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Objectives: Major Lower Limb Amputation (MLLA) is associated with significant peri- and post-operative pain and has been identified as a research priority by patient and healthcare groups. The PReliMinAry survey was designed to evaluate existing MLLA analgesia strategies; identifying areas of equipoise and informing future research., Methods: A targeted multi-national, multi-disciplinary survey was conducted via SurveyMonkey® (October 5, 2020-November 3, 2020) and advertised via social media and society email lists. The 10-questions explored 'pain-team' services, pre-operative neuroleptic medication, pre-incision peripheral nerve blocks and catheters, surgically placed nerve catheters, post-operative adjunctive regimens, future research engagement and equipoise., Results: Seventy-six responses were received from 60 hospitals worldwide. Twelve hospitals(20%) had a dedicated MLLA pain team, 7(12%) had none. Most pain teams (n = 52; 87%) assessed pain with a 0-10 numerical rating scale. Over half of respondents "never" preloaded patients with oral neuroleptic agents(n= 42/76; 55%). Forty-seven hospitals(78%) utilized patient controlled opioid analgesia. Most hospitals are able to provide pre-incision loco-regional peripheral nerve blocks, nerve catheters and surgical nerve catheters (95%, 77%, and 90% respectively), but use was variable. Ultrasound(US) guided peripheral nerve catheters were "infrequently" or "never" used in 57% of hospitals, whilst 23% "infrequently" or "never" utilize surgically placed nerve catheters., Conclusions: The survey revealed a preference towards 'single-shot' nerve blocks and surgical catheters. A difference between the use of US guided nerve catheters and those surgically placed likely reflects the difference of literature evaluating these techniques. Most respondents felt there was equipoise surrounding future trials evaluating nerve blocks/catheters, but less so for surgical catheters., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself., Study Design: Case series with chart review., Methods: We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR., Results: Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank)., Conclusion: In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation., Level of Evidence: 4 Laryngoscope, 131:2141-2147, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Objectives//hypothesis: To characterize long-term outcomes in pediatric patients requiring tracheotomy in the first year of life., Study Design: Retrospective case series., Methods: A retrospective longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points)., Results: The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long-term outcomes were similar: decannulation (X 2  = 2.19, P = .14), death (X 2  = 2.63, P = .11), and neurocognitive quality of life (X 2  = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48)., Conclusion: There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long-term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life., Level of Evidence: 3 Laryngoscope, 131:2115-2120, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Background and Purpose: To report on the feasibility, safety, and outcome of acute intracranial stenting (ICS) with the Acclino (Flex) Stent and NeuroSpeed Balloon Catheter in cases of failed mechanical thrombectomy (MT) for acute ischemic stroke (AIS)., Methods: We retrospectively reviewed the data of patients treated with acute bailout stenting after failed MT in three large neurointerventional centers using exclusively the Acclino (Flex) Stent and the NeuroSpeed Balloon Catheter. Functional outcome was assessed by the rate of major early neurological recovery (mENR) at 24 hours and at 90 days with the modified Rankin Scale (mRS). Safety evaluation included symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events (SAEs)., Results: 50 patients with a median age of 71 years met the inclusion criteria and 52% (26/50) of the occluded vessels were located within the anterior circulation. mENR was observed in 38.8% and 90-day favorable outcome (mRS ≤2) was 40.6% (13/32). Higher NIH Stroke Scale scores on admission were significantly associated with poor functional outcome (mRS ≥3) at 90 days (adjusted OR 1.28; 95% CI 1.07 to 1.53; p=0.007). sICH occurred in two cases of the study population. There were no intervention-related SAEs., Conclusion: Intracranial bailout stenting with the Acclino (Flex) Stent and the NeuroSpeed Balloon Catheter after failed MT is a feasible and effective recanalization method for atherosclerotic stenosis-based stroke that is associated especially with low rates of sICH., Competing Interests: Competing interests: CPS: Consultant and/or proctor for Acandis, Balt, and Rapid Medical. JF: Consultant for Acandis, Boehringer Ingelheim, Codman, Microvention, Sequent, Stryker. Speaker for Bayer Healthcare, Bracco, Covidien/ev3, Penumbra, Philips, Siemens. Grants from Bundesministeriums für Wirtschaft und Energie (BMWi), Bundesministerium für Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft (DFG), European Union (EU), Covidien, Stryker (THRILL study), Microvention (ERASER study), Philips. JHB: Received consultancy fees from Acandis, Cerenovus, MicroVention, Stryker. MB: Consultant for Acandis. RC: Consultant and/or proctor for BALT, Stryker, Microvention, Rapid Medical, Siemens Medical Systems. GT: Received personal fees as consultant/lecturer from Acandis, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Daichi Sankyo, Stryker, and research grants from Bayer, Federal Ministry for Economic Affairs and Energy (BMWi), Corona-Foundation, German Research Foundation (DFG), Else Kröner-Fresenius Foundation, European Union (Horizon 2020), German Innovation Fund. JR: Consultant for Acandis and Phenox. LUK: Received speaker honoraria from Boehringer Ingelheim, Medtronic and Stryker., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the safety and reproducibility of modified right vertical infra axillary thoracotomy (RVIAT) for repair of sinus venosus defects with right-sided partial anomalous pulmonary venous connection (PAPVC) in children., Methods: Between March 2017 and February 2018, we performed intracardiac repair for sinus venosus defects with right-sided PAPVC in 14 children through modified RVIAT. Median age and weight were 9.5 years and 21 kg, respectively. We modified RVIAT by avoiding central venous cannulation and used total peripheral venous cannulation (right internal jugular vein and right femoral vein). In all children double-patch technique was followed, using untreated autologous pericardium., Results: Intracardiac repair was safely performed in all children. There was no conversion to another approach and there were no complications related to peripheral venous cannulation. All children were in sinus rhythm with no residual defects, with non-obstructive pulmonary venous drainage at the time of discharge and during subsequent follow-ups., Conclusions: Modified RVIAT can be safely performed for repair of sinus venosus defects with right-sided PAPVC, without compromising on the quality of repair. With this modification not only the intracardiac repair was easier, also it provided more working space with minimal rib spreading.

