Is Guy's stone score useful for predicting outcomes in percutaneous nephrolithotomy?

INTRODUCTION

Percutaneous Nephrolithotomy (PCNL) is currently the treatment of choice in large kidney stones. Guy's stone score was developed to predict treatment outcomes. The aim of this study was to evaluate the relationship between Guy's score and outcomes in our institution.

MATERIALS AND METHODS

The medical records of patients diagnosed with urolithiasis and treated by PCNL were retrospectively evaluated between January 2017 and December 2018. Analyzed data included: age, sex, Guy's score based on preoperative findings, transfusion, stone-free rate and requirement of auxiliary procedures. Chi-square test was used for the comparison of proportions. Odds ratios (OR) with confidence intervals (CIs) of 95% were calculated by logistic regression.

RESULTS

A total of 386 patients, 53.89% female, mean age of 45.59 ± 15 years were analyzed. Guy's score was as follows: 112 patients (29.04%) were classified as Guy I, 92 patients (23.82%) as Guy II, 94 patients (24.34%) as Guy III, and 88 patients (22.80%) as Guy IV. There were no differences between groups in terms of blood transfusions. Stone-free rate was 96.43% (n = 108) for patients Guy I; 84.78% (n = 72) for Guy II; 76.59% (n = 72) for Guy III and 50% (n = 44) for Guy IV categories (p < 0.0001). Taking as a reference Guy I group, the OR to require new treatment for residual stones were: Guy II 4.85 (CI = 0.95 to 24.60, P = 0.05) to Guy III 8.25 (CI = 1.73 to 39.44, P = 0.008) and Guy IV 27 (CI = 5.84 to 124.70; p < 0.0001).

CONCLUSION

There was a statistically significant association between Guy's Score and stone-free rates following PCNL. Guy's score was useful to predict results of PCNL in our group.

Cases of Early, Aggressive In-Stent Restenosis in Left Main Double Kissing (DK) Crush Technique and Treatment Options

BACKGROUND/PURPOSE

We present three recent cases at our institution that demonstrate early, aggressive in-stent restenosis (ISR) of double-kissing (DK) crush technique despite careful adherence to the technique and compliance of the patient. There are multiple percutaneous coronary intervention strategies for left main (LM) coronary artery bifurcation disease. The DK crush technique has gained popularity for the treatment of complex bifurcation lesions, including distal LM bifurcations.

METHODS/MATERIALS

We reviewed clinical and procedural characteristics of three recent patients who presented at our tertiary center with non-ST-elevation myocardial infarction (NSTEMI) in the setting of early, aggressive ISR of DK crush. All patients underwent imaging-guided DK crush stenting with full adherence to all steps of the technique.

RESULTS

The median age was 65 years, median follow-up was 8 months from initial DK crush, and all three patients presented with NSTEMI. Patients had significant ISR in both limbs of the bifurcation involving aggressive tissue proliferation. These patients were treated differently: intracoronary brachytherapy, direct stenting, and coronary artery bypass grafting.

CONCLUSIONS

DK crush for unprotected LM distal bifurcation can result in aggressive ISR with tissue proliferation and target vessel failure despite adhering to all steps of the technique. More research is warranted before DK crush is adopted as the default technique for bifurcation lesions.

Procedural Outcomes of Patients Undergoing Percutaneous Coronary Intervention for De Novo Lesions in the Ostial and Proximal Left Circumflex Coronary Artery

Ostial coronary artery lesions can be challenging during percutaneous coronary intervention (PCI) because of elastic fiber content, calcium burden, and angulation. We assessed procedural and clinical major adverse cardiac events (MACE) associated with PCI for ostial lesions, focusing on ostial left circumflex (LC) lesions compared with ostial left anterior descending artery (LAD) and right coronary artery lesions. All patients with ostial or very proximal coronary artery lesions treated with PCI at MedStar Washington Hospital Center (Washington, DC) from 2003 to 2018 were included. The primary end point was target lesion revascularization (TLR)-MACE, defined as the composite of all-cause mortality, Q-wave myocardial infarction (MI), and TLR at 1 year. A total of 4,759 patients with available 1-year follow-up were included: 2,236 ostial/very proximal LAD, 980 ostial/very proximal LC, and 1,543 ostial/very proximal right. The presenting clinical syndrome for the LC group was mainly stable or unstable angina, whereas MI was more common in the LAD. At 1 year, the TLR-MACE rate was 16.7% in the LC group versus 12.5% in the LAD and 11.8% in the right group (p = 0.001). Mortality rates were 11.2% in the LC group versus 8.4% in the LAD and 6% in the right group (p <0.001). A Cox model showed that dialysis had the highest impact on TLR-MACE. In conclusion, compared with PCI of ostial or very proximal LAD or right lesions, PCI of ostial or very proximal LC lesions was associated with higher rates of TLR-MACE.

