The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization.

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Common Femoral Artery Caliber Changes after Percutaneous versus Surgical Access in Endovascular Aneurysm Repair in the Asian Population.

BACKGROUND: Western studies showed vascular caliber changes post-endovascular aneurysm repair (EVAR). This study aims to evaluate for postoperative changes of the common femoral artery inner diameter (CFA ID) in the Asian population. METHODS: From January 2011 to June 2016, 202 patients who underwent EVAR were reviewed. CFA IDs were evaluated at 3 fixed levels on computed tomography (CT) aortograms. Preoperative and postoperative measurements were compared. Per-groin analysis was carried out after division into percutaneous access endovascular aneurysm repair (PEVAR) and surgical access endovascular aneurysm repair (SEVAR) groups. Independent sample t-test compared for differences in overall CFA ID changes between PEVAR and SEVAR groups. Paired sample t-test evaluated CFA ID changes in each group. P value < 0.05 was considered significant. RESULTS: One hundred and twenty patients were included, with 200 groins subsequently analyzed. The PEVAR and SEVAR groups have no significant demographic differences, except in sheath size and duration of CT aortogram follow-up. No significant differences in overall CFA ID changes comparing PEVAR and SEVAR groups (-0.12 ± 1.05 mm, -0.10 ± 0.81 mm, P = 0.36). No significant overall CFA ID changes in both PEVAR (7.92 ± 1.23 mm, 7.80 ± 1.38 mm, P = 0.34) and SEVAR groups (7.47 ± 1.44 mm, 7.36 ± 1.64 mm, P = 0.15). CONCLUSIONS: No significant differences in CFA caliber changes comparing PEVAR and SEVAR. No significant CFA caliber changes in either group.

Sequential Irreversible Electroporation for Locally Advanced Pancreatic Cancer.

Pancreatic cancer is a lethal disease, with locally advanced pancreatic cancer (LAPC) having a dismal prognosis. For patients with LAPC, gemcitabine-based regimens, with or without radiation, have long been the standard of care. Irreversible electroporation (IRE), a non-thermal ablative technique, may potentially prolong the survival of patients with LAPC. In this article, the authors present a case of LAPC of the uncinate process (biopsy proven pancreatic neuroendocrine carcinoma) with duodenal invasion. The patient had a combination of chemotherapy and radiation therapy but was found to have stable disease. He then underwent intra-operative IRE with cholecystectomy, Roux-en-Y gastrojejunostomy and hepaticojejunostomy. He subsequently underwent percutaneous IRE 13 months post open IRE. The patient also completed peptide receptor radionuclide therapy and has been started on Lanreotide. Following combination therapy, the pancreatic tumor showed significant reduction in size, with patient survival at 53 months post-diagnosis at the time of writing.

Irreversible electroporation of the pancreas - A decade on.

Irreversible electroporation (IRE) employs the use of an electric field to cause irreversible permeability of the cell membrane, inducing apoptosis. The use of IRE for locally advanced pancreatic cancer (LAPC) was first described in 2012. The crucial advantage of IRE compared with other devices employing thermal ablation is the safety around vital structures such as vessels and ducts. This makes it an attractive option for use in the pancreas due to the close proximity of multiple major vascular structures, biliary ducts, and adjacent gastrointestinal organs. Over the past decade, IRE has established itself as a useful treatment adjunct and may soon become the standard of care, particularly for LAPC. This article will explore the current evidence and provide a concise summary of pertinent issues, including patient selection, preoperative management, clinical outcomes, radiological response and future prospects of IRE in pancreatic cancer.

Utility of BeBack crossing catheter in fistula creation during percutaneous deep vein arterialization.

For patients with "no-option" chronic limb-threatening ischemia, a final attempt can be made for limb salvage in the form of percutaneous deep vein arterialization (pDVA). In the present study, we describe five cases of pDVA using a BeBack crossing catheter (Bentley InnoMed GmbH; previously, the GoBack crossing catheter; Upstream Peripheral Technologies). From November 2021 to July 2022, five patients underwent pDVA using the BeBack crossing catheter. The demographic data, procedural details, and patient outcomes were recorded. Successful vascular crossing was achieved in all five cases using the BeBack device. No surgical complications were encountered. The limb salvage rate was 60%, and the wound closure rate was 40%. No mortalities occurred during the follow-up period. The findings from the present study demonstrate that the use of the BeBack crossing catheter for pDVA is safe and feasible.

