Editor's Choice - Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair.

OBJECTIVES: The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. METHODS: Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. RESULTS: In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). CONCLUSION: There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Mid-term Outcomes of Renal Branches Versus Renal Fenestrations for Thoraco-abdominal Aneurysm Repair.

OBJECTIVE/BACKGROUND: The objective was to investigate renal outcomes following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) comparing fenestrations with branches for the renal arteries. METHODS: Renal outcomes following TAAA endovascular repair performed with renal branches were collected from five high volume European centers and compared with renal outcomes following TAAA endovascular repair performed with renal fenestrations at one center. Renal re-intervention and occlusion rates, and freedom from any renal outcome and death were analyzed by patient and target vessel. Estimated glomerular filtration rate (eGFR) was calculated and collected pre-operatively and at the last available follow up. RESULTS: In total, 449 patients were included in this retrospective study (235 treated with branched devices [BEVAR] and 214 with fenestrated devices [FEVAR]). Altogether, 856 renal vessels were analyzed (445 perfused by branches and 411 by fenestrations). Both groups were comparable except for sex and smoking habits. Technical success rates were 95% and 99%, respectively. Mean ± SD follow up was 19 ± 18 months after BEVAR and 24 ± 20 months after FEVAR. During follow up, renal re-intervention rates were similar in both groups (4.7% vs. 5.2%). The renal occlusion rate was significantly higher following BEVAR (9.6% vs. 2.3%; p < .01), and the 2 year freedom for renal occlusion rate was 90.4% (SE 85.8-95.3%) following BEVAR and 97.1% (SE 94.6-99.7%) following FEVAR (p < .01). During follow up, a 12% median decrease in eGFR was observed following BEVAR versus 9% following FEVAR (non-significant). The 2 year survival rates were 73.4% (SE 66.6-80.9%) and 81.8% (SE 76.1-87.9%) following BEVAR and FEVAR, respectively. CONCLUSION: Mid-term renal outcomes following endovascular repair of TAAA are satisfactory. Endograft designs incorporating renal fenestrations rather than renal branches are associated with significantly lower occlusion rates. A prospective trial is now required to confirm these results.

The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair.

OBJECTIVE/BACKGROUND: Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage). METHODS: Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared. RESULTS: Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01). CONCLUSION: The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type I-III TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.

Renal Outcomes Following Fenestrated and Branched Endografting.

OBJECTIVE: The purpose of this study was to analyze immediate and long-term renal outcomes (renal function and renal events) after fenestrated (FEVAR) and branched endovascular aortic aneurysm repair (BEVAR). METHODS: All FEVAR and BEVAR performed between October 2004 and October 2012 were included in this study. Post-operative acute renal failure (ARF) was defined according to the RIFLE criteria. Renal volume (calculated with a 3D workstation) and estimated glomerular filtration rate (GFR) (estimated with the Modification of Diet in Renal Disease [MDRD] formula) were evaluated before the procedure, before discharge, 12 months after, and yearly thereafter. Renal stent occlusion, dissection, fracture, stenosis, kink, renal stent related endoleak, and renal stent secondary intervention were all considered "renal composite events" and analyzed. A time to event analysis was performed for renal events and secondary renal interventions. RESULTS: 225 patients were treated with FEVAR and BEVAR. Renal target vessels (n = 427) were perfused by fenestrations (n = 374), or branches (n = 53). Median follow up was 3.1 years (2.9-3.3 years). Technical success was achieved in 95.5% of patients. Post-operative ARF was seen in 64 patients (29%). Mean total renal volume and eGFR at 1 year, 2 year, and 3 year follow up were significantly lower when compared with pre-operative levels (after BEVAR and FEVAR); the decrease at 3 years was 14.8% (6.7%; 22.2%) (p = .0006) for total renal volume and 14.3% (3.1%; 24.3%) (p = .02) for eGFR. The 30 day and 5 year freedom from renal composite event was 98.6% (95.8-99.6%) and 84.5% (76.5-89.9%) after FEVAR and BEVAR (NS). The 30 day and 5 year freedom from renal occlusion was 99.5% (96.7-99.9%) and 94.4% (89.3-97.1%) after FEVAR and BEVAR (NS). CONCLUSION: FEVAR and BEVAR are durable options for the treatment of complex aortic aneurysms and are associated with low renal morbidity, without differences between devices types. The clinical impact of decreasing renal volume over time in these patients is yet to be fully understood.

Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR.

OBJECTIVES: This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). METHODS: Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. RESULTS: Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% (n = 7) and 33.3% (n = 18) (p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 (p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 (p = .978). Median radiation exposure due to CBCT was 7 Gy cm(2) (5.25-8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8-47.3) and 11 (5-20.5) mSv, and 184 (150-240) and 91 (70-132.8) mL respectively (reduction of 68% and 50%, p < .001). CONCLUSIONS: Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

Impact of hybrid rooms with image fusion on radiation exposure during endovascular aortic repair.