Micropuncture technique for femoral access is associated with lower vascular complications compared to standard needle

OBJECTIVES

We compared access-site complications with a Micropuncture 21-gauge (G) needle to a standard 18G needle in patients undergoing femoral-access percutaneous coronary intervention (PCI).

BACKGROUND

Vascular access-site complications are the most common complication after cardiac catheterization. These complications increase patient morbidity and mortality, along with healthcare costs.

METHODS

We retrospectively analyzed a cohort of 17,844 consecutive patients undergoing PCI. Micropuncture access was used in 2344 patients and a standard 18G needle in 15,500 patients. Primary endpoints included vascular perforation or limb ischemia requiring repair, retroperitoneal bleeding, pseudoaneurysm, arteriovenous fistula, groin hematoma (>4 cm).

RESULTS

Patients undergoing PCI with Micropuncture were at higher risk: they were on anticoagulation (557 [23.7%] vs. 1,590 [10.2%], p < .001), used steroids more frequently (131 [5.6%] vs. 638 [4.1%], p < .001) and required the use of an intra-aortic balloon pump more often (191 [(8.1%] vs. 896 [5.7%], p < .001). Overall, the access-site complications rate was lower using Micropuncture (58 [2.5%]) versus standard needle (558 [3.6%], p = .005). The Micropuncture group had a significantly lower rate of hematoma than standard needle (32 [1.4%] vs. 309 [1.9%], p = .03). There was no significant difference in the rate of limb ischemia (1 [0.04%] vs. 12 [0.07%], p = .56), perforation (2 [0.08%] vs. 14 [0.09%], p = .93), retroperitoneal bleeding (3 [0.12%] vs. 18 [0.11%], p = .87), pseudoaneurysm (18 [0.76%] vs. 170 [1.09%], p = .14), and arteriovenous fistula (2 [0.08%] vs. 35 [0.22%], p = .16), comparing the Micropuncture group to a standard needle, respectively.

CONCLUSIONS

Femoral access using a Micropuncture reduced the rate of vascular complications with significant reduction in the rate of groin hematomas.

High ultrasensitive serum C-reactive protein may be related to freezing of gait in Parkinson's disease patients

C-reactive protein (CRP) is a biomarker of systemic inflammation that has been linked to accelerated decline in walking speed in older adults. The aim of the present study was to compare the CRP levels of PD patients with vs patients without freezing of gait (FOG). Patients and controls participating in the COPPADIS-2015 study that performed blood extraction for determining molecular serum biomarkers were included. Patients with FOG were identified as those with a score of 1 or greater on item-3 of the Freezing of Gait Questionnaire (FOG-Q). Immunoassay was used for determining ultrasensitive CRP (US-CRP) level (mg/dL). In the PD group (n = 225; 61.8 ± 9.5 years old, 61.8% males), 32% of the patients presented FOG but none in the control group (n = 65; 60.3 ± 6.1 years old, 56.9% males) (p < 0.0001). Differences in US-CRP level were significant in patients with FOG vs patients without FOG and vs controls (0.31 ± 0.52 vs 0.16 ± 0.21 vs 0.21 ± 0.22; p = 0.04). Significant differences were also observed between patients with vs without FOG (p = 0.001) but not between patients and controls (p = 0.163). US-CRP level was related to FOG (OR = 4.369; 95% CI 1.105-17.275; p = 0.036) along with H&Y (OR = 2.974; 95% CI 1.113-7.943; p = 0.030) and non-motor symptoms burden (NMSS total score; OR = 1.017; 95% CI 1.005-1.029; p = 0.006) after adjusting for age, gender, disease duration, equivalent daily levodopa dose, number of non-antiparkinsonian drugs per day, motor fluctuations, cognition, motor phenotype, and chronic use of anti-inflammatory drugs. The present study suggests that serum US-CRP level is related to FOG in PD patients. Inflammation could be linked to FOG development.

Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Percutaneous Vascular Closure Device

Background:

Open surgical closure and small-bore suture-based preclosure devices have limitations when used for transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or percutaneous thoracic endovascular aortic aneurysm repair. The MANTA vascular closure device is a novel collagen-based technology designed to close large bore arteriotomies created by devices with an outer diameter ranging from 12F to 25F. In this study, we determined the safety and effectiveness of the MANTA vascular closure device.

Methods and Results:

A prospective, single arm, multicenter investigation in patients undergoing transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or thoracic endovascular aortic aneurysm repair at 20 sites in North America. The primary outcome was time to hemostasis. The primary safety outcomes were accessed site-related vascular injury or bleeding complications. A total of 341 patients, 78 roll-in, and 263 in the primary analysis cohort, were entered in the study between November 2016 and September 2017. For the primary analysis cohort, transcatheter aortic valve replacement was performed in 210 (79.8%), and percutaneous endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic aneurysm repair was performed in 53 (20.2%). The 14F MANTA was used in 42 cases (16%), and the 18F was used in 221 cases(84%). The mean effective sheath outer diameter was 22F (7.3 mm). The mean time to hemostasis was 65±157 seconds with a median time to hemostasis of 24 seconds. Technical success was achieved in 257 (97.7%) patients, and a single device was deployed in 262 (99.6%) of cases. Valve Academic Research Consortium-2 major vascular complications occurred in 11 (4.2%) cases: 4 received a covered stent (1.5%), 3 had access site bleeding (1.1%), 2 underwent surgical repair (0.8%), and 2 underwent balloon inflation (0.8%).

Conclusions:

In a selected population, this study demonstrated that the MANTA percutaneous vascular closure device can safely and effectively close large bore arteriotomies created by current generation transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, and thoracic endovascular aortic aneurysm repair devices.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02908880.

Alterations of Platelet Aggregation Kinetics with Ultraviolet Laser Emission: The “Stunned Platelet” Phenomenon

Platelets, a major constituent of thrombus, play a crucial role in the pathogenesis of acute ischemic coronary syndromes. The effect of ultraviolet laser emission on platelets within thrombi is unknown. The effects of increasing levels of laser energy on platelets in whole blood were investigated. Blood samples were obtained by aseptic venipuncture and anticoagulated with 3.8% sodium citrate. Samples were exposed to increased levels (0, 30, 45, 60 mJ/mm2; 25 Hz) of ultraviolet excimer laser fluence (308 nm wave-length) and then tested for ADP and collagen induced platelet aggregation, platelet concentration, and for platelet contractile force (PCF) development. Scanning electron microscopy was used to detect laser induced morphologic changes of platelets and by flow cytometric analysis to detect changes in expression of platelet surface antigens p-selectin (CD 62) and glycoprotein IIb/IIIa (CD 43). Exposure to excimer laser energy produced dose dependent suppression of platelet aggregation and force development (“stunned platelets”). ADP aggregation decreased from 8.0 ± 1.1 Ohms (mean ± SEM) to 3.7 ± 0.8 Ohms (p 0.001) to 2.7 ± 0.6 Ohms (p 0.001) and to 1.8 ± 0.5 Ohms (p 0.001) as the laser energy increased from 0 to 30 to 45 to 60 mJ/mm2, respectively. Collagen induced aggregation decreased from 21.4 ± 1.4 Ohms to 15.7 ± 1.2 Ohms (p 0.001) to 11.7 ± 1.1 Ohms (p 0.001) and to 9.9 ± 1.0 Ohms (p 0.001), in response to the same incremental range of laser energy. Platelet contractile forces declined from 34,500 ± 3700 to 27,800 ± 2700 dynes as laser energy increased from 0 to 60 mJ/mm2 (p 0.03). Platelet concentration did not change with increasing laser energy. The expression of platelet surface antigen p-selectin (CD 62) remained stable through increasing levels of laser energy exposures while the percentage of CD 43 positive platelets significantly increased with exposure to laser energy, yet the level of expression did not exceed 0.5% of cells. Thus, aggregation kinetics are altered in platelets exposed to ultraviolet laser energy as manifested by decreased platelet aggregation and reduction in platelet force development capability. The response is dose dependent and most pronounced at higher energy levels such as 60 mJ/mm2.

