'Post-Close' Femoral Arterial Haemostasis at Endovascular Aneurysm Repair using a Dedicated Large-Bore Vascular Closure Device: A Prospective Real-World Audit

PURPOSE

Percutaneous access for endovascular aneurysm repair (EVAR) is commonplace, with its attendant benefits. The combination of continued reduction in device profile and evolution of vascular closure device (VCD) design drives successful and safe percutaneous EVAR. A new such VCD is the MANTA Large-Bore Closure Device designed in two iterations for closure of arterial defects from 10 to 25F. We present a prospective audit of 131 large-bore femoral closures using an 'all-comers' approach to device selection.

MATERIALS AND METHODS

One hundred and thirty-one large-bore femoral arterial defects were analysed. Both 14F and 18F MANTA VCDs were deployed in this series as per instructions for use. Primary objectives were technical success, particularly successful deployment, and haemostasis achieved. Failures were denoted as failure to deploy; failure to achieve haemostasis was denoted as active bleeding, haematoma, or pseudoaneurysm formation requiring intervention. Later complications assessed were vessel occlusion/thrombosis or stenosis.

RESULTS

Seventy-six patients (65 males and 11 females, age 75.2 ± 8.7 years) underwent a range of procedures including EVAR (n = 66), TEVAR (n = 2), and reinterventions (n = 8) requiring large-bore percutaneous femoral arterial access in 131 groins. Of these, the 14F MANTA VCD was used in 61 closures (defects ranging from 12 to 18F) and the 18F in 70 closures (defects ranging from 16 to 24F). Deployments achieved successful haemostasis in 120 (91.6%), and failures occurred in 11(8.4%) groins.

CONCLUSIONS

This study indicates that a post-close approach using the novel MANTA Large-Bore Closure Device can be undertaken successfully to close a range of large-bore femoral arterial defects at EVAR/TEVAR with an acceptable rate of complications.

1430 Mid-Term Outcomes After Endovascular Repair of Popliteal Artery Aneurysms Demonstrate Satisfactory Patency Rates and Safety of Stent-Grafts

Aim

Popliteal artery aneurysms (PAAs) are increasingly treated via an endovascular approach. We present mid-term outcomes of popliteal endovascular aneurysm repair (PEVAR) from a single centre.

Method

A retrospective analysis of a prospective database of consecutive patients who underwent either elective or emergency PEVAR in a single regional vascular centre from January 2010 to August 2020. The patients underwent placement of a heparin-bonded stent-graft (Viabahn Endoprosthesis, WL Gore and Associates, Flagstaff, USA) for PAA >20mm or complications: thromboembolism, rupture or popliteal vein thrombosis. Patency and stent-graft related complications were assessed.

Results

A total of 64 PAAs (mean size 36.8±13.4mm) were treated in 56 patients (mean age 75±10.7 years, 54 (96%) male). Median follow-up was 29.5 months (IQR 36.75). 30-day mortality was 0%. Technical success rate of stent-graft insertion was 100%. 1-year and 5-year primary patency was 83% and 67% respectively; primary-assisted patency at these time points was 86% and 72%, and the corresponding secondary patency was 89% and 75%. 61 out of 64 treated limbs had >1 vessel runoff. The most frequently occurring complication was stent-graft occlusion which affected 11 (17%) limbs. Stent-graft fracture occurred in 1 patient, resulting in endoleak.

Conclusions

Viabahn Endoprosthesis can be used successfully in treatment of PAA with acceptable short- and mid-term patency rates. One in five patients in this cohort required a reintervention, with most complications occurring in the first year postoperatively. Stent-graft fracture occurred only in one patient demonstrating that PEVAR is a safe option for PAA management in the intermediate term.

Ultrasound Assisted On-Table Management of Type III Endoleak at Endovascular Repair of Isolated Giant Common Iliac Aneurysm

Objectives

This report presents the endovascular treatment of a large isolated common iliac artery aneurysm, focusing on the use of on table ultrasonography to characterise and treat an early endoleak that could not be defined by angiography alone.

Report

A 58 year old man presented with an asymptomatic, large (13cm) left common iliac artery aneurysm (LCIAA) whilst being investigated for change in bowel habit. This was treated successfully via a percutaneous approach using left internal iliac embolisation followed by endovascular aneurysm repair (EVAR) with deployment of an aorto-uni-iliac converter system from the LCIA origin to the external iliac artery. A non-characterised endoleak at the end of the procedure was shown to be a type IIIb endoleak by application of immediate on table ultrasonography, allowing immediate supplementary targeted stent graft deployment to cover the leaking segment.