OBJECTIVE: To evaluate exposure to radiation during endovascular aneurysm repair (EVAR) performed with intraoperative guidance by preoperative computed tomographic angiogram fusion. METHODS: All consecutive patients who underwent standard bifurcated (BIF) or thoracic (THO), and complex fenestrated (FEN) or branched (BR) EVAR were prospectively enrolled. Indirect dose-area product (DAP), fluoroscopy time (FT), and contrast medium volume were recorded. These data were compared with a previously published prospective EVAR cohort of 301 patients and to other literature. Direct DAP and peak skin dose were measured with radiochromic films. Results are expressed as median (interquartile range). RESULTS: From December 2012 to July 2013, 102 patients underwent standard (56.8%) or complex (43.2%) EVAR. The indirect DAP (Gy.cm(2)) was as follows: BIF 12.2 (8.7-19.9); THO 26.0 (11.9-34.9); FEN 43.7 (24.7-57.5); and BR 47.4 (37.2-108.2). The FT (min) was as follows: BIF 10.6 (9.1-14.7); THO 8.9 (6.0-10.5); FEN 30.7 (20.2-40.5); and BR 39.5 (34.8-51.6). The contrast medium volume (mL) was as follows: BIF 59.0 (50.0-75.0); THO 80.0 (50.0-100.0); FEN 105.0 (70.0-136.0); and BR 120.0 (100.0-170.0). When compared with a previous cohort, there was a significant reduction in DAP during BIF, FEN, and BR procedures, and a significant reduction of iodinated contrast volume during FEN and BR procedures. There was also a significant reduction in DAP during BIF procedures when compared with the literature (p < .01). DAP measurement on radiochromic films was strongly correlated with indirect DAP values (r(2) = .93). CONCLUSION: The exposure of patients and operators to radiation is significantly reduced by routine use of image fusion during standard and complex EVAR.

Correlation between dermoscopy and direct microscopy in Tineabarbae.

Tineabarbae is a rare form of dermatophytosis that affects hair follicles of the beard and moustache. Dermoscopy could prove useful to identify parasitism of hair of the beard, just as it has proven useful in the diagnosis of Tineacapitis. We present the first fully documented case series of T. barbae with clinical, dermoscopic and mycological features.

Evaluation of a new imaging software for aortic endograft planning.

OBJECTIVE: The aim of this study was to evaluate a new 3D Workstation workflow (EVAR Assist, Advantage Windows, GE Healthcare, Chalfont, UK) (EA-AW) designed to simplify complex EVAR planning. PATIENTS AND METHODS: All pre-operative computed tomography (CT) scans of patients who underwent repair at our institution of a complex aortic aneurysm using fenestrated endovascular repair (f-EVAR) between January and September 2014, were reviewed. For each patient, imaging analysis (12 measures: aortic diameters and length and "clock position" of visceral artery) was performed on two different workstations: Aquarius (TeraRecon, San Mateo, CA, USA) and EA-AW. According to a standardized protocol, three endovascular surgeons experienced in aortic endograft planning, performed image analyses and data collection independently. We analyzed an internal assessment between observers (on the Aquarius 3DWS) and an external assessment comparing these results with the planning center (PC) data used to custom the fenestrated endograft of the patients enrolled in this study. Finally, we compared both 3DWS data to determine the accuracy and the reproducibility. A p-value < .05 was considered as statistically significant. Complete agreement between operators was defined as 1.0. RESULTS: Intra- and inter-observer variability (interclass correlation coefficients - ICC: 0.81-.091) was very low and confirmed the reliability of our planners. The ICC comparison between EA-AW and Aquarius was excellent (> 0.8 for both), thus confirming the reproducibility and reliability of the new EA-AW application. Aortic and iliac necks diameters and lengths were similarly reported with both workstations. In our study, the mean difference in distance and orientation evaluation of target vessels evaluated by the two workstations was marginal and has no impact on clinical practice in term of device manufacturing. CONCLUSIONS: We showed that complex EVAR planning can be performed with this new dedicated 3D workstation workflow with a good reproducibility.

[Epidemiology of osteoporotic hip fractures in the province of Zamora (1993)]. / Epidemiología de la fractura osteoporótica de cadera en la provincia de Zamora (1993).

BACKGROUND: To identify epidemiological aspects of the osteoporotic hip fractures (OHF) in the province of Zamora in 1993, and the basic and standardised accumulative incidence rates amongst the Spanish population. METHODS: 215 OHF cases were studied in the province throughout 1993, 203 were admitted to hospital, 188 of which were treated surgically by the Traumatology Department. The surveyed variables were: sex, age, location (rural, urban), type of (cervical, trochanteric) fracture, surgical procedure (partial prosthesis. Ender stems, others), seasonal factors and average hospital stay. RESULTS: Global accumulative incidence: 100.6 per 100,000 inhabitants. With respect to people over 50, the rate was 246.5 per 100,000 inhabitants (according to the 1991 census). Female predominance (3.78:1). Average age: 81.3 +/- 8.8 years. 50% distribution of fracture type, both at global and female level. Dual incidence of trochanteric fracture suffered by males. Average stay: 15.35 days. Standardised accumulative incidence according to age and sex for the Spanish population in 1991 would be 202.99 fractures per 100,000 inhabitants and year, which would result in a total number of 23,740 fractures per year. CONCLUSIONS: The province of Zamora currently has one of the highest rates of OHF in Spain, both with respect to overall population as well as people over 50 years of age. Average age, predominance of the female sex, distribution of the type of fracture and average hospital stay are similar to the figures published in our country.

