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Venous fenestrations are rare and when present often are not pierced by regional nerves. Herein, we report an unusual case of a fenestrated superficial temporal vein (STV). Anterior to the external ear, where the STV and superficial temporal artery normally travel with the auriculotemporal nerve (ATN), the nerve was found to pierce the STV. The fenestration within the STV was approximately 0.35mm in diameter, and there was no sign of compression of the ATN as it traversed this vessel. Following the site of penetration of the STV by the ATN, the nerve had a normal course into the skin and surrounding fascia. To our knowledge, this is the first report of a fenestrated STV being pierced by the ATN. Such an anatomical variation might be considered by clinicians who treat patients with pathology of this region.

Objectives This study aimed to determine the correlation between alveolar cleft volume and fenestration and dehiscence in the adjacent alveolar bone in patients with unilateral cleft lip and palate (UCLP) using cone-beam computed tomography (CBCT) sections. Materials and methods In this descriptive, cross-sectional study, CBCT scans of 68 non-syndromic patients with UCLP aged between 6 and14 years were selected. All patients were treated in Iran and had undergone lip and palate repair surgery within the first 3 to 18 months after birth. CBCT scans had been taken after orthodontic expansion and prior to alveolar bone grafting surgery. Cleft volume, fenestration and dehiscence were assessed using Mimics software. Data were analyzed using independent t-test, Kruskal-Wallis test, Spearman's correlation coefficient and logistic regression model. Results The mean alveolar cleft volume was 628.66±172.84 mm3. There was a significant negative correlation between cleft volume and fenestration (P Conclusion The Mimics software can be successfully used to estimate the cleft volume prior to surgical procedures in UCLP patients. The results suggest that the alveolar cleft volume can be used as an aid to assess the periodontal condition of adjacent teeth. The cleft volume has a negative and positive correlation with fenestration and dehiscence respectively.

Impact of target visceral vessel anatomical configuration on early complicatins following endovascular repair of thoracoabdominal aortic aneurysms Objectives: Fenestrated and branched endovascular aortic repair (fEVAR-bEVAR) is a viable treatment option for thoracoabdominal aortic aneurysms but target visceral stent (TVS) endoleak and thrombosis remain a limiting factor. This study aims to evaluate TVS anatomy impact on one-year risk of thrombosis and endoleak. Methods: Patients treated with fEVAR-bEVAR for thoracoabdominal aneurysms between 2008-2020 in our centre were enrolled. We recorded comorbidities, operative details, one-month postoperative CT scan (anatomical reference), and TVS behaviour: thrombosis and endoleak at one-year follow-up. For each TVS, different points were identified using a centre-lumen-line: (A) TVS origin, (B) end of branch/fenestration, (C) visceral vessel entry, (D) end of TVS, (E) 1-cm distally. We analyzed TVS tortuosity ((centre-lumen-line/straight distance)-1, in %), image vector analysis of each segment in 2D (antero-posterior, left-right) and 3D (craneo-caudal displacement), and centre-lumen-line analysis (bending in ABC and CDE). Three independent observers performed a blind analysis, and anatomical differences between bEVAR/fEVAR, and cases with/without 1-year thrombosis and TVS endoleak, were compared using Kaplan-Meier curves (Log-Rank test), and T-Test/Wilcoxon signed-ranks test respectively. Results: 54 patients (72±713 years mean age; 182 TVS: 50 branches, 132 fenestrations) met the inclusion criteria. bEVAR cases had longer stents, with more caudal 3D angulation and greater ABC angulated segment. After excluding bEVAR cases (low case number), 97 fEVAR TVS were analyzed. Five thrombosis and seven endoleaks were observed. While anatomical configuration showed no association to thrombosis, it was related to endoleak: these cases presented more tortuous stents (5.97%±0.10, 21.40%±0,22, P=.011), with more angulated centre-lumen-line at ABC segment (5.69°±15.77°, 7.18°±7.77°, P=.012), and more upward-pointing stents in the origin of the stent (AB: 89.07°±24.46°, 109.09°±16.56°, P=.012; BC: 87.86°±21.10°, 113.11°±22.23°, P=.026). Conclusions: Anatomical configuration of the TVS is associated with stent type I-III endoleak, but not thrombosis, at one-year following fEVAR. Cases with endoleak presented more tortuous stents, with a more angulated exit from the endograft and upward-pointing of the origin of the stent.

Introduction Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch pathology provides a less-invasive treatment option for high-risk patients ineligible for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the mid-term outcomes after Zone 0 and Zone 1 TEVAR and describe the associated technical costs, revenues, and net margins at a single tertiary medical center. Methods We examined all patients who underwent TEVAR between April 2011 and August 2019 via retrospective chart review. Patients were categorized by proximal endograft extent to identify Zone 0 or Zone 1 repairs. Procedural characteristics and outcomes were described. Technical costs, revenues, and margins were obtained from the hospital finance department. Results We identified 10 patients (6 Zone 0, 4 Zone 1) who were denied open arch reconstruction. Patients were predominantly female (n=8; 80%) and the mean age was 72.8±5.5 years. TEVAR was performed in 5 asymptomatic patients, urgently in 3 symptomatic patients, and emergently in 2 ruptured patients. TEVAR plus extra-anatomic bypass was performed in 4 patients. Another 4 patients also received parallel stent-grafting while one patient received a branched thoracic endograft and yet another an in-situ laser fenestration followed by branch stent grafting. Within the 30-day postoperative period, 1 patient experienced stroke and 1 patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean 19.3 months). Mean total technical cost associated with all procedures or repair stages was $105,164±$59,338 while mean net technical margin was -$25,055±$18,746. The net technical margin was negative for 9 patients. Conclusions Endovascular repair of the proximal aortic arch is associated with good mid-term outcomes in patients considered too high-risk for open repair. However, reimbursement does not adequately cover treatment cost, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to both optimize aortic arch TEVAR delivery as well as advocate for reimbursement commensurate with associated costs.