Impact of waiting time on hepatocellular carcinoma progression in patients undergoing curative tumour ablation.

BACKGROUND: A feared consequence to delay in oncological treatment includes disease progression. This study aims to evaluate the relationship between waiting time for ablative therapy in patients with hepatocellular carcinoma (HCC), and the outcomes of local tumour progression, or new HCC foci. METHODS: Between January 2011 to July 2017, 215 patients with HCC underwent ablative (microwave and radiofrequency) procedures. Demographic information, and duration between diagnosis on imaging and ablative procedure were recorded. Follow-up imaging data were analysed to assess for development of either new HCC, or local tumour progression. The median waiting time to ablative therapy was 42 days, hence, patients were separated into two groups: wait time <42 days versus wait time ≥42 days. Simple cox regression was conducted to explore the association between wait time and the clinical outcomes of new HCC or local tumour progression. Survival analyses for outcomes of new HCC or local tumour progression were also compared between the two groups using log-rank test. All the statistical analyses were two sided and P value of less than 0.05 was considered as statistically significant. RESULTS: Hazard ratio for local tumour progression was 1.002 (0.996, 1.007) P=0.579, while hazard ratio for new HCC foci was 1.002 (0.998, 1.005) P=0.373. There was no statistically significant difference when comparing the two groups (wait time <42 versus ≥42 days) for survival estimates for local tumour progression P=0.346, and for new HCC P=0.680. CONCLUSIONS: This study demonstrates that delay in HCC ablative therapy is not associated with significant risk of local tumour progression, or new HCC foci.

Single-Setting Superior Vena Cava Biopsy and Stenting Utilizing Cone Beam Computed Tomography as an Additional Tool.

BACKGROUND Malignant disease is a common etiology of superior vena cava syndrome (SVCS). Being a medical emergency, it often requires rapid diagnostic evaluation and therapy. Transcaval biopsy and endovascular stenting in a single-setting has been described, but only in a handful of cases. These cases utilized intra-operative venograms. In this study, we also used intra-operative cone beam computed tomography (CBCT) to increase the safety and efficacy of such single-setting procedures. CASE REPORT From January 2017 to July 2019, there were 5 patients with malignant SVCS who underwent single-setting superior vena cava biopsy and endovascular stenting utilizing intra-operative CBCT as an adjunct. Demographic data, clinical presentation, investigation results, procedural details, and patient outcomes were recorded. CBCT was utilized in all cases to optimize sampling of biopsies, visualize subsequent stent positioning, and for early detection of procedure-related complications. Transcaval biopsy was diagnostic in 4 of the 5 patients. Endovascular stents were deployed successfully in all cases, with post-stenting venogram demonstrating relief of prior obstructed segments. One patient had a complication of an apical pneumothorax, with no associated long-term pneumothorax-related morbidity or mortality. CONCLUSIONS This study demonstrates that single-setting transcaval biopsy and stenting in the context of malignant SVCS is a cost-efficient, safe, and feasible approach. In addition, the additional use of intra-operative CBCT is a useful tool to increase procedure efficacy and safety.

Coil Embolization of Arc of Buhler Aneurysm Rupture.

The arc of Buhler (AOB) is a rare anatomical variant. Rupture of an AOB aneurysm is exceedingly rare. In this study, we report a case of AOB aneurysm rupture, which was successfully treated by transcatheter coil embolization. A 74-year-old man presented with symptomatic AOB aneurysm rupture. A computed tomography scan and subsequent angiography revealed the aberrant connection between the common hepatic artery and the superior mesenteric artery. A fusiform AOB aneurysm with focus of active bleeding was detected. This was successfully treated through embolization and sacrifice of the AOB. This suggests that conventional embolization with sacrifice of AOB is a feasible and safe approach.

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

INTRODUCTION: This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury. METHODS: We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage. RESULTS: In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4). CONCLUSION: Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.