Exclusion of complex aortic aneurysm with chimney endovascular aortic repair is applicable in a minority of patients treated with fenestrated endografts.

OBJECTIVES: The Medtronic Endurant II stent graft has recently received Conformité Européenne (CE) approval for the use in chimney endovascular aortic repair (ChEVAR) for the treatment for juxtarenal aortic aneurysms. The aim of this study was to assess the percentage of patients treated by fenestrated endovascular repair who would have been alternatively suitable for the treatment by the CE approved Medtronic ChEVAR. METHODS: Preoperative computed tomography scans of 100 patients who underwent fenestrated endovascular aortic repair (FEVAR) between April 2013 and February 2017 were retrospectively assessed for the applicability of the ChEVAR technique according to the Medtronic instructions for use. Eligibility criteria included an aortic neck diameter of 19-30 mm, a minimum infrarenal neck length of 2 mm, a total proximal sealing zone of at least 15 mm, thrombus in the aortic neck in ˂25% of the circumference, and maximum aortic angulations of 60° in the infrarenal, 45° in the suprarenal segment and ˂45° above the superior mesenteric artery. RESULTS: According to CE-approved inclusion criteria, 19 individuals (19%) would have been eligible for ChEVAR. In 81 patients, at least 1 measure was found outside instructions for use: (i) excluding factor was detected in 26 patients, (ii) incongruous measures in 28 patients and in 27 patients, 3-5 measures were outside the instructions for use. The most frequently identified excluding factor was an insufficient infrarenal neck at ˂2 mm length (n = 63; 63%). CONCLUSIONS: Patients with juxta- or pararenal aneurysm treated by FEVAR are in 19% of the cases alternatively suitable for the treatment by ChEVAR within CE-approved instructions for use. While ChEVAR is suitable in many emergency cases, FEVAR offers a broader applicability in an elective setting.

Production and Comprehension of Prosodic Markers in Sign Language Imperatives.

In signed and spoken language sentences, imperative mood and the corresponding speech acts such as for instance, command, permission or advice, can be distinguished by morphosyntactic structures, but also solely by prosodic cues, which are the focus of this paper. These cues can express paralinguistic mental states or grammatical meaning, and we show that in American Sign Language (ASL), they also exhibit the function, scope, and alignment of prosodic, linguistic elements of sign languages. The production and comprehension of prosodic facial expressions and temporal patterns therefore can shed light on how cues are grammaticalized in sign languages. They can also be informative about the formal semantic and pragmatic properties of imperative types not only in ASL, but also more broadly. This paper includes three studies: one of production (Study 1) and two of comprehension (Studies 2 and 3). In Study 1, six prosodic cues are analyzed in production: temporal cues of sign and hold duration, and non-manual cues including tilts of the head, head nods, widening of the eyes, and presence of mouthings. Results of Study 1 show that neutral sentences and commands are well distinguished from each other and from other imperative speech acts via these prosodic cues alone; there is more limited differentiation among explanation, permission, and advice. The comprehension of these five speech acts is investigated in Deaf ASL signers in Study 2, and in three additional groups in Study 3: Deaf signers of German Sign Language (DGS), hearing non-signers from the United States, and hearing non-signers from Germany. Results of Studies 2 and 3 show that the ASL group performs significantly better than the other 3 groups and that all groups perform above chance for all meaning types in comprehension. Language-specific knowledge, therefore, has a significant effect on identifying imperatives based on targeted cues. Command has the most cues associated with it and is the most accurately identified imperative type across groups-indicating, we suggest, its special status as the strongest imperative in terms of addressing the speaker's goals. Our findings support the view that the cues are accessible in their content across groups, but that their language-particular combinatorial possibilities and distribution within sentences provide an advantage to ASL signers in comprehension and attest to their prosodic status.