The CLOSER trial: a multi-center study on the clinical safety and effectiveness of CloserTM VSS, a novel resorbable transfemoral vascular access sealing system

OBJECTIVES

To evaluate the safety and effectiveness of the Closer Vascular Sealing System (VSS) against prespecified performance goals (PGs) in sealing femoral arterial access following 5-7 Fr procedures.

BACKGROUND

Inconsistent safety profiles, costs and learning curves of earlier generation vascular closure devices have limited their widespread use following transfemoral procedures.

METHODS

In this prospective single-arm, multi-center trial, we compared the clinical outcomes in patients undergoing 5-7 Fr transfemoral diagnostic or interventional procedures and access sites managed with Closer VSS against pre-specified PGs. The primary endpoints were time to hemostasis (TTH) and 30-day access site closure-related major complications; secondary endpoints included time to ambulation (TTA), time to discharge eligibility (TTDE), time to discharge (TTD), 30-day access site minor complications, procedure and device success.

RESULTS

A total of 220 subjects (49.5% interventional) were enrolled. The mean TTH was 1.78 ± 7.81 min in the intention to treat and 0.98 ± 3.71 min in the per protocol cohort. Median TTH was 0 min with immediate hemostasis achieved in 80.5% of subjects, mean TTA was 2.50 ± 1.05 hr, and mean TTDE was 2.83 ± 1.54 hr. Thirty-day follow-up was completed on 219 subjects. There were no access site closure-related major complications, minor complication rate was 0.0% for diagnostic and 2.75% for interventional procedures.

CONCLUSIONS

In patients undergoing 5-7 Fr transfemoral diagnostic and interventional procedures, the CLOSER Trial met both its primary effectiveness and safety PGs. Immediate hemostasis was achieved in the majority of patients without major complication.

Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions: A Prospective Multicenter Observational Study

Purpose: To report a prospective, multicenter, observational study (ClinicalTrials.gov identifier NCT01609621) of the safety and effectiveness of tibiopedal access and retrograde crossing in the treatment of infrainguinal chronic total occlusions (CTOs). Methods: Twelve sites around the world prospectively enrolled 197 patients (mean age 71±11 years, range 41-93; 129 men) from May 2012 to July 2013 who met the inclusion criterion of at least one CTO for which a retrograde crossing procedure was planned or became necessary. The population consisted of 64 (32.5%) claudicants (Rutherford categories 2/3) and 133 (67.5%) patients with critical limb ischemia (Rutherford category ≥4). A primary antegrade attempt to cross had been made prior to the tibiopedal attempt in 132 (67.0%) cases. Techniques used for access, retrograde lesion crossing, and treatment were at the operator’s discretion. Follow-up data were obtained 30 days after the procedure. Results: Technical tibiopedal access success was achieved in 184 (93.4%) of 197 patients and technical occlusion crossing success in 157 (85.3%) of the 184 successful tibial accesses. Failed access attempts were more common in women (9 of 13 failures). The rate of successful crossing was roughly equivalent between sexes [84.7% (50/59) women compared to 85.6% (107/125) men]. Technical success did not differ significantly based on a prior failed antegrade attempt: the access success rate was 92.4% (122/132) after a failed antegrade access vs 95.4% (62/65) in those with a primary tibiopedal attempt (p=0.55). Similarly, crossing success was achieved in 82.8% (101/122) after a failed antegrade access vs 90.3% (56/62) for patients with no prior antegrade attempt (p=0.19). Minor complications related to the access site occurred in 11 (5.6%) cases; no patient had access vessel thrombosis, compartment syndrome, or surgical revascularization. Conclusion: Tibiopedal access appears to be safe and can be used effectively for the crossing of infrainguinal lesions in patients with severe lower limb ischemia.

Unplanned flexible ureteroscopy during percutaneous nephrolithotomy in the prone position

BACKGROUND

Over time, the prone position has been shown to be effective and safe for performing percutaneous nephrolithotomy. One of its disadvantages, however, is the inability to simultaneously perform an ureteroscopy after positioning the patient, which is feasible in the supine position. Our objective is to demonstrate the feasibility of implementing flexible ureteroscopy with the patient in the prone position.

