A Novel REBOA Training Curriculum for Emergency Medicine Residents: A Pilot Study.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a potentially life-saving intervention to treat noncompressible torso hemorrhage. Traditionally, REBOA use has been limited to surgeons. However, emergency physicians are often the first point-of-contact and are well-versed in obtaining rapid vascular access and damage control resuscitation, making them ideal candidates for REBOA training. STUDY OBJECTIVES: To fill this gap, we designed and evaluated a REBOA training curriculum for emergency medicine (EM) residents. METHODS: Participants enrolled in an accredited 4-year EM residency program (N = 11) completed a 12-hour REBOA training course. Day 1 included lectures, case studies, and hands-on training using REBOA task trainers and perfused cadavers. Day 2 included additional practice and competency evaluations. Assessments included a 25-item written knowledge exam, decision-making on case studies, REBOA placement success, and time-to-placement. Participants returned at 4 months to assess long-term retention. Data were analyzed using t-tests and nonparametric statistics at p < 0.05. RESULTS: Scores on a 25-item multiple choice test significantly increased from pre-training (65% ± 5%) to post-training (92% ± 1%), p < 0.001. On Day 2, participants scored 100% on correct recognition of REBOA indications and scored 100% on correct physical placement of REBOA. Exit surveys indicated increased preparedness, confidence, and support for incorporating this course into EM training. Most importantly, REBOA knowledge, correct recognition of REBOA indications, and correct REBOA placement skills were retained by the majority of participants at 4 months. CONCLUSION: This course effectively teaches EM residents the requisite skills for REBOA competence and proper placement. This study could be replicated at other facilities with larger, more diverse samples, aiming to expand the use of REBOA in emergency physicians and reducing preventable deaths in trauma.

A Comprehensive Phylogenomic Platform for Exploring the Angiosperm Tree of Life.

The tree of life is the fundamental biological roadmap for navigating the evolution and properties of life on Earth, and yet remains largely unknown. Even angiosperms (flowering plants) are fraught with data gaps, despite their critical role in sustaining terrestrial life. Today, high-throughput sequencing promises to significantly deepen our understanding of evolutionary relationships. Here, we describe a comprehensive phylogenomic platform for exploring the angiosperm tree of life, comprising a set of open tools and data based on the 353 nuclear genes targeted by the universal Angiosperms353 sequence capture probes. The primary goals of this article are to (i) document our methods, (ii) describe our first data release, and (iii) present a novel open data portal, the Kew Tree of Life Explorer (https://treeoflife.kew.org). We aim to generate novel target sequence capture data for all genera of flowering plants, exploiting natural history collections such as herbarium specimens, and augment it with mined public data. Our first data release, described here, is the most extensive nuclear phylogenomic data set for angiosperms to date, comprising 3099 samples validated by DNA barcode and phylogenetic tests, representing all 64 orders, 404 families (96$\%$) and 2333 genera (17$\%$). A "first pass" angiosperm tree of life was inferred from the data, which totaled 824,878 sequences, 489,086,049 base pairs, and 532,260 alignment columns, for interactive presentation in the Kew Tree of Life Explorer. This species tree was generated using methods that were rigorous, yet tractable at our scale of operation. Despite limitations pertaining to taxon and gene sampling, gene recovery, models of sequence evolution and paralogy, the tree strongly supports existing taxonomy, while challenging numerous hypothesized relationships among orders and placing many genera for the first time. The validated data set, species tree and all intermediates are openly accessible via the Kew Tree of Life Explorer and will be updated as further data become available. This major milestone toward a complete tree of life for all flowering plant species opens doors to a highly integrated future for angiosperm phylogenomics through the systematic sequencing of standardized nuclear markers. Our approach has the potential to serve as a much-needed bridge between the growing movement to sequence the genomes of all life on Earth and the vast phylogenomic potential of the world's natural history collections. [Angiosperms; Angiosperms353; genomics; herbariomics; museomics; nuclear phylogenomics; open access; target sequence capture; tree of life.].