Objectives: In intrathecal drug delivery, visualization of the device has been performed with plain radiography. However, the visibility of the related structures can be problematic. In troubleshooting, after the contrast material injection via the catheter access port, a computed tomography (CT) scan has been used. In troubleshooting, we also used a non-contrast CT scan with 2D and 3D reconstructions. With the current phantom study, we aimed to obtain high-resolution imaging of a poor opaque catheter with the use of a low-dose single-energy 2D and 3D CT scan with limited radiation exposure as a substitute for plain radiography., Materials and Methods: The catheter was placed into a fatty substance and mounted on an anthropomorphic abdomen phantom followed by CT with varying kVp settings and with added tin beam filtering. Dose levels corrected based on the spinal catheter tip on T8 would result in a calculated effective dose in the range of the mSv's calculated for the plain x-ray examination., Results: Ultimately, Sn100 kVp has the best trade-off between visibility, artifacts, and noise for a fixed dose. Although 3D VRT imaging was challenging at this low dose level, we could make a full evaluation possible with complementary 2D projections., Conclusions: We could correctly identify the catheter and related structures, which supports the investigation of this in vivo and side-by-side evaluation with plain radiography. If found superior, then this technique may be able to replace plain radiography, while providing better visualization and acceptable radiation exposure., Conflict of Interest: Dr. Delhaas reports personal fees from Medtronic Inc., as a previous consultant, outside the submitted work; Prof. van der Lugt reports grants from GE Healthcare, Siemens, Stryker, Medtronic, and Penumbra outside the submitted work., (© 2019 The Authors. Neuromodulation: Technology at the Neural Interface published by Wiley Periodicals, Inc. on behalf of International Neuromodulation Society.)