MATERIAL AND METHODS

We present a case of percutaneous nephrolithotomy of partial staghorn calculi in the prone position during which access to the middle calyx was not possible. It was therefore necessary to conduct flexible ureteroscopy. The 64-year-old female patient had consulted for lumbar pain of 6 months of evolution.

RESULTS

We performed percutaneous nephrolithotomy in the prone position. After extracting calculi from the inner calyx and renal pelvis, access to the fragments located in the middle calyx could not be achieved. Rather than performing a new puncture, we decided to enter in a retrograde manner with a flexible ureteroscope, succeeding in extracting the residual calculi, leaving the patient completely free of calculi.

CONCLUSION

In our case, the implementation of retrograde flexible ureteroscopy was feasible without changing the patient's original position.

Reversal of pulmonary hypertension after percutaneous closure of congenital renal arteriovenous fistula in a 74-year old woman

We report the case of a large right renal arteriovenous fistula (AVF) in a 74-year old woman who presented with heart failure. Transthoracic echocardiography revealed normal left ventricular size and systolic function (ejection fraction 60-65%), moderately dilated right ventricle with severely depressed systolic function, and severe pulmonary hypertension. Right heart catheterization confirmed the elevated pulmonary pressures and showed a high cardiac output. Physical examination was remarkable for a right flank bruit. An abdominal ultrasound revealed an AVF originating from the distal right renal artery and dilated suprarenal inferior vena cava and hepatic veins. These findings were confirmed with an abdominal MRI. Percutaneous endovascular closure of the right renal AVF was successfully performed, with immediate reduction of pulmonary pressures and normalization of cardiac output. The patient's symptoms improved, and a post intervention echocardiogram revealed normalization of right ventricular size.

Hybrid strategy of a bare metal stent combined with a drug-eluting stent versus exclusive drug-eluting stent implantation for multivessel percutaneous coronary intervention

AIMS

This study aimed to examine the strategy of hybrid percutaneous coronary intervention (PCI) -bare metal stent (BMS) and drug-eluting stent (DES)- versus exclusive DES implantation for patients undergoing multivessel PCI.

METHODS AND RESULTS

A cohort of 2,065 patients who underwent PCI (698 hybrid, 1,367 exclusive DES) were followed clinically up to one year. The primary outcome was target vessel revascularisation-major adverse cardiac events (TVR-MACE). Patients presenting with cardiogenic shock, anaemia (haematocrit <25), and bypass graft PCI were excluded. Only patients with ≥ 2 stents in two different lesions were analysed for this study. Baseline and procedural characteristics were similar. Major in-hospital complications and subacute stent thrombosis rates were similar. At one year, there was no difference in TVR-MACE (hybrid 17.2% vs. DES 14.6%, p=0.128). On multivariable analysis, hybrid PCI was not a predictor of TVR-MACE. The strongest predictors of TVR-MACE at one year were hypertension and African American race. Cumulative stent thrombosis rates at one year were similar in both groups.

CONCLUSIONS

Patients who undergo hybrid PCI have similar composite in-hospital and 1-year outcomes as those who undergo exclusive DES PCI. The hybrid stent approach should be considered for patients with multivessel PCI since it can lower the procedure cost without increasing adverse events.

Comparison of effectiveness of excimer laser angioplasty in patients with acute coronary syndromes in those with versus those without normal left ventricular function