Improving Rates of Vitamin D Supplementation in Somali Immigrant Infants: A Prospective Interventional Pilot Trial.

PURPOSE: Rates of vitamin D deficiency and nutritional rickets have been rising over the past several decades, particularly in high-risk infants. This pilot study assessed the impact of providing free vitamin D supplements, a culturally-appropriate educational brochure, and a brief counseling session about the importance of both vitamin D supplementation and breastfeeding to the parents of Somali infants at routine office visits from newborn through 6 months of age at three Federally Qualified Health Centers in Colorado. We also assessed the impact this intervention had on rates of breastfeeding. METHODS: Twenty-five Somali infants aged 24 weeks or less were identified by searching electronic health records and enrolled into a historic control group. The parents were then surveyed by phone regarding breastfeeding and vitamin D supplementation. Subsequently, 37 families with newborn Somali infants were identified and enrolled into the intervention arm of the trial. RESULTS: The intervention group had a higher rate of vitamin D supplementation compared to the historical control group (67 vs. 48 percent, p=0.011) without significantly impacting breastfeeding rates. CONCLUSION: These results suggest a practical way to increase vitamin D status in this high-risk population. Trial not registered as it was a pilot study, not a phase II to IV prospective clinical trial.

Critical Assessment of Metagenome Interpretation-a benchmark of metagenomics software.

Methods for assembly, taxonomic profiling and binning are key to interpreting metagenome data, but a lack of consensus about benchmarking complicates performance assessment. The Critical Assessment of Metagenome Interpretation (CAMI) challenge has engaged the global developer community to benchmark their programs on highly complex and realistic data sets, generated from ∼700 newly sequenced microorganisms and ∼600 novel viruses and plasmids and representing common experimental setups. Assembly and genome binning programs performed well for species represented by individual genomes but were substantially affected by the presence of related strains. Taxonomic profiling and binning programs were proficient at high taxonomic ranks, with a notable performance decrease below family level. Parameter settings markedly affected performance, underscoring their importance for program reproducibility. The CAMI results highlight current challenges but also provide a roadmap for software selection to answer specific research questions.

Prolonged high-pressure is required for optimal stent deployment as assessed by optical coherence tomography.

AIMS: Optimizing stent deployment is important for both acute- and long-term outcomes. High-pressure balloon inflation is the standard for coronary stent implantation. However, there is no standardized inflation protocol. We hypothesized that prolonged high-pressure balloon inflation until stabilization of inflation pressure is superior to a rapid inflation/deflation sequence for both stent expansion and strut apposition. METHODS AND RESULTS: A high-pressure rapid inflation/deflation sequence was deployed followed by angiography to assure no residual stenosis. Optical coherence tomography (OCT) was then performed followed by prolonged inflation until balloon pressure was stabilized for 30 sec using the same balloon at the same pressure as the rapid sequence. A second OCT run was then done. Thirteen thousand nine hundred thirteen stent struts were evaluated by OCT in 12 patients undergoing successful stenting. Stent expansion improved with prolonged (206 ± 115 sec) vs. rapid (28 ± 17 sec) inflation for both minimal stent diameter (3.0 ± 0.5 vs. 2.75 ± 0.44 mm, P < 0.0001) and area (7.83 ± 2.45 vs. 6.63 ± 1.85 mm(2) , P = 0.0003). The number of malapposed struts decreased (45 ± 41 vs. 88 ± 75, P = 0.005) as did the maximal malapposed strut distance (0.31 ± 0.2 vs. 0.43 ± 0.2 mm, P = 0.0001). Factors related to strut malapposition after rapid inflation included localized asymmetry in 67%, stent underexpansion in 75%, and stent undersizing in 67%. CONCLUSIONS: These data demonstrate that prolonged inflation is superior to a rapid inflation/deflation technique for both stent expansion and strut apposition. We recommend for routine stent deployment a prolonged inflation protocol as described above to optimize stent deployment.