Aims: The instantaneous wave-free ratio (iFR) and whole-cycle Pd/Pa investigate coronary physiology during non-hyperaemic conditions. To test for unique physiologic properties of the wave-free period when making resting coronary pressure measurements, we compared post hoc a diastolic pressure ratio (dPR) and Pd/Pa against iFR for numerical similarity and test/retest repeatability., Methods and Results: Eight hundred and ninety-three lesions from 833 subjects were included from the VERIFY 2 and CONTRAST studies. Diastolic pressure ratio and a linear transform of Pd/Pa were compared against iFR for diagnostic performance. Mean difference between dPR and iFR [Δ = -0.006 ± 0.011, r2 = 0.993, area under receiver operating characteristic (ROC) curve (AUC) = 0.997] mirrored the difference of two iFR measurements repeated immediately (Δ = <0.001 ± 0.004, r2 = 0.998, AUC = 1.00). Minor variations in the definition of dPR changed its value by <1-2% over a broad range of the cardiac cycle. A linear transform of Pd/Pa showed very good diagnostic performance (Δ = -0.012 ± 0.031, r2 = 0.927, AUC = 0.979). Post hoc iFR values were validated against real-time iFR values and matched almost exactly (average Δ = <0.001 ± 0.004, 99.6% within ±0.01)., Conclusions: Our dPR offers numerical equivalency to iFR. Despite different technical approaches for identifying the relevant period of diastole, the agreement between dPR and iFR and the insensitivity of dPR to minor variations in its definition further confirm numerical equivalency among resting metrics., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Mitral valve ring annuloplasty is a surgical gold standard and is used routinely during surgical mitral valve repair of primary or secondary mitral regurgitation. The Millipede IRIS annuloplasty ring is the first transcatheter, transfemoral, transseptal, semirigid, complete annuloplasty ring to be delivered to the mitral valve annulus. Initial results in humans demonstrate that the Millipede IRIS ring is safe, and can effectively reduce the mitral annular diameter leading to a clinically significant reduction or elimination of mitral regurgitation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To evaluate changes in the use of catheter-directed therapy (CDT) for pulmonary embolism (PE) treatment with attention to primary operator specialty in the Medicare population., Methods: Using a 5% national sample of Medicare claims data from 2004 to 2016, all claims associated with PE were identified. The annual volume of 2 billable CDT services-arterial mechanical thrombectomy and transcatheter arterial infusion for thrombolysis-were determined to evaluate changes in CDT use and primary CDT operator specialty over time., Results: The total number of CDT procedures increased over the course of the study period, representing 0.457 and 5.057 service counts per 100,000 Medicare beneficiaries in 2004 and 2016, respectively. The proportion of PEs treated with CDT increased 10-fold from 2004 to 2016, increasing from 0.1% to 1.0%. Interventional radiologists performed most CDT therapies each year, with the exception of 2010 when vascular surgeons performed more. In 2016, interventional radiologists performed 3.54 CDT services for PE per 100,000 Medicare beneficiaries, which was 70% of total CDT for PE procedures, followed by interventional cardiologists and vascular surgeons performing 0.92 services (18%) and 0.60 services (12%), respectively., Conclusions: CDT is an increasingly used treatment for PE, with a 10-fold increase from 2004 to 2016. Interventional radiologists are the dominant providers of these services, followed by interventional cardiologists and vascular surgeons., (Copyright © 2019 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Successful vascular access (VA) cannulation is integral to the delivery of adequate dialysis, highlighting the importance of ensuring the viability of arteriovenous access in hemodialysis (HD) patients. Missed VA cannulation can lead to infection, infiltration, hematoma or aneurysm formation resulting in the need for access revision, central venous catheter (CVC) placement, or permanent loss of VA. Cannulation-related complications can also negatively impact on a patient's dialysis experience and quality of life. This study aimed to identify patient, VA and nurse factors associated with unsuccessful VA cannulations., Methods: A prospective cohort study was conducted in HD patients with a permanent VA from three HD units. Data on patient, VA and nurse characteristics, plus, cannulation technique were collected for each episode of cannulation. General Estimating Equation was used to fit a repeated measures logistic regression to determine the odds of cannulation success., Results: We collected data on 1946 episodes of cannulation (83.9% fistula) in 149 patients by 63 nurses. Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and was by rope ladder (73.8%) or area (24.7%) technique. The miscannulation rate was 4.4% (n = 85) with a third of patients (n = 47) having at least one episode of miscannulation. Extravasation (n = 17, 0.9%) and use of an existing CVC (n = 6, 0.6%) were rare. Multivariable characteristics of successful cannulation included fistula compared with graft [OR 4.38; 95%CI, 1.89-10.1]; older access [OR 1.68; 95%CI, 1.32-2.14]; absence of stent [OR 3.37; 95%CI, 1.39-8.19]; no ultrasound [OR 13.7; 95%CI, 6.52-28.6]; no tourniquet [OR 2.32; 95%CI, 1.15-4.66]; and lack of post graduate certificate in renal nursing [OR 2.27; 95%CI, 1.31-3.93]., Conclusion: This study demonstrated a low rate of miscannulation. Further research is required on ultrasound-guided cannulation. Identifying variables associated with successful cannulation may be used to develop a VA cannulation complexity instrument that could be utilised to match to the cannulation skill of a competency-assessed nurse, thereby minimising the risk of missed cannulation and trauma.

Introduction: Use of a microcatheter is essential for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Several microcatheters have recently been introduced in clinical practice aiming to improve deliverability and resistance to deformation. Areas covered: We review the technical characteristics of several new microcatheters (Mamba, Mamba Flex, Teleport Control, Teleport, Nhancer Rx, Sasuke, and ReCross) and compare them with existing microcatheters. Expert opinion: The recently developed microcatheters offer additional options for guidewire support during CTO PCI. Accumulation of clinical experience and performance of comparative effectiveness studies are needed for better understanding the role of these devices in contemporary CTO PCI.

Objective: Although blood pressure (BP) variability has been regarded as a risk factor for hemorrhagic transformation (HTF) after intravenous thrombolysis, its effect on HTF after endovascular recanalization therapy (ERT) remains to be elucidated. We aimed to study the relationship between BP variability and symptomatic intracerebral hemorrhage (sICH) after successful recanalization with ERT., Methods: A total of 211 patients with acute ischemic stroke and successful recanalization (thrombolysis in cerebral infarction 2b or 3) after ERT were included between January 2013 and May 2017. The BP data following ERT was obtained over the first 24 hours using parameters including mean, maximum, minimum, difference between maximum and minimum, standard deviation, coefficient of variation, successive variations, and time rate (TR) of BP variation for systolic BP (SBP) and diastolic BP. sICH was defined as parenchymal hemorrhage type 2 with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale., Results: Among the included patients, 20 (9.5%) developed sICH after successful ERT. The parameters linked with BP fluctuation over time were significantly related to sICH. After adjusting for confounders, the TR of SBP (per 0.1 mmHg/min increase) variation was independently associated with sICH (odds ratio = 1.71, 95% confidence interval = 1.013-2.886)., Interpretation: Time-related BP variability in the first 24 hours following successful ERT was more correlated with sICH than other absolute BP levels. This suggests that maintaining a stable BP may be an important factor in preventing sICH after successful ERT. Ann Neurol 2019;85:574-581., (© 2019 American Neurological Association.)