Depressed left ventricular (LV) ejection fraction (EF) adversely affects procedural outcome during percutaneous coronary revascularization. This study examined the acute results, effectiveness, and safety of excimer laser coronary angioplasty (ELCA) in patients with acute coronary ischemic syndromes whose LVEF was depressed (<40%) versus those with preserved LVEF. One hundred patients with acute coronary syndromes (51 with unstable angina and 49 with acute myocardial infarction) underwent ELCA. Twenty-five patients (group 1) (29 lesions; 72% thrombotic) had decreased LVEF (mean 28 +/- 6%) and 75 patients (group 2) (81 lesions; 60% thrombotic) had preserved LVEF (mean 53 +/- 8%). Group 1 had a higher incidence of 3-vessel disease, Q-wave acute myocardial infarction, cardiogenic shock, diabetes, and hypertension. High laser success (87% group 1 vs 93% group 2, p = NS) and procedural success (93% group 1 vs 98% group 2, p = NS) were achieved in both groups. Minimal luminal diameter in group 1 increased from 0.7 +/- 0.5 to 1.4 +/- 0.5 mm after the laser procedure and finally to 3.0 +/- 0.4 mm; in group 2, minimal luminal diameter increased from 0.7 +/- 0.4 to 1.3 +/- 0.5 mm after the procedure to a final of 3.0 +/- 0.5 mm. The laser energy vaporized 75% of thrombus burden from the target lesion in group 1 versus 79% in group 2 (p = NS). Thrombolysis In Myocardial Infarction flow in group 1 increased from 1.4 +/- 1.2 to 2.7 +/- 0.7 by laser and finally to 2.9 +/- 0.3, and in group 2 from 2.0 +/- 1.0 to 2.8 +/- 0.6 after the laser procedure to a final of 2.9 +/- 0.4. There were no deaths, emergency bypass surgeries, strokes, or acute vessel closures in either group. Thus, ELCA is a safe and feasible revascularization modality for patients with acute coronary syndromes whose LVEF is depressed. The laser energy vaporizes a large thrombus burden from the treated plaque. Angiographic intracoronary thrombus does not adversely affect device and procedural success in these select patients.

Coronary revascularization in heart transplant recipients by excimer laser angioplasty

BACKGROUND AND OBJECTIVE

Aggressive development of allograft coronary artery disease is a major cause of death in heart transplant recipients. Percutaneous balloon angioplasty is considered suboptimal for complex lesions in native coronary vessels and heart transplant recipients, alike. Excimer laser energy (308-nm wavelength) can successfully remove and vaporize atherosclerotic plaques in native coronary vessels; however, its application in heart transplant recipients has not been studied clinically yet.

STUDY DESIGN/MATERIALS AND METHODS

Six heart transplant recipients underwent percutaneous excimer laser (CVX-300, Spectranetics, Colorado Springs, CO) coronary angioplasty for treatment of a total of 10 discrete, obstructive coronary artery lesions. By using concentric or eccentric multifiber laser catheters, energy parameters were set at a fluence of 45 mJ/mm(2) or 60 mJ/mm(2) with a frequency of 25 Hz and 40 Hz, respectively, with a pulse duration of 135 ns and output of 200 mJ/pulse. The "saline flush" and "pulse and retreat" lasing techniques were used. In each case, adjunct balloon angioplasty was performed; in five lesions, an intracoronary stent was implanted. Angiographic evaluation was performed by visual assessment.

RESULTS

Each procedure was successful as defined by laser recanalization of the target lesion (reduction of target lesion stenosis in more than 20%) and subsequent adequate final luminal patency (reduction of target lesion stenosis to less than 50%) and absence of any major in-cardiac catheterization complication (such as perforation, acute closure, dissection, emergency coronary artery bypass surgery), or in-hospital complications (such as death, myocardial infarction, cardiac enzyme elevation, major bleeding), or need for surgical revascularization. A 92 +/- 5% preprocedural percent diameter stenosis was reduced by laser to 35 +/- 16% and by adjunct balloon angioplasty in all lesions and stenting in five lesions, to final residual stenosis of 2 +/- 6%. Angiographic follow-up between 2 and 6 months after the procedure demonstrated a target lesion restenosis rate of 22%.

CONCLUSION

Percutaneous excimer laser is safe and efficacious in the treatment of focal obstructive lesions caused by allograft coronary artery disease. These data represent an early clinical experience; thus, the long-term outcome of this revascularization method in recipients of heart transplantation will have to be determined by a large scale prospective, randomized, multicenter clinical study.