Background: Lymphocele is a common complication after kidney transplantation, which does not require treatment unless it is symptomatic. In this study, we aimed to evaluate the incidence, clinical symptoms, treatment choices, and success of different treatment methods of symptomatic lymphocele. Materials and Methods: We evaluated 168 patients who had kidney transplantation between January 2012 and January 2020. Patients with decreased kidney functions due to lymphocele formation during the clinical follow-up were included in the study. External drainage catheter was placed in all patients, except one. In case of treatment failure with external drainage, laparoscopic fenestration guided by intraperitoneal ultrasonography was performed. Clinical symptoms and success rates of treatments were evaluated. Results: Symptomatic lymphocele requiring interventional treatment was detected in 15 (8.9%) of 168 renal transplant patients. All of the symptomatic lymphocele cases had increased serum creatinine levels, whereas 10 had decreased urine volume, 4 had abdominal discomfort, and 2 had ipsilateral lower extremity edema. External drainage catheter was placed as the first-line treatment in 13 patients. In 6 cases, due to treatment failure with external drainage and in 2 patients as a first-choice treatment, laparoscopic fenestration was performed. No lymphocele recurrence was observed during follow-up. Conclusion: Among various methods defined in the treatment of lymphocele, use of laparoscopic fenestration is increasing because of its high success rate and advantages over other methods. Intraperitoneal ultrasound-guided laparoscopic fenestration is a useful and safe method that can be performed as a first-choice treatment since it eliminates the risk of organ injury or bleeding.

Acute type A aortic dissection is a surgical emergency associated with high mortality and morbidity. When complicated with mesenteric malperfusion, its management carries a very high mortality. Many innovations in the field of vascular and cardiothoracic surgery in the last two decades have been tried in the continuous efforts to improve on the surgical outcomes. Although some reports have documented better mortality rates with reperfusion-first strategies, there is still room for improvement in the absence of a general consensus on its management.

This report describes a single center experience with laser fenestration of the inferior vena cava for the treatment of type 2 endoleak after endovascular abdominal aortic aneurysm repair. Our technique is reviewed, and clinical data after treatment are reported. Twelve patients underwent transcaval embolization via laser fenestration. Technical success was achieved in all cases (100%) with no postoperative complications. At a median follow-up of 12.9 months, no patient demonstrated a persistent endoleak and there were no cases of aortocaval fistula. Transcaval embolization, via laser fenestration, provides an additional strategy for the management of type 2 endoleak after endovascular abdominal aortic aneurysm repair.

Background For completely impacted teeth, it is of great significance to locate teeth accurately, preserve hard tissue and recovering the height of alveolar ridge. This can be effectively solved by the digital three-dimensional printing guide technology. Methods Ten patients with completely impacted tooth were selected in this experiment. After cone-beam computed tomography scan, the dicom formal computed tomography data was analyzed for three-dimensional reconstruction by mimics 17.0 software. Then determining the surgical plan and making surgical guide plate. Three-dimensional printing guide plate assisted piezosurgery was used to remove bone and extract impacted teeth. After that, the removed bone cap was back to the original position. Cone-beam computed tomography was used for each operated patients after 1 week and 6 months. Result The surgical guide plates can locate teeth accurately and the surgery time was reduced for all patients. A week later, all patients healed well and removed the stitches on time. Cone-beam computed tomography showed that the retention of bone caps was good and there was no displacement. All patients showed a normal parameter of pain. Six months later, cone-beam computed tomography showed good bone formation in the extraction area, which filled with new bones completely. The recovery of bone outline and height of alveolar crest at the surgical site were basically consistent with those before the operation. Conclusions Three-dimensional printing guide plates combining with fenestration and bone-cap restoration can locate impacted teeth accurately, reduce the extraction volume of bone, shorten surgery time, and alleviate complications. This was conducive to preserve and restore hard tissue and had great prospective.

This study is designed to know the effect of fenestration on the epiphyseal plate as amethod to truma and know it is effect on length of long bones Eleven of local breed bitched is used in this research are put in four group depending on the site of operation , tthree dogs in each group except for the last group which included tow dogs as follows: *the first group : the operation was performed on the distal epiphyseal plate of the femur *the second group : the operation was performed on the proximal epiphyseal plate of the tibia and fibula *the thrid group : the operation was performed on the distal epiphyseal plate of the tibia and fibula *the fourth group : the operation was performed on all sites mentioned above the cases was folowed up clinically and radiographically for six months , an x-Ray film was taken every fifteen days for the first three months and monthly for the other three months, the other hind limb of the animal was used for comparison. the clinical and radiographical follow up showed that fenestration of the epiphyseal platewas succssful to induce epiphysiodesis in first, third and fourth group without complication while it failed in the second group.