Background: The Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for Nomenclature in Extracorporeal Life Support (ECLS) established consensus nomenclature and abbreviations for ECLS to ensure accurate, concise communication., Methods: We build on this consensus nomenclature by layering a framework of precise and efficient abbreviations for cannula configuration that describe flow direction, number of cannulae used, any additional ECLS-related catheters, and cannulation sites. This work is a consensus of international representatives of the ELSO, including those from the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters of ELSO., Results: The classification increases in descriptive capability by introducing a third (cannula tip position) and fourth (cannula dimension) level to those provided in the previous consensus on ECLS cannulation configuration nomenclature. This expansion offers the simplest level needed to convey cannulation information yet allows for more details when required., Conclusions: A complete nomenclature for ECLS cannulation configurations accommodating future revisions was developed to facilitate ability to compare practices and results, to promote efficient communication, and to improve quality of registry data.

Background: Sustainability of ERP is a challenge and data are scarce on the subject. The aim of this study was to assess if application of enhanced recovery elements through the Francophone Group of Enhanced Recovery after Surgery (Grace) in the anaesthesia management was sustainable 2 years after its implementation., Materials and Methods: We conducted a retrospective analysis of the prospective Grace database between October 2014 and October 2016. The evolution of each recommendation item over time was analysed using non-parametric Spearman correlation coefficient., Results: A total of 67 and 43 centres corresponding to 2067 and 3022 patients participated to the Grace audit in colorectal and orthopaedics surgery, respectively. Colorectal surgery: Mean length of stay was 5 (±4) days and readmission rate was 6.6%. Application of most items did not statistically change. It worsened over time for PONV prophylaxis (P=0.01) and prevention of intraoperative hypothermia (P=0.02); and improved for NSAID administration (P=0.01). Orthopaedics surgery: Mean length of stay was 3 (±2) days and readmission rate was 1.7%. There was a trend towards improvement for most items. It reached statistical significance for PONV prophylaxis (P=0.001), limited preoperative fasting (P=0.01). While the use of a perineural catheter (P=0.001) decreased over time, infiltration of the surgical site statistically increased (P=0.05)., Conclusion: This study shows on a large scale a trend towards less application of all ERP items over time. Continuous audits should be encouraged to expect further improvements., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Purpose of Review: We provide a timely update on treatment care issues facing clinicians and patients with acute pulmonary embolism accompanied by either right ventricular strain (sub-massive pulmonary embolism) or shock (massive pulmonary embolism)., Recent Findings: Care and research changes over the last several years have resulted in four important trends: more consensus and accuracy in the way acute pulmonary embolism severity is described and communicated among acute care clinicians and researchers, increased availability and use of risk prediction scoring systems, increased use of advanced invasive therapy in the setting of severe right ventricular dysfunction, and emergence of multidisciplinary pulmonary embolism response teams to guide standard care decision-making., Summary: Pulmonary embolism with shock should be treated with either systemic or catheter-based thrombolytic therapy in the absence of contraindications. Patients with sub-massive pulmonary embolism accompanied by right heart dysfunction who are treated with thrombolytic therapy likely will experience more rapid improvement in RV function and are less likely to progress to hemodynamic decompensation. This comes, however, with an increased risk of major bleeding. Our recommendation is to consider catheter-based or systemic fibrinolytic therapy in sub-massive pulmonary embolism cases where patients demonstrate high-risk features such as: severe RV strain on echo or CT, and importantly worsening over time trends in pulse, SBP, and oxygenation despite anticoagulation. Understanding the impact of advanced therapy beyond standard anticoagulation on patient-centered outcomes, such as functional status and quality of life represent a research knowledge gap.

The current state and the future direction.

Interventional pulmonology is an innovative branch of pulmonary medicine that uses minimally invasive diagnostic and therapeutic approaches to airway, parenchymal, and pleural disease. The author reviews recent high-impact trials including randomized trials describing the use of endobronchial coils and valves in the management of severe emphysema. Novel approaches to the palliation of malignant and benign pleural effusion including increasing the frequency of drainage and instillation of talc via tunneled pleural catheters are also presented. In addition, a recent consensus paper discussing the optimal use and technique of cryobiopsy in diffuse parenchymal disease is reviewed, as well as a systematic review and meta-analysis of its diagnostic yield. The final trial reviewed in this article describes the preliminary safety and efficacy study of a novel endobronchial, balloon, and injection catheter for the local administration of chemotherapy into the airway mucosa so as to minimize the systemic absorption of these agents., (Copyright © 2018. Published by Elsevier Inc.)