Living, Leading & Medicine: A two-tiered leadership development programme for family medicine residents.

BACKGROUND: There is increasing awareness of the necessity and importance for physician leadership in health care. Despite this, formal leadership training is not widespread in medical education. APPROACH: We describe the structure, curriculum and development of a robust two-tiered leadership development programme within a community-based family medicine residency programme. Living, Leading & Medicine (LLM, tier 1) consists of nine 2.5-h discussion-based training sessions occurring thrice annually. The Advanced Leadership Track (ALT, tier 2) includes mentoring, additional readings, personal evaluations and leadership projects. EVALUATION: We used post-session surveys and exit surveys for LLM and ALT, respectively. We utilised the modified Kirkpatrick framework for programme evaluation to present outcomes from the first 3 years for each tier. Over three quarters (40 out of 53) of residents participated in LLM sessions. The post-session survey response rate for LLM was 95% (124 out of 130 participants). Eighteen out of 33 residents (54.5%) completed the ALT. Of these, 72% (13 of 18) returned exit surveys. Residents found the programme valuable and relevant (Kirkpatrick level 1). Residents demonstrated improvements in leadership knowledge and skills (3.85 v. 3.11, p < 0.0001; Kirkpatrick level 2) compared with an internal, historic control group. We noted changes in resident behaviour and attitudes towards leadership (Kirkpatrick level 3). Finally, the completion of leadership projects demonstrates Kirkpatrick level 4 outcomes. IMPLICATIONS: We have created a longitudinal, two-tiered leadership development programme that has improved the leadership capabilities of our family medicine residents.

Policy Recommendations for Increasing the Use of Evidence-Based Psychotherapy for Posttraumatic Stress Disorder in the Military Health System.

Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS.

Soybean Knowledge Base (SoyKB): a web resource for soybean translational genomics.

BACKGROUND: Soybean Knowledge Base (SoyKB) is a comprehensive all-inclusive web resource for soybean translational genomics. SoyKB is designed to handle the management and integration of soybean genomics, transcriptomics, proteomics and metabolomics data along with annotation of gene function and biological pathway. It contains information on four entities, namely genes, microRNAs, metabolites and single nucleotide polymorphisms (SNPs). METHODS: SoyKB has many useful tools such as Affymetrix probe ID search, gene family search, multiple gene/metabolite search supporting co-expression analysis, and protein 3D structure viewer as well as download and upload capacity for experimental data and annotations. It has four tiers of registration, which control different levels of access to public and private data. It allows users of certain levels to share their expertise by adding comments to the data. It has a user-friendly web interface together with genome browser and pathway viewer, which display data in an intuitive manner to the soybean researchers, producers and consumers. CONCLUSIONS: SoyKB addresses the increasing need of the soybean research community to have a one-stop-shop functional and translational omics web resource for information retrieval and analysis in a user-friendly way. SoyKB can be publicly accessed at http://soykb.org/.

Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities.

INTRODUCTION: Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS: As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS: There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS: The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.

An analysis of ED utilization by adults with intellectual disability.