Background To evaluate the quality of in vitro fenestrations during in situ fenestration (ISF) and investigate the differences between needle and laser puncture in current stent-grafts. Methods An in vitro study evaluated the damage created by needle ISF on stent-graft fabrics versus laser ISF. Fenestrations were made in 5 different commercially available stent-grafts, including polyester stent-grafts (Relay, Valiant and Hercules) and expanded polytetrafluoroethylene (ePTFE) stent-grafts (TAG and Ankura). Each stent-graft received fenestration by needle and laser separately, followed by gradual dilation (4 mm, 6 mm, 8 mm, and 10 mm sequentially) of noncompliant balloons. Quantitative and qualitative evaluations including fenestration diameter, area, shape and margins were conducted using light microscopy and scanning electron microscope. Results The primary fenestrations created by needle were slit-like with visible cut-off fibers in polyester stent-grafts and were almost circular with clear margins in ePTFE stent-grafts; those created by laser were squared or elliptical with ragged edges and burned fibers in all the stent-grafts. Fabric debris and toxic particles due to burning of the material were generated during laser-assisted fenestration. The Primary holes in polyester stent-grafts (Relay, Valiant and Hercules) by needle showed smaller area (0.05 mm2 vs. 0.22 mm2, 0.52 mm2 vs. 0.70 mm2 and 0.28 mm2 vs. 0.46 mm2; P 0.05). Ankura stent-graft showed the largest holes with best quality than the others. Conclusions The primary fenestrations were different between needle and laser puncture, laser induced fabric debris and toxic particles release should be cautiously considered. The final fenestrations were similar after gradual balloon dilation.

In performing laparoscopic deroofing (LD) of liver cysts, indocyanine green (ICG) fluorescent imaging is particularly useful for delineating adequate margins for the procedure and for avoiding duct injuries. However, the optimal timing of ICG injection has not yet been clarified. Herein, we describe a patient who had a large liver cyst, in whom safe and efficient LD was performed under sharp fluorescent imaging obtained by intravenous injection of ICG 1 hour before cyst fenestration.

The article presents a clinical case of the simultaneous execution of endoscopic ventriculocisternostomy of the third ventricle floor (ETV), aqueductoplasty, fenestration of the supracerebellar cyst in occlusive hydrocephalus using a semi-rigid needle neuroendoscope. The authors describe a child who, at the age of 1 month, was admitted to Neurosurgical Department No. 1 of the Federal Center for Neurosurgery of the Ministry of Health of the Russian Federation in Tyumen with a diagnosis of congenital internal occlusive hydrocephalus, subcompensated course. MRI scan of the brain: triventricular occlusive asymmetric hydrocephalus is visualized, adhesions in the upper parts of the aqueduct, supracerebellar arachnoid cyst were visualised. ETV, aqueductoplasty, fenestration of the supracerebellar cyst were performed. There were no postoperative neurological, endocrine and infectious complications. The observation period after surgery is 7 years from today. Conclusion: preoperative MRI analysis of the structures of the third ventricular floor, interventricular and prepontine cisterns is important for understanding endoscopic, microsurgical anatomy and surgical planning. The use of modern improved endoscopic instruments, low-traumatic performance of all stages of the operation allow to restore cerebrospinal fluid circulation and achieve high efficiency in the treatment of occlusive hydrocephalus in the long-term period. This, in turn, relieves patients of the shunt-dependent state, constant correction of the dysfunctions of the shunt system and long-term, and often ineffective, treatment performed by neurologists and pediatricians.

OBJECTIVE To evaluate the audiologic outcomes of microdrill fenestration for obliterative otosclerosis compared to traditional stapedotomy technique. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Adult patients undergoing stapedotomy for otosclerosis. MAIN OUTCOME MEASURES Patients were separated into groups that underwent either microdrill or laser fenestration based on intraoperative severity of disease. Audiologic outcomes and complications were compared between the two groups. RESULTS There were 588 ears in 519 patients that were evaluated. There was a significant postoperative improvement in pure tone average, air-bone gap, and mean bone conduction thresholds for both the obliterative and nonobliterative group (p

Zusammenfassung Hintergrund Die enge anatomische Beziehung zu den Viszeralgefäßen macht die Behandlung der komplexen thorakoabdominellen Aortenpathologien zu einer Herausforderung. Im Notfall stehen zu ihrer endovaskulären Behandlung Off-the-Shelf-Prothesen und parallele Techniken zur Verfügung, alternativ kann für komplexe Aortenanatomien die Modifizierung herkömmlicher Stentgrafts durch die behandelnden Chirurginnen und Chirurgen erfolgen, im Sinne eines Surgeon-modified Stentgrafts (SMSG). Ziel der vorliegenden Publikation ist die Darstellung der Möglichkeiten und Ergebnisse, die dieses Verfahren bietet. Ergebnisse Die Planung der Fenestrierungen des SMSG kann mittels manueller Messungen in Centerline of Flow-Rekonstruktionen der aortalen Computertomografie-Angiografie erfolgen. Vereinfacht und standardisiert wird die Planung des SMSG durch die Erstellung von personalisierten 3-D-Aortenmodellen und die Entwicklung von Algorithmen zur automatisierten Ermittlung der idealen Fenestrierungspositionen. Zur Herstellung des SMSG können die meisten zugelassenen Stentgrafts verwendet werden. Für die Anfertigung selbst sind unterschiedliche Techniken beschrieben. Außer der einfachen Fenestrierung ist auch die Erstellung von Mini-Cuffs, Directional Branches und Inner Branches beschrieben, weiterhin die Ergänzung von Diameter reducing Ties und das Vorladen von Führungsdrähten zur Erleichterung der Implantation. Die Behandlung mit SMSG zeigt gute Ergebnisse mit hohen technischen Erfolgsraten um 90–100% und niedriger 30-Tage-Mortalität, vor allem im Vergleich zur offen-chirurgischen Behandlung ähnlicher PatientInnen. Auch die Rate an Endoleaks ist mit 0–14% akzeptabel. Langzeitergebnisse zur Nachhaltigkeit der modifizierten Stentgrafts sind bislang noch nicht verfügbar. Schlussfolgerung Die Surgeon-modified Stentgrafts stellen eine sichere und machbare Ergänzung der Palette endovaskulärer Behandlungsoptionen für PatientInnen mit dringlichen komplexen thorakoabdominellen Aortenpathologien dar. Sie können im Rahmen eines individuellen Heilversuches eingesetzt werden und zeigen in der Literatur vielversprechende Ergebnisse.