Background: Current status and clinical significance of interventional nephrology has not been reported from Japan., Methods: Questionnaires were mailed twice to the directors of all 534 Japanese certificated nephrology training institutions in 2014. The main questions were current performance, categorized annual procedure volume and managers of peritoneal dialysis (PD) access, vascular access (VA) surgery, endovascular intervention, and kidney biopsy. Frequencies of nephrologist involvement between high volume center and low volume center and association between the level of nephrologists' involvement to each procedure and annual procedure volume were examined., Results: 332 (62.2%) institutions answered performance of all procedures and 328 (61.4%) institutions answered all procedure volume. Kidney biopsy, VA surgery, endovascular intervention and PD access surgery were performed by any doctors in 94.2, 96.3, 88.4, and 76.2% and each involvement of nephrologist was 93.9, 54.1, 53.1 and 47.6%, respectively. Cochran-Armitage analyses demonstrated significant increases in all 4 procedure volume with greater management by nephrologists (p < 0.01). Nephrologists involvement to VA surgery associated with procedure volume increase in not only VA surgery, but also PD catheter insertion (p < 0.01) and kidney biopsy (p < 0.05). And nephrologists involvement to PD catheter insertion also associated with surgical volume increase in both VA surgery (p < 0.01) and endovascular intervention (p < 0.05)., Conclusions: Main manager of all 4 procedures was nephrologist in Japan. Each procedure volume increased as nephrologists become more involved. Acquisition of one specific procedure by nephrologist associated with increase not only in this specific procedure volume, but also the other procedure volume.

Objective: The management of venous thromboembolism (VTE) has evolved during the last decade. This study sheds light on the national trends in hospital admissions, outcomes, and economic burden for VTE., Methods: The National Inpatient Sample (NIS) was reviewed between 2003 and 2013 for hospitalizations for VTE, defined as admissions with a principal diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE). Outcomes measured were incidence, inpatient mortality, rates of interventions, hospital length of stay (LOS), and charges. A multivariate analysis was used to identify independent predictors of mortality in patients with VTE., Results: There were 3,368,409 admissions for VTE (54% female; mean age, 62.9 years), at an average of 818 per 100,000 admissions per year. Hospitalizations for PE and VTE significantly increased (P < .01), with no change for DVT (P = .13). Use of catheter-directed thrombolysis increased (0.8% to 2.7%; P < .01), with no significant change in use during the study period (P = .10). The mortality associated with hospitalizations for VTE, PE, and DVT decreased (P < .01). Mean LOS decreased from 5.79 to 4.77 days (P < .01), whereas mean hospital charges increased from $29,755 to $39,171 (P < .01). At the national level, the economic burden of VTE hospitalizations increased from $7.8 billion in 2003 to $12.1 billion in 2013 (P < .01). Older age (odds ratio [OR], 1.03), female gender (OR, 1.05), race (OR, 1.43 for Asian, 1.18 for African American, and 1.18 for Hispanic compared with white), PE (OR, 4.12), and Charlson Comorbidity Index (CCI) ≥3 (OR, 2.75) were all predictors of inpatient mortality (P < .01 for all ORs)., Conclusions: Hospitalizations for VTE increased during the past decade, whereas mortality decreased. Despite a decrease in LOS, there is a rise in economic burden of VTE on the health care system., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We sought to estimate the efficacy and safety outcomes of catheter-directed treatment (CDT) for patients with acute pulmonary embolism (PE)., Methods: We searched SCOPUS for studies reporting outcomes after CDT for acute PE. Studies were categorized in three groups for analyses due to heterogeneity in the classification of acute PE: 1) patients with PE causing right ventricular dysfunction and haemodynamic instability: unstable haemodynamic status, 2) patients with PE causing right ventricular dysfunction where study outcomes were not stratified by haemodynamic status: stable and unstable haemodynamic status, and 3) patients with PE causing right ventricular dysfunction who remained haemodynamically stable: stable haemodynamic status. Efficacy and safety outcomes were estimated and presented as point estimates with 95% confidence intervals., Results: In 35 studies with 1253 patients, 1277 CDTs were performed. The in-hospital mortality rates for the unstable haemodynamic status, stable and unstable haemodynamic status, and stable haemodynamic status groups were 18.1% (7.3-38.2%), 7.1% (5.0-10.1%), and 2.6% (0.8-7.3%), respectively. The major bleeding rates across the groups were estimated to be 4.5, 8.5 and 3.9 per 100 CDTs, respectively. Minor bleeding occurred in 6.2, 11.9 and 9.1 per 100 CDTs, respectively. After CDT, all groups had improvements in mean pulmonary artery pressure and right ventricular function., Conclusions: We provide descriptive measures of efficacy and safety for patients who underwent CDT for acute PE., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To conduct a survey across European cardiac centres to evaluate the methods used for cerebral protection during aortic surgery involving the aortic arch., Methods: All European centres were contacted and surgeons were requested to fill out a short, comprehensive questionnaire on an internet-based platform. One-third of more than 400 contacted centres completed the survey correctly., Results: The most preferred site for arterial cannulation is the subclavian-axillary, both in acute and chronic presentation. The femoral artery is still frequently used in the acute condition, while the ascending aorta is a frequent second choice in the case of chronic presentation. Bilateral antegrade brain perfusion is chosen by the majority of centres (2/3 of cases), while retrograde perfusion or circulatory arrest is very seldom used and almost exclusively in acute clinical presentation. The same pumping system of the cardio pulmonary bypass is most of the time used for selective cerebral perfusion, and the perfusate temperature is usually maintained between 22 and 26°C. One-third of the centres use lower temperatures. Perfusate flow and pressure are fairly consistent among centres in the range of 10-15 ml/kg and 60 mmHg, respectively. In 60% of cases, barbiturates are added for cerebral protection, while visceral perfusion still receives little attention. Regarding cerebral monitoring, there is a general tendency to use near-infrared spectroscopy associated with bilateral radial pressure measurement., Conclusions: These data represent a snapshot of the strategies used for cerebral protection during major aortic surgery in current practice, and may serve as a reference for standardization and refinement of different approaches., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Interventional pulmonology (IP) remains a rapidly expanding and evolving subspecialty focused on the diagnosis and treatment of complex diseases of the thorax. As the field continues to push the leading edge of medical technology, new procedures allow for novel minimally invasive approaches to old diseases including asthma, chronic obstructive pulmonary disease and metastatic or primary lung malignancy. In addition to technologic advances, IP has matured into a defined subspecialty, requiring formal training necessary to perform the advanced procedures. This need for advanced training has led to the need for standardization of training and the institution of a subspecialty board examination. In this review, we will discuss the dynamic field of IP as well as novel technologies being investigated or employed in the treatment of thoracic disease.

