silicone Blocker.

OBJECTIVE: Massive hemoptysis (MH) has a high mortality rate. Therapeutic options include bronchoscopy for endobronchial lesions, bronchial artery embolization (BAE), and emergency surgery. Scant options exist for patients who are not candidates for these modalities. Culprit bronchial segment occlusion is an option to prevent "spillover flooding → hypoxia." Applying this concept, we describe a case series of MH control using a novel bronchoscopically inserted customized endobronchial silicone blocker (CESB). We analyzed the safety and efficacy of CESBs in a select subset of patients with MH. METHODS: Inclusion criteria were patients with MH who were unstable for surgery/BAE, failed BAE, or relatively contraindicated/refused BAE. CESBs were manufactured on-site by modifying silicone stents, inserted using rigid bronchoscopy and reinforced with glue. The CESB was removed after 6 weeks when possible. A successful outcome was defined as immediate bleeding control with no recurrence after removal. RESULTS: Over 4.5 years, 13 episodes of MH in 12 patients meeting the criteria specified earlier were treated with CESBs. Seven of 12 patients had tuberculosis, 4 active and 3 inactive. One patient had mucormycosis, 1 post-lobectomy, 1 endobronchial renal cell carcinoma, 1 fibrosing mediastinitis, and 1 patient had metastatic laryngeal Ca. Eight of 12 patients were taken for primary-CESB placement. Four of 12 patients were sent for BAE, which was unsuccessful, and rescue-CESB was done for definitive management. The success rate, as defined earlier, was 92.3%, with no deaths from MH. CONCLUSIONS: Innovative bronchoscopically inserted CESBs are an effective strategy in MH when patients are unstable or fail conventional management.

Three-Dimensional Imaging Improves Accuracy in Clip Sizing During Thoracoscopic Left Atrial Appendage Exclusion.

The AtriClip is an epicardially applied occlusion device for the left atrial appendage. Accurate sizing and placement of the device is essential to its success. We describe the use of 3-dimensional computed tomography imaging to aid in accurate sizing of the AtriClip device during thoracoscopic surgical ablation. This technique reduces the risk of improper sizing of the device and thus mitigates the risk of malpositioning and potential damage or compression to surrounding structures such as the circumflex coronary artery.

Posterior Cerebral Artery Aneurysms: Parent Vessel Occlusion Being a Viable Option in the Era of Flowdivertors.

BACKGROUND AND PURPOSE: The purpose of this study is to evaluate posterior cerebral artery (PCA) aneurysms along with the efficacy, safety, procedural, and clinical outcome of the endovascular management of these aneurysms. We studied different techniques of endovascular treatment such as selective aneurysmal coiling, parent artery occlusion, and stent-assisted coiling in PCA aneurysms. METHODS: From 2010 to 2017, 11 patients (8 females, 3 males) harboring a PCA aneurysm were treated via an endovascular approach. Seven of eleven aneurysms were saccular in nature; four were fusiform shaped. All aneurysms were treated using detachable coils either by selective obliteration of the aneurysm sac or by parent artery occlusion. In one patient, stent-assisted coiling of PCA aneurysm was done, and in one patient, flowdivertor along with few coils used to treat the aneurysm. RESULTS: Five of the eleven aneurysms were successfully treated with preservation of the parent artery, and the other six were treated with aneurysm coiling along with parent vessel occlusion. Of the six where parent vessel occlusion was done, one developed transient hemiparesis which recovered on follow-up and none developed significant disabling vision abnormality. No mortality was noted. CONCLUSION: Aneurysms of the PCA are rare compared with other locations in the intracranial circulation. These aneurysms can effectively be treated by permanent occlusion of the parent artery even in this era of flowdivertors - however, in these cases, thorough knowledge of PCA segmental anatomy is crucial in order to select the site of occlusion and to avoid major neurological deficits.

A novel simple intra-corporeal Pringle maneuver for laparoscopic hemihepatectomy: how we do it.

INTRODUCTION: To prevent and control hemorrhage is the key to successfully perform laparoscopic hemihepatectomy (LHH). Pringle's maneuver (PM) is the standard hepatic inflow occlusion technique. Our study was to describe a novel simple way to perform totally intra-corporeal laparoscopic PM and to explore the feasibility of combining PM and selective hemihepatic vascular occlusion technique in LHH. METHODS: We extracted and analyzed the data of patients who consecutively underwent LHH to validate this new surgery technique. Between January, 2016 and December, 2017, 34 patients were included. Data of pre-operation, operation and post-operation were collected, including some demographic data, operative time, operative blood loss, transfusion rate, hepatic hilum occlusion rate and time, pathologic results, short-term complication, and postoperative hospitalization days. RESULTS: Only one patient (3.0%) in our series required conversion to laparotomy as a result of the severe adhesion. The average operative time was 216.9 ± 60.3 min. The mean hepatic inflow occlusion time was 25.3 ± 14.5 min. The average estimated blood loss was 192.9 ± 152.2 ml. All patients received R0 resection. CONCLUSION: The novel hepatic inflow occlusion device is a safe reliable and convenient technique for LHH that is associated with favorable perioperative outcomes and low risk of conversion.

Intermittent Splenic Artery Occlusion Plus Gauze Compression Is a Simple and Effective Treatment for Iatrogenic Splenic Injury.

BACKGROUND The aim of this study was to evaluate the feasibility and safety of intermittent splenic artery occlusion plus gauze compression in treating iatrogenic splenic injury. MATERIAL AND METHODS We retrospectively analyzed 12 iatrogenic splenic injury cases (grade I to III) treated with intermittent splenic artery occlusion plus gauze compression. The hemostatic effect was then observed after unblocking and decompression. The total operation time, gauze compression time, total blood loss, blood loss from the injured spleen, and platelet counts of each patient before and 1 week after surgery were noted. RESULTS The average operation time was 209.58±57.11 min, and the average gauze compression time after spleen artery occlusion was 23.75±4.33 min. The average total blood loss and blood loss due to iatrogenic spleen injury were 468.33±138.22 ml and 264.17±165.72 ml, respectively. Two cases (both grade I) had successful hemostasis after 15 min of splenic artery occlusion and wound compression. Another 9 cases (all grade II) and 1 case (grade III) attained hemostasis after 25 min and 30 min, respectively, of splenic artery occlusion and wound compression. The platelet counts of all patients were within the normal range before and 1 week after surgery. No postoperative complications occurred. CONCLUSIONS Intermittent splenic artery occlusion plus gauze compression is a simple and effective treatment for iatrogenic splenic injury.