Discussion

The patient was discharged uneventfully and will remain on follow up. On table ultrasonography allowed both localisation and characterisation of an immediate intra-procedural endoleak and confirmed cessation of the endoleak with supplementary stent grafting and thrombosis within the sac.

Conclusions

Isolated CIAA is rare, and endovascular therapy is appropriate for them, given that open surgery, whilst feasible, carries a high morbidity and mortality risk. Application of on-table ultrasound allows definition and targeted treatment of endoleaks, reducing the need for further intervention at a later stage, and thus also reducing the risk of continued pressurisation of the large sac post-EVAR till the next surveillance episode.

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Isolated common iliac artery aneurysms (CIAAs) are very rare.

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They can be asymptomatic but have a high risk of rupture.

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Open repair is high risk and associated with high morbidity/mortality.

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This paper highlights successful endovascular repair of a giant isolated CIAA.

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On table ultrasound helps immediately to characterise and treat endoleaks at EVAR.

Ilioprofunda Endobypass Can Successfully Treat a Post-Operative Femoral Pseudo-Aneurysm

INTRODUCTION

A 75-year-old male patient with significant cardiopulmonary comorbidity presented with a 70-mm left femoral pseudoaneurysm 6 years after aortobifemoral bypass (and prior femoral endarterectomy).

REPORT

As the left superficial femoral artery was occluded, an ilioprofunda endobypass was undertaken following extraperitoneal exposure of the left limb of the bypass graft with subsequent deployment of four Viabahn endoprostheses via the left limb into the proximal left deep femoral artery with successful exclusion of the pseudoaneurysm. The endografts remain patent at 6 months with regression noted in the pseudoaneurysm itself.

DISCUSSION

Post-operative femoral pseudoaneurysm following anastomotic dehiscence has traditionally been treated by open surgical repair. Re-re-do open femoral vascular surgery has a high complication rate. Scarring and potential graft infection may necessitate ligation of involved arteries and extra-anatomic bypasses with an attendant risk of limb loss. Although the common femoral artery is conventionally contraindicated for endograft deployment because of the perceived high risk of stent fracture in a highly mobile zone, an endobypass can avoid the potential complications of open revision groin surgery in an unfit, high-risk patient.

Limit on Tensor Currents from ^{8}Li β Decay

In the standard model, the weak interaction is formulated with a purely vector-axial-vector (V-A) structure. Without restriction on the chirality of the neutrino, the most general limits on tensor currents from nuclear β decay are dominated by a single measurement of the β-ν[over ¯] correlation in ^{6}He β decay dating back over a half century. In the present work, the β-ν[over ¯]-α correlation in the β decay of ^{8}Li and subsequent α-particle breakup of the ^{8}Be^{*} daughter was measured. The results are consistent with a purely V-A interaction and in the case of couplings to right-handed neutrinos (C_{T}=-C_{T}^{'}) limits the tensor fraction to |C_{T}/C_{A}|^{2}<0.011 (95.5% C.L.). The measurement confirms the ^{6}He result using a different nuclear system and employing modern ion-trapping techniques subject to different systematic uncertainties.

Epidemiology of epilepsy and its burden in Kolkata, India

BACKGROUND

Disability-adjusted life year (DALY) is a time-based measure of disease burden incorporating both disability and mortality. Our study aimed to determine the DALY lost from epilepsy in an Indian metropolis.

METHODS

A population-based prospective study on epilepsy was conducted over 5 years (2003-8) in Kolkata, India, on randomly selected 100,802 subjects (males 53,209, females 47,593) to assess prevalence as well as to capture incident cases of epilepsy and those incident cases that died. Standard case definitions were used. The data were used to estimate years of life lost (YLL) due to premature mortality, years of life lived with disability (YLD), and DALY, utilizing the prevalence-based Global Burden of Disease (GBD) 2010 approach. Age- and gender-specific figures were computed.

RESULTS

During 2003-2004, a total of 476 subjects with active epilepsy were detected and the age-adjusted prevalence rate was 4.71 per 1000. Over 5 years, there were 197 incident cases of epilepsy of whom 26 died. The age-adjusted annual incidence rate of epilepsy was 38.3 per 100,000. The all-cause standardized mortality rate (SMR) of epilepsy was 2.4. The burden of epilepsy in the year 2007-8 revealed the overall YLL was 755 per 100,000, and the overall YLD ranged from 14.45 to 31.0 per 100,000 persons depending on the clinical severity of the epilepsy. Both YLL and YLD values were higher in males than in females. The overall DALY lost due to epilepsy in 2007-8 was found to be 846.96 (males 1183.04, females 463.81) per 100,000.