Background The aim of this study was to evaluate the safety, applicability and outcomes of the endovascular in situ fenestration (ISF) technique for patients with aortic arch pathologies by performing a systematic review. Methods We conducted a systematic search using the PubMed, Embase, and Cochrane databases to identify English language articles between January 2004 and March 2019 on the management of aortic arch pathologies using an in situ fenestration technique. Two independent observers selected studies for inclusion in the study, assessed the methodological quality of the included studies, and extracted the data. The studies included all investigated the clinical outcomes and postprocedural complications of using ISF techniques. Results Seven studies reported on a total of 117 aortic arch pathologies patients. Including 52 dissection patients, 47 aneurysm patients, 18 intramural hematomas and penetrating ulcers patients. Needle fenestration and laser fenestration were performed in 62 and 45 patients respectively, and the rest 10 patients received radiofrequency fenestration. The follow-up period ranged from 1 to 55 months. The pooled technical success rates were 94% (95% confidence interval [CI]: 79–98%). The stroke rate was 6% (95% CI: 3–13%). The 30-day MAE was 11% (95% CI: 6–18%). Conclusion The results of the study showed that using the in-situ fenestration technique for treating patients with aortic arch pathologies produced encouraging mid-outcomes. Long-term outcomes remain undefined.

Alba Ramírez-Sarmiento,1– 3 Orlando Aya,3,4 Diana Cáceres-Rivera,1,2 Carlos F Reyes,2– 4 Angela Espitia,1,2 Camilo Pizarro,3,4 Joaquim Gea,5,6 Victor R Castillo,7,8 Mauricio Orozco-Levi1– 3,6 1Respiratory Department, Instituto Cardiovascular y Hospital Internacional de Colombia, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 2EMICON Research Group MINCIENCIAS, Bogotá, Cundinamarca, Colombia; 3Universidad de Santander (UDES), Bucaramanga, Santander, Colombia; 4Department of Critical Care, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 5Respiratory Department, Parc de Salut Mar, Barcelona, Catalonia, Spain; 6CEXS-Universidad Pompeu Fabra, Barcelona, Catalonia, Spain; 7Department of Cardiovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 8Biomedical and Translational Research Group, Fundación Cardiovascular de Colombia, Floridablanca, Santander, ColombiaCorrespondence: Mauricio Orozco-LeviRespiratory Department, ICV-HIC, Fundación Cardiovascular de Colombia, Calle 155a no. 23-58, El Bosque, Floridablanca, Santander, ColombiaTel +57 3175741421Email mauricioorozco@fcv.orgBackground: Bronchoaspiration of content that accumulates in the supraglottic area (eg, saliva, gastroesophageal reflux) is a risk factor for ventilator-associated pneumonia. A continuous supraglottic suction system may decrease the risk of bronchoaspiration in these patients.Objective: (1) Constructing a conceptual model and functional prototype of a continuous supraglottic suction device for use in humans; (2) defining functional characteristics in ex vivo swine head models; and (3) evaluating its efficacy and safety in mechanically ventilated patients.Methods: Study conducted in three phases. First phase: definition of distances and diameters of the triangle determined by dental arch, posterior oropharynx and vallecula, and diameter of the oropharynx in axial projection; and identification of the declining area of supraglottic suction. Second phase: design engineering and functional prototype evaluated in ex vivo models. Third phase: evaluation of device use in terms of safety and efficacy in ventilated patients.Results: We obtained a final functional model of the SUPRAtube device injected into PVC for medical use. Device effectiveness in in vitro simulation showed a high and fast suction capacity of liquid and thick volumes. Study of swine heads allowed to validate the shape, size and functional fenestration of the device. Study in intubated and mechanically ventilated patients showed a high supraglottic suction capacity and the absence of local adverse events during 72 (7– 240) hours of continuous operation.Conclusion: Our study describes the process of conceptualization, design and production of a practical, safe, low-cost continuous supraglottic suction device without representing antibiotic pressure, which appears to be a new complementary preventive strategy for the standard management of intubated and mechanically ventilated patients.Keywords: mechanical ventilation, bronchoaspiration, supraglottic suction, SUPRAtube, endotracheal tube, gastroesophageal reflux

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bail-out maneuvers are sparse in the literature. Herein, we describe seven patients with errant endoprosthesis re-routed with minimally invasive intervention into the true lumen.

We previously described a transfemoral antegrade in situ laser fenestration technique (in situ fenestrated endovascular abdominal aortic aneurysm repair) for ruptured thoracoabdominal aortic aneurysms. In the present report, we have described an alternative technique of caudally directed in situ fenestrated endografts using upper extremity access for branch vessel incorporation. This technique involves partial deployment of the aortic stent graft in the thoracic aorta to achieve proximal control, followed by sequential branch incorporation using a laser probe through a steerable sheath, from the upper extremity access. The advantages of the technique include rapid proximal aortic control before branch incorporation without target vessel prestenting and separation of in situ fenestration from the target branch vessel origin, facilitating cannulation of angulated branch vessels.