Background: Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial., Objective: To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging., Methods: Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram., Results: Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients., Conclusion: Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.

Introduction: Device developments and evolution in technique over the past decade make the treatment of aneurysms which were previously considered poor candidates for coiling more feasible. The authors describe their experience treating aneurysms at a single high-volume tertiary care center, focusing particularly on the use of adjunctive devices., Methods: A retrospective review was undertaken of all the aneurysms treated at the Cleveland Clinic between 2003 and 2010., Results: A total of 1455 aneurysms were treated (45% subarachnoid hemorrhage). In 2003, aneurysms were treated equally with clipping (49.6%) and coiling (50.4%). Over the 8-year period reviewed there was a decline in the percentage of aneurysms treated surgically. By 2010, 25.5% of aneurysms were treated surgically and 74.5% by endovascular coiling. Among aneurysms that were coiled there was an increase in the cases treated with adjuncts including balloon remodeling and stents. The most dramatic increase in the relative proportion of a single method was the more widespread use of the combined 'balloon stent' technique. Initially used in 12% of stent-assisted cases, it is currently employed in 35.4% of cases., Conclusions: Significant changes in practice trends for aneurysm treatment have been observed at a single high-volume tertiary care center over the past decade. Although these changes are multifactorial, they are explained in part by institutional comfort level with the adoption of adjunctive techniques, with a growing number of aneurysms treated with balloon remodeling and the 'balloon stent' technique.

Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23 mm) and a larger (28 mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.

Aim: To evaluate the evolution of surgical management in a large population of patients with Marfan syndrome., Methods: This is a retrospective study of patients fulfilling the Ghent criteria for Marfan syndrome, who visited the Centre de référence national pour le syndrome de Marfan et apparentés and underwent a surgical event before or during follow-up in the centre., Results: One thousand and ninety-seven patients with Marfan syndrome, according to international criteria, came to the clinic between 1996 and 2010. Aortic surgery was performed in 249 patients (22.7%; 20 children and 229 adults), including the Bentall procedure in 140 patients (56%) and valve-sparing surgery in 88 patients (35%); a supracoronary graft was performed in 19 patients (7.6%), usually for aortic dissection. During the past 20 years, the predominant reason for aortic surgery has switched from aortic dissection to aortic dilatation, while age at surgery has tended to increase (from 32.4 ± 11.9 years to 35.2 ± 12.4 years; P=0.075). Mitral valve surgery was performed in 61 patients (5.6%; six children and 55 adults), including 37 valvuloplasties (60.6%) and 18 mitral valve replacements (29.5%). No significant difference was observed when comparing mitral valve surgery before and after 2000., Conclusion: Surgery performed in patients with Marfan syndrome has switched from emergency surgery for aortic dissection to elective surgery for aortic dilatation; this is associated with surgery performed at an older age despite the indication for surgery having decreased from 60mm to 50mm. No significant evolution was observed for mitral valve surgery., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

In 2011, both the PARTNER-A trial, in high-risk patients with severe aortic stenosis, and EVEREST II, in patients with mitral insufficiency, showed noninferiority of transcatheter interventions compared with surgery for the chosen primary end points. However, both of the trials, and important registry data, identified limitations of transcatheter valve interventions.