CONCLUSIONS

This is the first study in India to determine the DALY of epilepsy using GBD 2010. The results reveal a substantial burden of epilepsy in our setting. Similar such studies are needed in other parts of India in both urban and rural settings.

A mixed anti-inflammatory and pro-inflammatory response associated with a high dose of corticosteroids

OBJECTIVE

Hydrocortisone, at a low dose (100 mg), induces an anti-inflammatory response including inducing IkBα and suppressing intranuclear NFκB and AP-1 binding and the expression of pro-inflammatory mediators like MMPs. We have now investigated the effect of a high dose of hydrocortisone (300mg=60 mg prednisolone) on NFκB binding and the expression of TLRs, the mediators of TLR signal transduction, MyD88 and TRIF and HMG-B1.

DESIGN AND SUBJECTS

A 300mg of hydrocortisone or saline was injected intravenously in ten normal subjects during 2 separate visits, in a randomized crossover study. Blood samples were obtained at 0, 1, 4, 6 and 24h after the injection and mononuclear cells (MNC) were prepared.

RESULTS

There was a significant increase in glucose (from 92±4 to 116±6 mg/dl), insulin (from 4.5±0.7 to 5.3±0.8 mU/ml) and FFA concentrations (from 0.38±0.1 to 0.80±0.15mM) following the administration of hydrocortisone compared to placebo treatment. While NFκB binding and the mRNA expression of MyD88, TRIF, chemokines and chemokine receptors were suppressed significantly in MNC, there was a paradoxical increase in the mRNA expression of TLR 2, 5 and 9 and HMG-B1 was increased by 103±24%, 107±19%, 56±13% and 58±12% above the baseline, respectively in the MNC. Plasma concentrations of HMG-B1 and MMP-9 increased by 37±12% and 125±22%, respectively, while TNF-α concentrations fell by 27±9%.

CONCLUSION

While this high dose of hydrocortisone exerts a powerful anti-inflammatory effect, it also exerts certain proinflammatory effects mainly on TLRs expression. The known pro-inflammatory effects of glucose and FFAs may have contributed to these effects. These paradoxical pro-inflammatory effects may account for the inability of these drugs to show benefit in clinical trials of septicemia and other severe pro-inflammatory states and might contribute to some of the side effects of corticosteroids use.

Effect of progressive muscle relaxation in female health care professionals

BACKGROUND

Increasing population, fast paced industrialization, increased, competitiveness, unanticipated problems in the work place have increased the stress among the females working in health care in recent times.

AIM

The aim of the following study is to detect the stress levels among female health care professionals in the age group of 25-35 years and its impact on health.

SUBJECTS AND METHODS

A prospective cross-sectional pilot project was conducted in a tertiary care hospital in Eastern part of India, after receiving approval from the Institutional Ethics Committee and informed consent form was taken from the subjects. Stress level in the subjects was assessed according to the presumptive life event stress scale. Females with scores above 200 were selected. For these, initial assessment of anthropometric measurement, electrocardiogram and lipid profile analysis, resting pulse rate, blood pressure, physical fitness index (PFI), breath holding time (BHT), isometric hand grip (IHG) test results were evaluated and recorded. All subjects were given training of progressive muscle relaxation (PMR) for 3 months. After 3 months, the lipid profile and vital parameters, Perceived Stress Scale values were re-evaluated and subjects were asked to repeat the same exercises and data thus recorded were analyzed using Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.).

RESULTS

Significant decrease in resting heart rate, blood pressure and Perceived Stress Scale levels was seen after PMR training in the subjects. Results of BHT, IHG tests and PFI were significantly increased after PMR training. There was a significant decrease in total cholesterol, triglyceride and low-density lipoprotein cholesterol in subjects after practicing PMR for 3 months.

CONCLUSIONS

Increasing stress among female health care professionals is a cause for concern and there is a need to adopt early life-style modification by practicing relaxation exercises to ameliorate stress and to improve not only their quality-of-life in general, but patient care in particular.

Quantitative adsorbate structure determination for quasicrystals using x-ray standing waves

The quantitative structure determination of adsorbed species on quasicrystal surfaces has so far appeared to present insurmountable problems. The normal incidence standing x-ray wave field technique offers a simple solution, without extensive data sets or large computations. Its application to quasicrystals raises several conceptual difficulties that are related to the phase problem in x-ray diffraction. We demonstrate their solution for the case of Si atoms adsorbed on the decagonal Co-rich modification of the Al-Co-Ni quasicrystal to determine the local structure, comprising 6-atom clusters in particular hollow sites.