Acute thrombotic-ischemic coronary syndromes: the usefulness of TEC

Transluminal extraction catheter (TEC) is a percutaneous device that performs simultaneous thrombus aspiration and plaque excision. Clinical indications for its application are acute myocardial infarction, unstable angina, and stable angina caused by atherosclerotic, thrombotic lesions located within native coronary arteries and degenerated saphenous vein grafts. The device is useful in management of ischemic patients with contraindications to either pharmacologic thrombolytics or platelet GPIIb/IIIa receptor inhibitors, and can also effectively be used in combination with these agents. A successful TEC procedure requires careful patient selection, strict adherence to recommended indications, optimal equipment selection, familiarity with mechanical components of the device, full understanding of safe and efficacious techniques for deployment and activation, as well as recognition of unique associated angiographic manifestations such as the "empty-pouch phenomenon." As with other debulking devices, the incidence of restenosis post-TEC appears to be directly related to acute luminal gain at the time of procedure and therefore requires the need for adjunct stenting. This communication describes and illustrates various clinical, technical, and angiographic aspects of TEC procedure in patients with acute ischemic-thrombotic coronary syndromes. Cathet. Cardiovasc. Intervent. 48:406-420, 1999.

Endopyelotomy review

Open pyeloplasty remained the standard treatment until the mid-1980s. The advantages of the open pyeloplasty include mucosa-to-mucosa anastomosis and excision of redundant renal pelvis and diseased ureter. Over the past decade, antegrade endopyelotomy has evolved as the treatment of choice for obstructions of the UPJ. Further experience has shown that primary UPJ obstruction responded equally well, with long-term success rates for both groups of patients approaching 85%. Endopyelotomy results in significantly less morbidity, and should this technique fail, subsequent open pyeloplasty is no more difficult than had it been performed initially. A 20% incidence of stones associated with UPJ obstruction has been reported. Antegrade endopyelotomy can treat these patients simultaneously. Our series of more than 400 endopyelotomies showed that success was based on the degree of preoperative hydronephrosis and renal function. The presence of massive hydronephrosis had a pejorative influence on endopyelotomy, lowering the success rate from 96% to 50%. Similarly poor renal function (less than 25% of total function) reduced the success rate from 92% to 54%. Although not as extensively reported in the urologic literature, indeed fewer patients with fewer follow-ups have undergone a ureteroscopic endopyelotomy compared with an antegrade endopyelotomy, success rates have ranged between 79% and 94%. Nephrectomy was required in 2.5% for bleeding and 5% for poor renal function. In patients with primary UPJ obstruction, Acucise has a success rate that is 15% lower than antegrade endopyelotomy. Acucise endopyelotomy is a blind procedure, with 1.5% of bleeding reported requiring transfusion and 3% has undergone postoperative embolization. Laparoscopic pyeloplasty is also a relatively new technique which has only been reported with some extensive experience in two institutions, although the success rate has been extremely high, despite a short follow-up. Overall, the incidence of crossing vessels at the UPJ is approximately 50%. The greatest problem lies in determining whether a crossing vessel is etiologically or clinically significant. Thus, the presence of a crossing vessel was potentially causally related to endopyelotomy failure in 4% of the patients. Our overall success rate of 78% for endopyelotomy is comparable and sometimes higher than the reported success rate for open pyeloplasty for horseshoe kidneys, which ranged from 55 to 80%. However, endopyelotomy has become an established treatment modality in the adult, with a decreased morbidity in comparison with open pyeloplasty. The benefits of endourologic management of pediatric UPJ obstruction are less well established.

CONCLUSIONS

Endopyelotomy is a safe and effective treatment for primary and secondary UPJ obstruction for most patients. The biggest experience with better results has been reported with antegrade endopyelotomy, which permits the treatment of associated stones. Laparoscopic pyeloplasty, which is technically demanding, may be considered the best treatment in patients with severe hydronephrosis and poor renal function, which resulted in a success rate of only 38% and 57%, respectively, with endopyelotomy. If we are going to minimize morbidity for our patients, open pyeloplasty is only the first choice for neonates and younger children, and should be considered in patients after failed endopyelotomy.

[Correlation between computed axial tomography and ileum obturating lymphadenectomy in localized adenocarcinoma of the prostate]

OBJECTIVE

To correlate the findings of CT and ileoobturator lymphadenectomy in patients with localized adenocarcinoma of the prostate.

METHODS

94 patients with adenocarcinoma of the prostate were evaluated. Ileoobturator lymphadenectomy and brachytherapy were performed in 61.1%, radical prostatectomy in 22.5% and lymphadenectomy with prostatic labeling for subsequent external radiation therapy in 5%. Lymph node CT and pathology findings were correlated.