Background In people with a Fontan circulation, serial cardiopulmonary exercise testing (CPET) to evaluate change in peak exercise capacity has been increasingly recognised as a useful prognostic tool; a decline is associated with adverse clinical outcomes. The aim of this study is to describe the “natural” history of exercise capacity in the Australian and New Zealand (ANZ) Fontan cohort and to identify factors associated with a decline. Methods The ANZ Fontan registry was retrospectively reviewed for adolescent and adult patients (≥16 years) with serial CPET results performed on a cycle ergometer ≥6 months apart. Patients were excluded if they underwent a surgical procedure or fenestration closure in-between tests or if the tests were considered as submaximal effort. Exercise capacity trajectory was defined as the change in percentage of predicted peak oxygen uptake (% pred VO2peak) points per year. Results Thirty-seven (37) patients (59.5% male, mean age 24±7 years) were eligible. Average duration between CPET was 5.3±3.9 years. At baseline, % pred VO2peak was 61.3±14.5%. Thirteen (13) (35%) had a systemic right ventricle, and 14 (38%) had an atriopulmonary type Fontan circulation. Average change in % pred VO2peak overall was +1.3±6.4 percentage points per year. Sixteen (16) had a negative exercise capacity trajectory, and the average decline in that group was −2.7±3.4 percentage points per year. There was no association between exercise capacity trajectory and clinical characteristics. Of the 18 patients with physical activity levels recorded, 12 (67%) were physically active and % pred VO2peak in that group increased by 2.7±4.0 percentage points per year compared with the physically inactive group who fell by 0.5±0.8 percentage points per year. Conclusions In this ANZ series of Fontan patients, over half of our cohort had stable, or an increase, in peak exercise capacity. Regular participation in physical activity was common in patients with a positive exercise capacity trajectory. Clinical characteristics were not associated with exercise capacity trajectory.

Using entry and re-entry analysis we report a simple technique designed to solely manage the fenestrations in an aortic aneurysm caused by chronic type A or B dissections. With meticulous computed tomography mapping of each fenestration, endovascular management can be customized to those areas only. Several cases are presented using this selective approach resulting in durable thrombosis of the false lumen. Targeted coverage of fenestrations in a chronic type B dissecting aneurysm is a feasible and effective management option resulting in reliable false lumen occlusion whilst maintaining visceral perfusion.

Fenestration transcatheter closure is widely considered to eliminate persistent right-to-left shunt after Fontan surgeries. Three consecutive children with stage III-palliated univentricular hearts recently underwent successful endovascular fenestration closure using 43 mm/Large Optimus-CVS™ that were implanted using the new Altosa-XL™ PTA balloon catheters (AndraTec GmbH). The procedure was fast with no complication and patients were discharged the following day with complete shunt closure. One-month follow-up confirmed excellent outcomes. This report aims to highlight and discuss the competitive advantages of these promising new materials in this particular intervention.

Objectives This study evaluated the feasibility and safety of total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft on zone 0 landing for aortic arch pathologies. Methods Between June 2016 and October 2019, 37 consecutive patients underwent total endovascular arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and branch artery patency. Results During the study period, 37 patients were treated with total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft. Twenty-one (56.8%) patients were diagnosed with aortic dissections, 15 (40.5%) patients with aneurysms, and 1 (2.7%) patient required reintervention due to endoleak and sac expansion from previous thoracic endovascular aortic repair for thoracoabdominal aneurysm. The proximal landing zone for all patients were in zone 0, and all branch arteries of aortic arch were reconstructed. Technical success was achieved in 34 cases (91.9%). Three (8.1%) patients had fenestrations misaligned with target arteries, and the chimney technique was applied as a complementary measure. Thirty-day mortality rate was 5.4% (n=2). Thirty-day stroke rate was 5.4% (n=2). Thirty-day reintervention rate was 2.7% (n=1). At a median follow-up of 20 months (range, 3–49 months), 5 (13.5%) patients died, including 2 aortic-related deaths, 1 nonaortic-related death, and 2 deaths of unknown reason. One (2.7%) patient had stroke. Four patients (10.8%) had reintervention during the follow-up, including 2 cases of left subclavian artery occlusion and 2 cases of type II endoleak. The estimated survival (±SE) at 2 years was 72.4%±9.7% (95% CI 53.4%–91.4%). The estimated freedom from reintervention (±SE) at 2 years was 87.4%±5.9% (95% CI 75.84%–98.96%). Conclusions Total endovascular aortic arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing is an alternate option for the treatment of aortic arch pathologies in experienced centers.

OBJECTIVE Hallux sesamoid injuries are well described and can be debilitating and chronically disabling. The role of orthobiologics such as platelet-rich plasma (PRP) in sesamoid injuries has not been reported. This study describes three cases of recalcitrant hallux sesamoid injuries in teenage athletes who returned to impact activities, pain free, following one treatment of PRP. METHODS This is a case-series study describing three teenage athletes presenting to a tertiary level pediatric sports medicine practice with chronic hallux sesamoid injuries. RESULTS The three patients (two female, one male) described in this case series were 13-, 16-, and 17-year-old athletes. Their primary sports were ballet, basketball, and Irish step dance, respectively. All three athletes received PRP: two received unilateral treatment (one tibial sesamoid, one fibular sesamoid) and one received treatment to bilateral tibial sesamoids. The average duration of symptoms prior to PRP was 52.5 weeks (14-128 weeks). The average time out of their primary sport was 48.7 weeks (20-78 weeks). Three of the 4 sesamoids treated with PRP were tibial sesamoids. Each site of injury was treated with one treatment of leukocyte-rich PRP. All three athletes were cleared to return to impact activities such as running and jumping at 6-9 weeks following PRP, specifically 9 weeks after the final PRP injection for the patient who underwent bilateral treatments. CONCLUSION In the three cases provided of sesamoid injuries treated with PRP, the time to return to impact activities was less than reported for athletes not treated with PRP. Acknowledging that other management factors likely contributed to return to impact activities, this case series sets the groundwork for future research investigating the role of PRP with needle fenestration in the treatment of sesamoid injuries.