In-trap spectroscopy of charge-bred radioactive ions

In this Letter, we introduce the concept of in-trap nuclear decay spectroscopy of highly charged radioactive ions and describe its successful application as a novel spectroscopic tool. This is demonstrated by a measurement of the decay properties of radioactive mass A=124 ions (here, ^{124}In and ^{124}Cs) in the electron-beam ion trap of the TITAN facility at TRIUMF. By subjecting the trapped ions to an intense electron beam, the ions are charge bred to high charge states (i.e., equivalent to the removal of N-shell electrons), and an increase of storage times to the level of minutes without significant ion losses is achieved. The present technique opens the venue for precision spectroscopy of low branching ratios and is being developed in the context of measuring electron-capture branching ratios needed for determining the nuclear ground-state properties of the intermediate odd-odd nuclei in double-beta (ββ) decay.

Breakdown of the isobaric multiplet mass equation for the A = 20 and 21 multiplets

Using the Penning trap mass spectrometer TITAN, we performed the first direct mass measurements of (20,21)Mg, isotopes that are the most proton-rich members of the A = 20 and A = 21 isospin multiplets. These measurements were possible through the use of a unique ion-guide laser ion source, a development that suppressed isobaric contamination by 6 orders of magnitude. Compared to the latest atomic mass evaluation, we find that the mass of (21)Mg is in good agreement but that the mass of (20)Mg deviates by 3 σ. These measurements reduce the uncertainties in the masses of (20,21)Mg by 15 and 22 times, respectively, resulting in a significant departure from the expected behavior of the isobaric multiplet mass equation in both the A = 20 and A = 21 multiplets. This presents a challenge to shell model calculations using either the isospin nonconserving universal sd USDA and USDB Hamiltonians or isospin nonconserving interactions based on chiral two- and three-nucleon forces.

Immune cell function assay does not identify biopsy-proven pediatric renal allograft rejection or infection

Management of pediatric renal transplant patients involves multifactorial monitoring modalities to ensure allograft survival and prevent opportunistic infection secondary to immunosuppression. An ICFA, which utilizes CD4 T-cell production of ATP to assess immune system status, has been used to monitor transplant recipients and predict susceptibility of patients to rejection or infection. However, the validity of this assay to reflect immune status remains unanswered. In a two-yr retrospective study that included 31 pediatric renal transplant recipients, 42 patient blood samples were analyzed for immune cell function levels, creatinine, WBC (white blood cell) count, immunosuppressive drug levels, and viremia, concurrent with renal biopsy. T-cell ATP production as assessed by ICFA levels did not correlate with allograft rejection or with the presence or absence of viremia. ICFA levels did not correlate with serum creatinine or immunosuppressive drug levels, but did correlate with WBC count. The ICFA is unreliable in its ability to reflect immune system status in pediatric renal transplantation. Further investigation is necessary to develop methods that will accurately predict susceptibility of pediatric renal transplant recipients to allograft rejection and infection.

Electrospray ionization tandem mass spectrometry study of six isomeric cationic amphiphiles with ester/amide linker

RATIONALE

Isomeric cationic amphiphiles differing only in the orientation of the linker group have been demonstrated to possess dramatically changed gene transfer efficacies. Studies aimed at understanding structure-stability correlations of such isomeric cationic amphiphiles at the molecular level are yet to be undertaken. Such studies may throw significant new insights into the mechanistic origin on their contrasting bioactivities.

METHODS

Electrospray ionization mass spectrometry (ESI-MS) and multi-stage tandem mass spectrometric (MS(n)) experiments were performed on a LCQ ion trap mass spectrometer. The decomposition pathway was confirmed by high-resolution mass spectrometry data from a quadrupole time-of-flight (Q-TOF) mass spectrometer. Dissociation curves were drawn based on the intensities of precursor and product ions.

RESULTS

The collision-induced dissociation (CID) spectra of the M(+) ion of each isomeric pair showed distinct product ions (3 pairs). Normal esters (1 and 3) showed abundant product ions with a neighboring group participation (NGP) reaction and reverse esters (lipid 2 and 4) showed McLafferty rearrangement product ions. The spectra of a normal amide (5) and a reverse amide (6) are similar to that found in the corresponding ester, except for the absence of the McLafferty rearrangement in 6. Dissociation curves revealed that normal esters/amide decompose at lower energy than those of corresponding reverse esters/amide.

CONCLUSIONS

The lipids which easily decompose (flexible) show dramatically enhanced gene delivery capabilities and the lipids which decompose at higher collision energy (CE) values (rigid) are transfection incompetent.