OBJECTIVES: We sought to identify factors increasing the odds of ED utilization among intellectually disabled (ID) adults and differentiate their discharge diagnoses from the general adult ED population. METHODS: This was a retrospective, observational open cohort study of all ID adults residing at an intermediate care facility and their ED visits to a tertiary center (January 1, 2007-July 30, 2008). We abstracted from the intermediate care facility database subjects' demographic, ID, health and adaptive status variables, and their requirement of ED care/hospitalization. We obtained from the hospital database the primary International Classification of Diseases 9 ED/hospital discharge diagnoses for the study and general adult population. Using multivariate logistic regression, we computed odds ratios (OR) for ED utilization/hospitalization in the cohort. Using the conditional large-sample binomial test, we differentiated the study and general populations' discharge diagnoses. RESULTS: A total of 433 subjects met the inclusion criteria. Gastrostomy/jejunostomy increased the odds of ED utilization (OR, 4.16; confidence interval [CI], 1.64-10.58). Partial help to feed (OR, 2.59; CI, 1.14-5.88), gastrostomy/jejunostomy (OR, 3.26; CI, 1.30-8.18), and increasing number of prescribed medications (OR, 1.08; CI, 1.03-1.14) increased the odds of hospitalization. Auditory impairment (OR, 0.45; CI, 0.23-0.88) decreased the odds of hospitalization. For ED discharge diagnoses, ID adults were more likely (P < .05) than the general population to have diagnoses among digestive disorders and ill-defined symptoms/signs. For hospital discharge diagnoses, ID adults were more likely (P < .05) to have diagnoses among infectious/parasitic, nervous system, and respiratory disorders. CONCLUSION: Among ID adults, feeding status increased the odds of ED utilization, feeding status, and increasing number of prescribed medications of that hospitalization. Intellectually disabled adults' discharge diagnoses differed significantly from the general adult ED population.

Urticaria and edema in a 2-year-old boy.

The absence of blisters, the presence of mild systemic symptoms, and the patient's age guided the diagnosis.

Variation of anti-A and anti-B titers in group O potential blood donors: A pilot study.

BACKGROUND: Resuscitation with fresh whole blood is vital to preserving life on the battlefield. Transfusing low titer O whole blood (LTOWB), defined as anti-A and anti-B titer levels of <1:256, is safe because LTOWB alleviates the risk for hemolytic transfusion reactions. Because of possible variations in titer levels over time, a study was needed using US Navy and Marine Corps personnel to assess how these titers change across two assessments. METHODS: Retrospective data from group O marines and sailors (M = 25 years of age; range, 19-35 years) stationed in the San Diego region were acquired from the Armed Services Blood Program and the Composite Health Care System. Of 972 group O donors between January 2016 and November 2019, 55 donors with 2 samples were identified (N = 55). Analysis included contrasting rates of high (≥1:256) and low (<1:256) anti-A and anti-B titers on the initial and second blood tests, along with the time between testings. RESULTS: The average time between testing was 332 days (range, 35-1,121 days), which far exceeded the recommended 90-day interval (p < 0.00001). Only 45% met the 90-day recommendation. Titer status changed frequently, from low to high (anti-A, 18%; anti-B, 13%; LTOWB to not LTOWB, 21%) or from high to low (anti-A, 62%; anti-B, 78%; not LTOWB to LTOWB, 62%). CONCLUSIONS: Anti-A and anti-B titers change frequently enough to warrant testing immediately before deployment and even during deployment. The observed time elapsed between testing is unacceptably long. The present pilot study provides a foundation for a larger formal study to more fully characterize titer changes over repeated testing. LEVEL OF EVIDENCE: Diagnostic test, level IV.

Planning for the storm: Considering renewable energy for critical infrastructure resilience.

OBJECTIVE: Benchmark the economic value of renewable energy and battery storage systems to extend operation of certain critical infrastructure facilities in different markets. DESIGN: This study uses the renewable energy optimization model to assess three critical facilities in North Caro-lina. Techno-economic results were then compared to analyses completed for critical facilities in California and New York to assess energy system cost effectiveness. RESULTS: Though solar photovoltaic (PV) arrays are cost-effective across each of the three North Carolina facili-ties, adopting battery storage to enable PV to operate with existing diesel generators in a hybrid energy system re-duces the economic value of the system. This is in contrast to more economically viable systems in California and New York. All of these systems also offer unquantified resilience benefits by extending operation from hours to weeks across the facilities. CONCLUSION: If decision makers were able to value the resilience benefits offered by each system or utility rate structures were changed to incentivize battery storage during normal operations, it would impact these assessments. Even so, this analysis provides decision makers a key set of cost benchmarks when considering how they might im-prove resilience at their critical operations.