Objective Intervertebral disc fenestration has been shown to reduce the risk of extrusion in the thoracolumbar region in dogs, but use of the technique varies between individual neurologists and surgeons. Our aim was to investigate opinions and practices regarding disc fenestration amongst those involved in neurosurgery in dogs. Study Design A web-based survey containing questions relating to the use of fenestration during treatment of intervertebral disc extrusion in dogs was distributed to board-certified neurologists and surgeons. Results were analysed using Microsoft Excel. Results There were 323 responses from 190 neurologists and 133 surgeons. Seventy-one per cent of respondents routinely used concurrent disc fenestration when performing decompressive surgery in the thoracolumbar region, although the rate was lower amongst surgeons (55%) than neurologists (82%). Only 25% of respondents performed concurrent fenestration in the cervical spine. Forty-five per cent of respondents reported having experienced complications, with haemorrhage being the most common. Conclusion Fenestration is widely used in the management of thoracolumbar intervertebral disc extrusion, but a universally accepted approach does not exist, and differences are seen between neurologists and surgeons.

Neurenteric cysts (NCs) are rare benign congenital neoplasms in the central nervous system that originate from endodermal elements. NCs are more commonly located in the spine than in the brain. Although almost all intracranial NCs are found in the posterior fossa, some have reported supratentorial NCs. The complete excision of the cyst wall is suggested as a curative treatment; however, endoscopic treatment is less discussed. We present a supratentorial intraparenchymal NC in the frontal lobe treated by neuroendoscopic fenestration and review the literature regarding supratentorial NCs. A 43-year-old woman presenting with right hemiparesis and gait disturbance who was found to have a huge cystic lesion with calcification in her left frontal lobe underwent endoscopic fenestration to the ipsilateral lateral ventricle and biopsy. The histopathological diagnosis was consistent with NC. Postoperatively, her right hemiparesis and gait disturbance disappeared. Postoperative MRI showed shrinkage of the cyst. She was discharged without neurological deficits and no recurrence was seen 1 year after surgery. To the best of our knowledge, there have been no reports of a supratentorial intraparenchymal NC treated by neuroendoscopic fenestration. Minimally invasive treatments, such as neuroendoscopic cyst fenestration, can be considered depending on the location of the cyst.

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

We describe a case of frozen elephant trunk deployment unintentionally malpositioned into the false lumen. An 83-year-old man underwent total arch repair with a frozen elephant trunk for type A acute aortic dissection complicated by mesenteric malperfusion. However, intraoperative transesophageal echocardiography showed expansion of the false lumen in the descending aorta, suggesting a malpositioned frozen elephant trunk into the false lumen. Endovascular fenestration of the dissecting flap and subsequent endograft deployment from the inside of the malpositioned frozen elephant trunk graft to the true lumen of the descending aorta was successfully performed under intravascular ultrasound guidance.

The irregular reflection and transmission properties of innovative fenestration allow the redirection, selectively admittance, or blocking of solar irradiation based on its incident direction. Compared to systems that implement adaptivity by mechanical transformations, such tailored light scattering reduces the complexity of installation, operation, and maintenance as well as the impact on outward view and the aesthetical appearance of buildings. Examples of such fenestration techniques (e.g., light redirecting films and Venetian blinds featuring irregular reflection properties) are presented with their gonio-photometrically measured scattering properties. Techniques to model optically complex fenestration to support product development and planning are presented. Effects on daylight availability, glare, and solar gains are demonstrated. Preliminary results indicate the potential to control and modulate rather than to block irradiation through the design of buildings aiming at high comfort and energy efficiency.

Ebstein’s anomaly is a rare congenital malformation of the right ventricle and tricuspid valve which is characterized by several features that can exhibit an infinite spectrum of malformation.The abnormalities include: i) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamination); ii) anterior and apical rotational displacement of the functional tricuspid annulus (septal > posterior > anterior leaflet); iii) dilatation of the right atrioventricular junction (the true tricuspid annulus) with variable degrees of hypertrophy and thinning of the wall; iv) dilatation of the “atrialized” portion of the right ventricle; and v) redundancy, fenestration, and tethering of the anterior leaflet.

This cone beam computed tomography (CBCT) study aimed to assess the root fenestration (RF) frequency in healthy, intact teeth and analyse their features in a Greek subpopulation. 432 CBCT scans were examined. 5486 teeth were evaluated for RF prevalence. RF prevalence and distribution were recorded for each jaw, tooth group, as well as patient age and sex. RF symmetry, distribution to the affected root surface and the effects of age and sex were evaluated. The prevalence of RF ranged from 0.57% (central incisors) to 7.18% (first premolars) and from 0.48% (second premolars) to 10.79% (lateral incisors) for the maxilla and the mandible, respectively. No symmetrical occurrence of RF was detected. Most RF patients presented one or two defects in both jaws. Types I and IV were the most prevalent in the maxilla, while Types III, II and V were the most prevalent in the mandible. No statistical difference was detected between different sexes and age groups (P > 0.05).

Objectives To investigate the effectiveness of modified stent-grafts (SGs) for the management of ascending aortic pathologies. Materials and Methods From January 2015 to December 2019, 31 individuals were treated by ascending aortic endovascular repair with a back-table modified SG for acute (n=4) or chronic (n=1) type A aortic dissections, penetrating aortic ulcers (n=18), pseudoaneurysms (n=2), anastomotic fistula (n=1), and endoleaks after thoracic endovascular aortic repair (TEVAR) (n=5). The commercially available thoracic aortic SGs were modified with a fenestration or truncation technique on the back-table according to aortography during the operation. Results The 30-day mortality and aorta-related mortality rates were 12.9% and 6.5%, respectively. There were 2 strokes, 3 respiratory insufficiencies, and 6 endoleaks during hospitalization. During a mean follow-up of 28.8±16.6 months, the overall survival rates at 1 year and 3 years were both 80.6%. Free from adverse event rates at 1 year and 3 years were 88.9% and 84.7%, respectively. There were 2 deaths during follow-up: One patient died of cachexia 1 month after discharge, and the other patient died of acute myocardial infarction 3 months after discharge. One patient with a pseudoaneurysm underwent open ascending aorta replacement 3 months after discharge for a type Ia endoleak. Another patient suffered from cerebellar infarction 17 months after discharge. Conclusion The modified SG for endovascular repair of the ascending aorta is a practicable alternative and presents acceptable outcomes in high-risk patients.

