Cerebral Protection in Trans-Catheter Aortic Valve Replacement: Review and Contemporary Assessment of Randomized Trial Data.

As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.

Videoscopic basilic vein harvest for creation of transposed brachiobasilic arteriovenous fistulae.

INTRODUCTION: Due to the extensive dissection required during the standard transposed brachiobasilic arterial venous fistula (BB-AVF) procedure and the potential for postoperative complications, many surgeons are reluctant to construct BB-AVFs. Less invasive vein harvest has been performed for this procedure with good results, but this procedure remains rarely used. METHODS: We began to perform videoscopic-assisted BB-AVF creation in selected patients at our institution in 2006. Vein harvesting from the antecubital fossa to the level of the axilla is performed by an experienced surgical technician under the guidance of the dialysis access surgeon. Perioperative data and postoperative outcomes were retrospectively reviewed with institutional review board approval. RESULTS: From 2006 to 2010, we performed videoscopic-assisted BB-AVF in 21 patients. Median age was 59 years and median body mass index was 30; women comprised 52% of the cohort. Previous vascular access procedures had been performed on 81% of patients. Of the 21 attempts with the video-assisted approach, only 1 required conversion to a standard open procedure. Of the remaining cases, there were no significant intraoperative or postoperative surgical complications with a median operative time of 159 minutes and maximum length of stay of 1 night. Maturation of the fistula sufficient for cannulation and use occurred in 80% of patients, with the median time to first access in patients who matured being 60 days. At 3 years follow-up, 47% of fistulas that matured were still functional, with 33% lost to death or successful renal transplantation. CONCLUSION: Videoscopic-assisted transposition of the basilic vein is a reasonable option for BB-AVF placement. The procedure can be performed in an acceptable expeditious fashion with near elimination of infection, wound breakdown, lymph drainage, nerve injury, and satisfactory maturation (80%) and patency rates. Technicians experienced in lower extremity vein harvest can perform this procedure successfully under the supervision of an experienced access surgeon.

Cervical HPV Infection in Indian Women: Screening and Immunization as Preventive Strategies.

Invasive cervical cancer (ICC) is the second leading cause of cancer related mortality among women in India. Human papillomavirus (HPV), the etiological agent of cervical cancer is widely prevalent worldwide. Persistent HPV infection, particularly with HPV 16, is essential for progression to cervical cancer. Human papillomavirus 16 and 18 are the most common genotypes detected among Indian HIV-infected and uninfected women, although their relative contributions vary. HIV-infected Indian women experience a higher risk for HPV infection compared to the general population. Although cervical screening and vaccination to protect against HPV infection are the two main strategies for prevention, there are significant challenges to their implementation in India. Scaling up of cervical screening using simple, rapid tests followed by colposcopy and treatment within a minimal number of visits is essential to prevent loss to followup. Increasing the uptake of the HPV vaccine combined with cervical screening can greatly reduce the burden of ICC in India.