Background: The value of balloon valvuloplasty of the aortic valve in childhood is still under debate., Objective: To evaluate the results of the procedure in a retrospective multicenter survey of a large cohort over a long time interval., Methods: Retrospective analysis of 1004 patients with balloon valvuloplasty of the aortic valve performed between 9/1985 and 10/2006 at 20 centers in Germany, Austria and Switzerland. Amongst others, the following parameters were evaluated before and after the procedure as well as at the end of follow-up or before surgery: clinical status, left ventricular function, transaortic pressure gradient, degree of aortic regurgitation, freedom from re-intervention or surgery., Patients: Patients from 1 day to 18 years of age with aortic valve stenosis were divided into four groups: 334 newborns (1-28 days); 249 infants (29-365 days); 211 children (1-10 years), and 210 adolescents (10-18 years)., Results: Median follow-up was 32 months (0 days to 17.5 years). After dilatation the pressure gradient decreased from 65 (± 24)mm Hg to 26 (± 16)mm Hg and remained stable during follow-up. The newborns were the most affected patients. Approximately 60% of them had clinical symptoms and impaired left ventricular function before intervention. Complication rate was 15% in newborns, 11% in infants and 6% in older children. Independently of age, 50% of all patients were free from surgery 10 years after intervention., Conclusions: In this retrospective multicenter study, balloon valvuloplasty of the aortic valve has effectively postponed the need for surgery in infants, children and adolescents up to 18 years of age., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Drug-coated balloons (DCB) represent a novel clinical treatment modality for coronary and peripheral artery disease. Advantages over standard angioplasty and stent technologies including homogeneous drug delivery to the vessel wall, immediate drug release without the use of a polymer, the option of using balloon catheters alone or in combination with a bare metal stent, no foreign object that remains in the body, the potential of reducing antiplatelet therapy, and lower restenosis rates in some indications. As with drug-eluting stents (DES), one cannot assume a class effect for DCB. So far, data from randomized clinical trials identify the treatment of coronary in-stent restenosis (ISR) and of de novo and restenotic lesions in peripheral artery disease as viable options. Furthermore, treatment of de novo lesions in small coronary vessels, bifurcation lesions, long lesions, pediatric interventions, and cerebrovascular applications are potential beneficial indications. In the coronary application, a strategy of DCB angioplasty with provisional spot-stenting in the case of severe dissections may become a better alternative in long and complex lesions, bifurcations, or in patients with contraindications for DES.

Transapical aortic valve implantation (TA-AVI) is a truly minimally invasive technique allowing for off-pump aortic valve implantation in selected high-risk patients. Potential advantages are the avoidance of cardiopulmonary bypass, cross-clamping and sternotomy. Compared to transfemoral aortic valve implantation the current strengths of the transapical approach are the avoidance of the femoral arteries as well as a very low stroke risk due to minimal manipulations in the aortic arch. TA-AVI has evolved to a routine procedure in selected specialized centers providing a safe and reproducible treatment option for high-risk elderly patients suffering from severe symptomatic aortic stenosis.

A total of 33 patients with severe aortic stenosis undergoing percutaneous aortic balloon valvuloplasty (PABV) for bridging or palliative therapy were reviewed; the emerging treatment patterns for this procedure are described. Longitudinal data suggest that PABV provides a significant reduction in peak and mean aortic valve gradients with > 12-month survival for more than half of observed patients. This supports the current application of PABV, which is currently limited to palliative care and bridging therapy to more definitive forms of future treatment, including transcatheter aortic valve implantation., (2011 MedReviews®, LLC.)

The authors present results of examination and treatment of 272 patients with Zenker diverticulums of different localization. Features and problems in fibroesophagoscopy in patients with Zenker diverticulum are discussed. Surgical interventions with endoscopic assistance were fulfilled in 37 patients with diverticulum. A new way of endoscopic management of Zenker diverticulum using preparation "Disport" and the method of endoscopic incision of cricofaringeal muscle are proposed. Good clinical results of the treatment were obtained.

Innovative, nonthoracotomy, catheter-delivered therapies have redefined the approach to and treatment of congenital heart defects. Starting in the 1960s with the creation of an opening in the atrial septum to permit effective blood mixing and improve oxygen saturation in cyanotic infants, interventional cardiac procedures continue to replace many of the time-honored surgeries that were the mainstay of repair or correction for infants and children with heart defects. Now as those children reach adulthood and still require modifications of their defects, catheter-based interventions are becoming more important. This article examines some of the more recent applications of device therapy currently available to patients with congenital heart, including heart failure, septal defects, vascular problems and heart valves. Device use in deference to surgery, risks and benefits as well as complications associated with such catheter-delivered therapies are discussed.