Background/aim The aim of this study is to present our experience on various endovascular treatment modalities of basilar fenestration aneurysms and to review our findings along with the literature data. Materials and methods A total of 24 patients with 26 BAF aneurysms who have admitted to our clinics were endovascularly treated, and two centers were used for this purpose. All patients were evaluated with computed tomography (CT), CT angiography (CTA) and digital subtraction angio graphy (DSA) before the procedure. Results Whole aneurysms were successfully occluded with 100 per cent rate of technical success. Procedure-related complications were encountered in two patients. Our comprehensive literature research has revealed that most of the papers related with the topic were case reports. In the literature, it has been reported from 46 studies that 101 patients with 113 BAF aneurysms were endovascularly treated between years 1993 and 2019. The overall positive outcome, clinical success, and the complication rate values of the studies in the literature were 97, 91 and 8.8 percent, respectively, whereas these values were 100%, 92% and 7.6% in our study. Conclusions Despite the low number of cases in the current study, it is by far the most comprehensive series in the literature to date. Our results suggest that BAF aneurysms can be successfully and safely treated with different endovascular techniques, with the gradually increased use of stents in recent years.

Objectives To summarize the experience and midterm outcomes of physician-modified endovascular grafts for zone 2 thoracic endovascular aortic repair. Methods A retrospective analysis was conducted of 51 consecutive patients (mean age 57.6 ± 12.5 years, 39 males) treated with thoracic endovascular aortic repair using physician-modified endovascular grafts for reconstructing the left subclavian artery from November 2015 to December 2019. The primary endpoints during follow-up were the overall mortality, aorta-related mortality, and major complications. The secondary endpoints were reintervention and the patency of the target branches, the demographics and technical details were also described and analyzed. Results Sixty-three thoracic stent-grafts were deployed in 51 patients and emergency surgery was performed in 10 patients (19.6%). Technical success was 94.1% (48/51). The incidence of perioperative complications was 15.7%, and the 30-day mortality was 0%. At a mean follow-up of 42.0 ± 14.4 months (range, 14–63 months), all the left subclavian arteries remained patent. All-cause mortality was 3.9% (2/51) and not aorta-related deaths. Estimated survival at one and three years was 98.0 ± 1.9% and 96.0 ± 2.8%, respectively. Conclusions The physician-modified endovascular grafts is feasible and effective to preserve left subclavian artery in thoracic endovascular aortic repair for aortic arch pathologies with unhealthy proximal landing zone.

Background Beam hardening and scattering artifacts from high-density objects such as dental implants adversely affect the image quality and subsequently the detection of fenestration or dehiscence around dental implants. Objective This study aimed to assess the efficacy of metal artifact reduction (MAR) algorithm of two cone-beam computed tomography (CBCT) systems for detection of peri-implant fenestration and dehiscence. Material and methods In this experimental study, thirty-six titanium implants were placed in bone blocks of bovine ribs. Fenestration and dehiscence were created in the buccal bone around implants. CBCT images were obtained using Cranex 3D and ProMax 3D CBCT systems with and without MAR algorithm. Two experienced radiologists observed the images. Data were analyzed using SPSS software. The Kappa coefficient of agreement, the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, and accuracy of different imaging modalities were calculated and analyzed. Results In both CBCT systems, the use of MAR algorithm decreased the area under the ROC curve and subsequently the diagnostic accuracy for the detection of fenestration and dehiscence. The sensitivity, specificity and accuracy of both CBCT systems were higher in absence of the MAR algorithm. The specificity of ProMax 3D for detection of fenestration was equal with/without the MAR algorithm. Conclusion Although CBCT is suitable for detection of peri-implant defects, the application of the MAR algorithm does not enhance the detection of peri-implant fenestration and dehiscence.

Purpose Endovascular repair of chronic thoracoabdominal aortic dissection with aneurysmal degeneration presents a therapeutic challenge when one or more visceral branches arise from the false lumen without an adjacent reentry. The chronic dissection flap can be thick and resistant to flap fenestration with standard techniques. Technique The powered cheese wire technique facilitates cutting of a dissection flap using electrical current on a noninsulated through-and-through wire segment. The mid-shaft of the guidewire is denuded and kinked to form the “flying V” configuration. This solution is based on the BASILICA procedure, which uses electrosurgery to split aortic valve tissue lengthwise prior to transcatheter aortic valve replacement to prevent coronary artery obstruction. We demonstrate the technique in a case of branched endovascular aortic repair of a complex thoracoabdominal dissecting aneurysm in which a renal artery from the false lumen was catheterized by creating a powered cheese wire fenestration. Conclusion The powered cheese wire technique is an effective approach to access false lumen originating branches during endovascular aortic repair of chronic aortic dissections.