Chronic dissection - indications for treatment with branched and fenestrated stent-grafts.

The treatment of chronic aortic dissection is a major challenge for the vascular surgeon. Close imaging follow-up after the acute episode frequently identifies dilation of untreated aortic segments. Aortic dissection often extends to both the supra-aortic trunks and to the visceral aorta. The poor medical condition that often characterizes these patients may preclude extensive open surgical repair. Recent advances in endovascular techniques provide a valid alternative to open surgery. These complex lesions can now be managed using thoracic branched and fenestrated endografts. However, clinical data are scarce and only 3 small series from 3 high-volume aortic centers are currently available. Careful anatomical study on 3D workstations is mandatory to select patients that are candidates for complex endovascular exclusion; a specific focus on the available working space within the true lumen, extension to the arch and/or the visceral/renal arteries, and false lumen perfusion of visceral vessels is required. An excellent understanding of those anatomic details demands high-quality preoperative CTA. Intraoperative advanced imaging applications are a major adjunct in the achievement of technical success.

Pathological gambling and hypersexuality due to dopaminergic treatment in Parkinson' disease.

INTRODUCTION: Prevalence of psychiatric disorders in patients suffering from Parkinson's disease varies from 12 to 90%. The most common disorder in the natural evolution of Parkinson's disease is depression. However, episodes of psychosis and hypomania are related to treatment with L-dopa and dopaminergic agents. Other recognized, although less frequent, psychiatric disorders are hypersexuality and development of certain addictive behaviors, which is compulsive gambling and overdosing of anti-Parkinson agents. CLINICAL CASE: A case is presented of a male patient diagnosed with Parkinson's Disease at an early age who was treated with L-dopa and a combination of dopaminergic agents. During the course of his evolution he manifested symptoms of hypersexuality and pathological gambling which were unrelated to psychotic or mood changes. CONCLUSIONS: A number of hospital admissions were needed into order to detect a pattern of abusive consumption of L-dopa as the main factor behind his behavior changes. The possibility of overdosage of L-dopa and dopaminergic drugs should be considered when there is pathological gambling conduct and/or hypersexuality, without psychotic or accompanying affective symptoms, in a male who develops Parkinson's disease at an early age and who undergoes treatment with these drugs and manifests motor fluctuations and dyskinesias. Early detection of the presence of these alterations, included within those described as "dopaminergic dysregulation syndrome", would allow for an early intervention on the cause behind them and would hence avoid the possible medical and social complications.

[Woolly hair nevus associated with an ipsilateral linear epidermal nevus]. / Nevus de pelo lanoso asociado a nevus epidérmico lineal ipsilateral.

We report a 4-year-old boy with two areas of woolly hair in the right parietotemporal region and a linear epidermal nevus in the areas of woolly hair as well as in the ipsilateral hemiface and chin. Evaluation by scanning electron microscopy showed woolly hair with oval transverse section and longitudinal groove. A complete examination ruled out associated anomalies.

[Teledermatology. Review of 917 teleconsults]. / Teledermatología. Revisión de 917 teleconsultas.

INTRODUCTION: Teledermatology is been currently introduced as a diagnostic tool in the daily practice of the dermatologist. Many published works regarding teleconsult show the high sensitivity and economic saving of this technique as a diagnostic method. MATERIAL AND METHODS: In this article we report our experience with nearly 1,000 teleconsults carried out in a period of two years, from October 2004 to October 2006. RESULTS: The majority of the 917 teleconsults performed were for benign lesions, notably seborrheic keratosis in 201 cases; among malignant lesions actinic keratosis appeared in 161 cases and melanoma was diagnosed in 5 cases. Fifty-eight percent of teleconsults have been arranged for a face-to-face consult in order to perform adequate treatment, in 90 % of cases, or to confirm diagnosis or carry out complementary exams, in 10 % of cases. CONCLUSION: The image is the gold standard for dermatological diagnosis. Currently, digital phototography gives us such a high image quality that, based on our experience, it can be stated that a neoplastic lesion that cannot be diagnosed by a high quality digital image with the available technology, rarely could be diagnosed in a face-to-face consult without the aid of complementary exams.

[Thyrotoxic periodic paralysis in a Spanish male]. / Parálisis periódica tirotóxica en un varón español.

One of the few cases of thyrotoxic periodic paralysis in our country is reported. A twenty-one year old male patient with Graves disease for more than three years had a poor compliance with the therapeutical regimen, with mainly nightly episodes of self-limited limb weakness associated with hypokalemia. The patient has no familiar antecedents of periodic paralysis and the clinical manifestations resolved with treatment of hyperthyroidism.