Predictive value of myocardial perfusion single-photon emission computed tomography and the impact of renal function on cardiac death.

BACKGROUND: Patients with chronic kidney disease (CKD) have worse cardiovascular outcomes than those without CKD. The prognostic utility of myocardial perfusion single-photon emission CT (MPS) in patients with varying degrees of renal dysfunction and the impact of CKD on cardiac death prediction in patients undergoing MPS have not been investigated. METHODS AND RESULTS: We followed up 1652 consecutive patients who underwent stress MPS (32% exercise, 95% gated) for cardiac death for a mean of 2.15+/-0.8 years. MPS defects were defined with a summed stress score (normal summed stress score <4, abnormal summed stress score>or=4). Ischemia was defined as a summed stress score >or=4 plus a summed difference score >or=2, and scar was defined as a summed difference score <2 plus a summed stress score >or=4. Renal function was calculated with the Modified Diet in Renal Disease equation. CKD (estimated glomerular filtration rate <60 mL . min(-1) . 1.73 m(-2)) was present in 36%. Cardiac death increased with worsening levels of perfusion defects across the entire spectrum of renal function. Presence of ischemia was independently predictive of cardiac death, all-cause mortality, and nonfatal myocardial infarction. Patients with normal MPS and CKD had higher unadjusted cardiac death event rates than those with no CKD and normal MPS (2.7% versus 0.8%, P=0.001). Multivariate Cox proportional hazards models revealed that both perfusion defects (hazard ratio 1.90, 95% CI 1.47 to 2.46) and CKD (hazard ratio 1.96, 95% CI 1.29 to 2.95) were independent predictors of cardiac death after accounting for risk factors, left ventricular dysfunction, pharmacological stress, and symptom status. Both MPS and CKD had incremental power for cardiac death prediction over baseline risk factors and left ventricular dysfunction (global chi(2) 207.5 versus 169.3, P<0.0001). CONCLUSIONS: MPS provides effective risk stratification across the entire spectrum of renal function. Renal dysfunction is also an important independent predictor of cardiac death in patients undergoing MPS. Renal function and MPS have additive value in risk stratisfying patients with suspected coronary artery disease. Patients with CKD appear to have a relatively less benign prognosis than those without CKD, even in the presence of a normal scan.

Effectiveness of anemia and chronic kidney disease as predictors for presence and severity of coronary artery disease in patients undergoing stress myocardial perfusion study.

Chronic kidney disease (CKD) and anemia portend a higher risk of cardiac events and mortality. We sought to ascertain whether coronary artery disease (CAD) by myocardial perfusion single-photon emission computed tomography is more common in patients with CKD (glomerular filtration rate < or =60 ml/min/1.73 kg/m(2)) and/or anemia (hemoglobin level < or =13 g/L) and the impact of different degrees of CKD. One thousand five hundred eighty patients (mean age 65 +/- 10 years) underwent gated myocardial perfusion single-photon emission computed tomography and clinical evaluation. Patients were divided into 4 groups (group 1, no anemia/no CKD, n = 800; group 2, anemia/no CKD, n = 195; group 3, CKD/no anemia, n = 332; group 4, anemia/CKD, n = 253). Multivariate logistic regression analysis was undertaken to examine the association of these diagnoses with abnormal myocardial perfusion single-photon emission computed tomogram. Compared with patients with neither diagnosis, an abnormal scan was more common in those with anemia or CKD. Patients with anemia and CKD exhibited more severe CAD (mean summed stress score 6.8 vs 4.7, p <0.01). Established high-risk findings were more prevalent in patients with anemia and/or CKD, including a summed stress score > or =8, transient ischemic dilation, or a left ventricular ejection fraction < or =40% (group 1 28%, group 2 38%, group 3 38%, group 4 48%, all p values <0.01). Patients with moderate CKD demonstrated an increased risk of an abnormal scan (odds ratio 2.66, p <0.0001). After adjustment in multivariate analysis, anemia and CKD each remained predictors for an abnormal scan. The association was stronger in those with the 2 conditions (odds ratio for high-risk scan 1.89, p = 0.0002). In conclusion, in patients with suspected CAD, anemia and CKD are predictors of myocardial perfusion single-photon emission computed tomographic markers for worsened outcomes. The relation was independent of other risk factors, supporting the inclusion of anemia and CKD in global risk assessment for patients with suspected CAD.