Since the 2006 Surgical Technology International monograph on valvular prostheses, there have been significant developmental and investigative advances, particularly for transcatheter implantation. Aortic bioprostheses and mechanical prostheses continue to incorporate design changes to optimize hemodynamics and prevent prosthesis-patient mismatch and to have a potential satisfactory influence on survival. There have been continual technological improvements striving to bring forward advances that improve the durability of bioprostheses and reduce the thrombogenicity of mechanical prostheses. There also has been a continuance to preserve biological tissue with glutaraldehyde, rather than clinically evaluate other cross-linking technologies, by controlling or retarding calcification with therapies to control phospholipids and residual aldehydes. The techniques of mitral valve reconstruction have now been well established, and annuloplasty rings have been designed for the potential of maintaining the anatomical and physiological characteristics of the mitral annulus. There has been limited advancement in the past four years for interventional annuloplasty, for remodeling of the length and shape of the dilated annulus, prevention of dilatation of the annulus, and support for the potentially fragile area after partial-leaflet resection. Currently, there continues to be emergence of catheter-based therapies, particularly for management of aortic stenosis but not mitral regurgitation. For management of selected populations with critical aortic stenosis, the techniques for aortic valve substitution have had further advancement for retrograde catheter techniques, as well as apical transventricular implantation. There has not been significant advancement during the past four years to address mitral regurgitation by experimental transcoronary sinus, stent-like devices and transventricular, edge-to-edge leaflet devices. The devices, descriptions, and pictorial images comprising this monograph have been limited to technologies that are considered to be predominant, at least for the immediate duration. The general purpose of the monograph is to serve as an educational document.

Surgical aortic valve replacement remains the gold standard for the treatment of severe, symptomatic aortic stenosis. However, percutaneous treatments are challenging this paradigm in high-risk surgical patients. Technological developments have been rapid in the field of percutaneous aortic valve intervention. Two devices have been approved for general use in Europe: the Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) and the CoreValve ReValving((R)) System (CoreValve ReValving((R)) Technology Medtronic Inc., Minneapolis, MN), with 15 potential new designs for percutaneous aortic valves in development around the world. Both systems can be delivered via the transfemoral, transapical and the axillary/subclavian routes, depending upon patient characteristics, anatomy, and the device available to the operator. Careful selection of appropriate patients is essential to ensure a safe procedure. This necessitates a multidisciplinary approach, with multiple imaging modalities used to fully delineate the peripheral vasculature, aortic anatomy and the valve itself. It is important to remember, however, that just because we can treat aortic valve disease percutaneously, it does not mean that we necessarily should. The gold standard treatment for aortic stenosis remains thoracotomy and surgical replacement of the valve; to this end it is essential that surgeons play a central role in the decision-making processes for transcatheter aortic valve implantation and that they embrace this new and exciting technology, which promises to dramatically change the way their high-risk aortic valve patients are managed over the course of the next 10 years.

The hybrid operating room is the venue for transcatheter therapy with the convergence of 3 specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Because pharmacologic conditioning and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia, and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass graft (CABG) surgery. Although off-pump CABG surgery is equivalent to on-pump CABG surgery, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel recently was approved for platelet blockade in PCI, it may be superseded by ticagrelor. Although PCI and CABG surgery appear equivalent for multivessel coronary disease, CABG surgery lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Because eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide, and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements., (Copyright 2010 Elsevier Inc. All rights reserved.)

Endovascular techniques are well established in minimally invasive vascular surgery. Stent-graft technology is evolving. This will allow more complex aortic pathology to be treated. Current limitations in this equipment include the reliance on selective catheters along with trial and error to cannulate visceral or aortic arch branch vessels. This can lead to prolonged operations with increased radiation and contrast load to the patient with inevitable increase in peri-operative morbidity. A smart catheter that could expedite target vessel catheterization, minimize repeat catheter changes, and provide greater haptic feedback would enhance the endovascular surgeon's armamentarium. This would lead to broader and safer application of endovascular surgery.

For the treatment of symptomatic gallbladder stones, laparoscopic cholecystectomy is the procedure of choice. However, open cholecystectomy is advisable in some situations, and a new technique - natural-orifice transluminal endoscopic surgery - has been described recently. In addition, nonsurgical approaches have also been used in patients with gallbladder stones. For the treatment of common bile duct stones, endoscopic approaches comprise the most important and commonly used modality but, under certain conditions, surgical removal should be considered if the stones cannot be managed nonsurgically. Patients with concomitant gallbladder and common bile duct stones may have various options, depending on the patient's condition and the availability of local expertise. Intrahepatic stones usually have a lower rate of successful treatment compared with gallbladder or extrahepatic bile duct stones. Localized intrahepatic bile duct stones may be cured by surgical resection, or they may be safely and effectively managed using peroral or percutaneous cholangioscopy. Overall, a multidisciplinary approach is important for the optimal management of difficult gallstone diseases.