RESULTS

Of 92 patients with a normal CT scan, 18 had positive nodes and 19.1% were understaged. Two patients with a CT scan suggestive of metastatic adenopathy had negative pathology findings. Seventy-two of the 92 patients with normal CT scans had negative nodes, accounting for a specificity of 76.6%.

CONCLUSION

Pelvic lymph node involvement changes the prognosis of prostate cancer. However, the ability of CT to detect lymph node metastasis is limited. It is therefore not a reliable method and raises the costs of staging unnecessarily.

[Correlation between prostate specific antigen and histopathologic findings in ileum-obturator node dissection]

OBJECTIVE

To determine the correlation between PSA values and the histopathological findings of ileo-obturator node dissection in prostatic cancer.

METHODS

We reviewed the data of 51 patients with clinically localized prostatic carcinoma, submitted to ileo-obturator node dissection before definitive treatment of the tumor. The patients were classified into 4 groups according to their previous PSA values: A < 10 ng/ml, B > 10 and < 20 ng/ml, C > 20 and < 50 ng/ml and D < 50 ng/ml.

RESULTS

Overall 17.6% of the patients had positive lymph nodes; 9.9% of the patients in group A, 15.4% of the patients in group B, 11.1% of those in group C and 41.7% of those in group D had positive nodes. Using 50 ng/ml as the cut-off point, 10% of those with PSA < 50 ng/ml had positive nodes vs 42.3% of those with PSA > 50 ng/ml, which was statistically significant with the Fischer test.

CONCLUSION

Preoperative PSA has a statistically significant correlation with positive nodes, considering 50 ng/ml as the cut-off point. PSA determination in patients that have received no treatment is essential in the diagnosis and evaluation of therapy in prostate cancer.

[Correlation between specific prostatic antigen and findings with total body bone scintigraphy]

OBJECTIVES

To analyze the correlation between PSA values, bony symptoms and total body bone scintiscanning in order to determine the utility of the latter technique in patients with adenocarcinoma of the prostate.

METHODS

We analyzed the correlation between the PSA values, bony symptoms and total body bone scintiscan findings of 191 patients with adenocarcinoma of the prostate; of these, 129 patients met the criteria for inclusion into the study.

RESULTS

Of the 128 patients, 32 (25%) had PSA value < 20 ng/ml, 48 (37.5%) had values ranging from 20-50 ng/ml and 48 (37.5%) had values > 50 ng/ml. The bone scintiscan was positive in only one of the 32 patients with PSA < 20 ng/ml, 45.8% of those with PSA values between 20-50 ng/ml and 70.8% of those with PSA values > 50 ng/ml. All of the patients with PSA < 20 ng/ml and no bony symptoms had a negative bone scintiscan. All patients with PSA > 20 ng/ml and bony symptoms had a positive bone scintiscan.

CONCLUSIONS

PSA is a biological marker that can effectively predict the scintiscan findings. The bone scintiscan was negative in 96.9% of the patients with PSA < 20 ng/ml. Total body bone scintiscanning can therefore be obviated in patients with PSA < 20 ng/ml and no bony symptoms, thereby reducing health costs without altering the benefits.

[Treatment of the regional lymph nodes in squamous carcinoma of the penis]

OBJECTIVES

We evaluated the management of the regional lymph nodes to determine the appropriate treatment for carcinoma of the penis.

METHODS

The records of 36 patients with carcinoma of the penis were reviewed. Lymphadenectomy was performed in 18 patients, 17 were managed conservatively (watchful waiting) and 1 patient had a biopsy and received radiotherapy.

RESULTS

Positive nodes were found in 2 of 2 pT4, 2 of 3 pT3, 8 of 13 pT2 and 2 of 12 pT1 patients submitted to lymphadenectomy. Concerning the histological grade, positive nodes were found in all of the 4 G3, 5 of 12 G2 and 3 of 20 G1 patients. The survival rate was 100% for the patients with negative lymph nodes (pNO = 6) or a single positive inguinal lymph node (pN1 = 5). A correlation was found between the T and the histological grade and the likelihood of lymph node invasion.

CONCLUSIONS

The T and the histological grade of the primary lesion must be considered when deciding the approach in the management of the lymph nodes as unnecessary lymphadenectomy can be avoided and those at high risk of lymph node invasion can be treated radically and timely.