Intensive coping skills training to reduce anxiety and depression for forward-deployed troops.

This study provides descriptive information and 2-year outcome data on the first intensive, outpatient, coping skills training program for forward-deployed troops in the Western Pacific Ocean region. Established in February 2003 by the Mental Health Department of the U.S. Naval Hospital in Okinawa, Japan, the Outpatient Crisis Prevention Program was designed as a multidisciplinary training program to reduce anxiety and depression and to enhance the coping skills of active duty personnel. This study describes the rationale for creating the program, the patient population, and treatment outcome data collected during the first 2 years. The Beck Depression Inventory II and the Beck Anxiety Inventory were administered as pretraining and posttraining measures to patients who completed the program between February 2003 and February 2005 (N = 326). Results revealed that the Outpatient Crisis Prevention Program was effective in reducing depression and anxiety symptoms and promoting healthy coping behaviors among participants. Follow-up data indicated that gains were maintained 1 month after treatment.

Review of the first year of an overseas military gambling treatment program.

This study provides descriptive information and preliminary first-year outcome data on the only overseas military gambling treatment option currently available. Implemented in January 2003 within the Substance Abuse Rehabilitation Program, U.S. Naval Hospital, Okinawa, Japan, gambling treatment was developed as a specific track within the overall substance abuse program. The present study explores the various considerations and requirements for setting up such a program, as well as a description of individuals seeking gambling treatment and preliminary outcome data. Participants consisted of all gambling referrals (N = 35, 26 males; mean age, 33.2 years; SD = 8.93) obtained over the first year that gambling services were offered. A significant degree of depression, suicidality, and substance abuse problems were observed in the sample. Results revealed that the gambling program was easily implemented within an established substance abuse program. The program was effective in preventing suicides in both military members and eligible beneficiaries and was effective in facilitating the retention of military members with gambling problems.

Intramedullary transmetatarsal Kirschner wire fixation of Lisfranc fracture-dislocations.

Lisfranc joint injuries are frequently the result of high-energy accidents. The usual method of treatment is open reduction and internal fixation or closed reduction with percutaneous pinning. In cases in which soft tissue injury may compromise open reduction and internal fixation or traditional pinning techniques, transmetatarsal Kirschner wire fixation may be performed, allowing the placement of temporary hardware away from the site of soft tissue injury. The following report details this technique as it has been used in 3 patients.

Intervention in the occluded vein graft: with high risk can come great reward: review of techniques with case examples.

Total occlusion of a saphenous vein graft (SVG) can present as abrupt thrombotic occlusion in an atherosclerotic graft with resultant acute cardiac events or chronic total occlusion (CTO) with resultant angina symptoms. The risks of percutaneous coronary intervention (PCI) within an occluded graft include not only periprocedural myocardial infarction (MI), but also the risks that come part and parcel with any CTO intervention which include an increased probability of procedural failure, vessel perforation, dissection, high radiation, and contrast exposure, and the potential for worse outcomes. PCI of a chronically occluded graft remains a class III indication in current PCI guidelines because of the increased procedural risk and modest clinical data supporting improved outcomes. Acute-type occlusions, with bulky and thrombotic obstruction, while not specifically addressed in the guidelines, are also fraught with somewhat similar risks. In this review, we describe four case scenarios with occluded SVG and discuss challenges and techniques and available evidence that support these interventions.