Lymphocutaneous fistula after lymph node dissection is intractable, yet there is no established treatment strategy. This study demonstrates the wound closure time achieved by a new method of combined internal and external negative pressure wound therapy (CIEN) in patients with lymphocutaneous fistula. The subjects of this study were six consecutive patients with lymphocutaneous fistula after lymphatic surgery, who were treated with CIEN between 2018 and 2020. The CIEN technique can be summarized as follows: first, internal foam is inserted into the fistula from the opening of the fenestration. Next, a slightly larger area of external foam is applied above the fistula flap outside the external margin of the foam-filled fistula. After bridging the internal foam and external foam, negative-pressure wound therapy is carried out on this bridging foam block. CIEN led to rapid and complete wound healing in all six patients. Fistula flap margin ischemia developed in one patient, but adjusting the mode and pressure settings resulted in improvement. Three patients suffered contact dermatitis. There were no signs of tumor or fistula recurrence in any patients after at least 3 months of follow-up. CIEN is an effective and less invasive treatment modality than the conventional method of managing lymphocutaneous fistula.

OBJECTIVES The aim of this study was to present a multicentre experience of technical results and mid-term follow-up using a custom-made iliac fenestrated device (Terumo Aortic, Inchinnan, Renfrewshire, UK) for the treatment of iliac aneurysms and endoleaks. METHODS A multicentre retrospective evaluation of 22 patients (3–12 per institution) with either an iliac artery aneurysm or endoleak treated with an iliac fenestrated device was performed. Data were gathered from 3 departments of vascular and endovascular surgery at 3 European institutions. RESULTS Ten of the included patients (45.5%) were treated for an endoleak and 12 had aorto-iliac aneurysms (54.5%). Two patients underwent bilateral fenestrated device implantation for a total of 24 devices included in this analysis. Primary technical success was 91.7% (22 of 24 implanted devices). One of the 24 internal iliac arteries could not be cannulated and was covered (primary assisted technical success rate 95.8%) and 1 patient required a relining of the stent graft due to a mid-grade stenosis opposite the internal iliac artery fenestration. Survival at the last available follow-up (mean 15.2 ± 12.0 months, range 0.5–36.6 months) was 90.9%. CONCLUSIONS The present investigation adds to a growing body of literature on custom-made endografts and their usefulness in achieving endovascular repair without compromising blood flow via important arterial branch vessels, such as the internal iliac artery. It presents encouraging technical and mid-term follow-up data from consecutive patients treated for iliac aneurysms or endoleaks using this custom-made device. The technique may help avoid adverse sequelae associated to a coil-and-cover approach when iliac branch devices are not feasible.

Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate of associated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 year-old-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.

Video Video 1 Endoscopic fenestration of a large esophageal duplication cyst with an electrocautery knife, combined with interventional endosonography techniques to ensure safety.

In situ laser fenestration (ISLF) is currently used to reconstruct the aortic major branches during thoracic endovascular aortic repair (TEVAR). To our knowledge, there have been no reports on the application of ISLF for delayed revascularization of the LSA previously sealed in TEVAR. This report describes 5 patients who underwent ISLF for delayed LSA revascularization, with a technical success rate of 80%. No endoleakage occurred, and stents remained patent during more than 6-month follow-up. ISLF is an effective, safe and minimally invasive method for delayed revascularization of the LSA following TEVAR for type B aortic dissection (TBAD) when patients are selected appropriately.

To evaluate the change in intraocular pressure (IOP) in patients with idiopathic intracranial hypertension (IIH) who underwent optic nerve sheath fenestration (ONSF) and to determine if radiographic evidence of posterior scleral or globe indentation influenced IOP.This is a retrospective analysis of IOP in IIH patients who underwent ONSF. The study included all patients from September 2010 to March 2018 operated on by a single surgeon (R.M.). IOPs preoperatively and postoperatively were recorded along with the acetazolamide dosage and whether there was evidence of posterior scleral or globe indentation on preoperative MRI.A total of 29 patients (35 eyes) with IIH underwent ONSF. The average reduction in IOP among all patients was 1.24 mm Hg (P = 0.0218), but this increased to 2.69 mm Hg (P = 0.004) in patients who were maintained on the same dosage of acetazolamide in the preoperative and postoperative period. Furthermore, the reduction in IOP in those with posterior scleral or globe indentation was 2.5 mm Hg (P = 0.0095). When the perioperative period was evaluated, the mean decrease in IOP was 1.83 mm Hg (P = 0.0217).Reducing the cerebral spinal fluid pressure (CSFP) at the level of the intraorbital optic nerve through an ONSF can slightly reduce the IOP. In those with evidence of posterior globe or scleral indentation/flattening, the reduction in IOP was higher, which supports the theory that CSF pressure indents the globe and leads to an increase in IOP. Although these changes in IOP are small, this study provides further evidence for a connection between IOP and CSFP.

OBJECTIVES The present study was performed to compare the effectiveness of Ankaferd Blood Stopper® (ABS) with enamel matrix derivatives (EMD) for treating fenestration defects in rats. MATERIALS AND METHODS Forty-eight male Wistar rats were randomly divided into six groups (each n = 8). Fenestration defects were created in all rats, to which ABS, EMD, or saline (S) was then applied. The rats were grouped and sacrificed at one of two different time points, as follows: ABS-10-group, ABS-treatment/sacrifice on day 10; EMD-10-group, EMD-treatment/sacrifice on day 10; S-10-group, S-treatment/sacrifice on day 10; ABS-38-group, ABS-treatment/sacrifice on day 38; EMD-38-group, EMD-treatment/sacrifice on day 38; and S-38-group, S-treatment/sacrifice on day 38. Then, histomorphometric analysis including measurements of new bone area (NBA) and new bone ratio (NBR), and immunohistochemical analysis including the determination of osteopontin (OPN) and type-III-collagen (C-III) expression were performed. RESULTS The NBA and NBR were significantly higher in the ABS-10-group and EMD-10-group compared to the S-10-group (p