Distal anastomosis support for bypass grafting with coronary endarterectomy for the severe diseased posterior descending artery

Background: The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency. Methods: Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG. Results: There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842–60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453–9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081–0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139–0.812, p = 0.015) were significant protective factors. Conclusions: Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

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Effect of Proximal Anastomotic Diameter on Venous Bypass Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting

The Heart Surgery Forum ◽

10.1532/hsf.1304 ◽

2015 ◽

Vol 18 (5) ◽

pp. 201

Author(s):

Mehmet Kaya ◽

Taner İyigün ◽

Mugisha Kyaruzi ◽

Okan Akıncı ◽

Hafize Otcu ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Graft Failure ◽

Protective Factor ◽

Artery Bypass ◽

Bypass Graft ◽

Graft Patency ◽

Proximal Anastomosis ◽

Cox Regression Analysis ◽

Significant Difference

Background: In this study, the relationship between patency of saphenous vein (SV) graft and different sizes of aorta wall punches was investigated during the follow-up period after coronary artery bypass graft surgery. We also evaluated the other possible factors affecting SV graft patency. Methods: This study consisted of 266 consecutive and symptomatic patients with postoperative angiography. The primary endpoint was at least one saphenous graft failure observed from coronary computed tomography angiography (cCTA) and/or invasive angiography after surgery. Groups were created as SV occluded and patent group. Survival curves of patients in groups were estimated using Kaplan-Meier method and compared by log-rank test. Multivariate analysis was performed using the Cox proportional hazard model. Results: Cox-regression analysis demonstrated influence of older age (P = .023) and Diabetes Mellitus (DM) (P = .002) on SV graft failure. However, increasing ejection fraction (P = .011) was a protective factor against SV graft failure. There was no significant difference between the two groups in terms of usage rate of the punches with different diameters (P = .296). Conclusion: The incidence of SV graft patency does not seem to increase in patients whose 4.8-mm aortic punch was used during proximal anastomosis compared to the reference group in which a punch of 4.0 mm was used. Also, the final proximal anastomosis graft size that was measured using cCTA was similar between patients with 4.8-mm punch and patients with 4-mm punch. Results from this study could help to determine which size for aortosaphenous anastomosis is clinically optimal.

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Head and neck cutaneous melanoma: 5-year survival analysis in a Serbian university center

World Journal of Surgical Oncology ◽

10.1186/s12957-020-02091-4 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Aleksandar Višnjić ◽

Predrag Kovačević ◽

Asen Veličkov ◽

Mariola Stojanović ◽

Stefan Mladenović

Keyword(s):

Survival Analysis ◽

Head And Neck ◽

Cutaneous Melanoma ◽

Cox Regression ◽

Total Sample ◽

Advanced Stage ◽

Cross Sectional ◽

Cox Regression Analysis ◽

Significant Difference

Abstract Background Head and neck melanoma (HNM) is specific from the anatomical and etiopathogenetic aspects. In addition to morphopathological parameters, rich vascularization and lymphatic drainage of the head and neck affect the occurrence of lymphogenic and hematogenous metastases, as well as the metastases on both sides of the neck. Methods A retrospective cross-sectional study included cutaneous melanoma patients who underwent surgery at a clinical center over a 10-year period. The clinical follow-up was at least 60 months. The Kaplan-Meier method was used for the survival analysis. The predictor effect of certain independent variables on a given dichotomous dependent variable (survival) was measured by the Cox regression analysis. Results The analysis of demographic and clinical characteristics of 116 patients with HNM revealed that there was no statistically significant difference in age and gender in the total sample. Thirty-three (28.45%) patients were already in stage III or IV of the disease at the first examination, which affected the overall survival rate. The overall 5-year survival was 30.2%. No statistically significant difference in 5-year survival was found in relation to age and location. The period without melanoma progression decreased progressively in the advanced stage. Forty-nine patients (42%) underwent surgery for lymphogenic metastases in the parotid region and/or neck during the follow-up. Conclusions Patients with HNM included in this study frequently presented an advanced stage of the disease at the first examination, which is reflected in a low rate of 5-year survival. Early diagnosis and adequate primary treatment can ensure longer survival.

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Assessment of Losartan 50 mg on Survival of Post-Dialysis Euvolemic Hypertensive Patients: Findings from HELD Trial

Blood Purification ◽

10.1159/000500997 ◽

2019 ◽

Vol 48 (3) ◽

pp. 233-242

Author(s):

Raja Ahsan Aftab ◽

Amer Hayat Khan ◽

Azreen Syazril Adnan ◽

Syed Azhar Syed Sulaiman ◽

Tahir Mehmood Khan

Keyword(s):

Cox Regression ◽

Dialysis Session ◽

Hypertensive Patients ◽

Cox Regression Analysis ◽

Probability Of Survival ◽

End Point ◽

Kaplan Meier ◽

Significant Difference ◽

Single Blind

Aims and objective: To estimate the effect of losartan 50 mg on survival of post-dialysis euvolemic hypertensive patients. Methodology: A single center, prospective, single-blind randomized trial was conducted to estimate the survival of post-dialysis euvolemic hypertensive patients when treated with lorsartan 50 mg every other day. Post-dialysis euvolemic assessment was done by a body composition monitor. Covariate Adaptive Randomization was used for allocation of participants to the standard or intervention arm, and the follow-up duration was twelve months. The primary end point was achieving targeted blood pressure (BP) of <140/90 mm Hg and maintaining for 4 weeks, whereas secondary end point was all cause of mortality. Pre-, intra-, and post-dialysis session BP measurements were recorded, and survival trends were analyzed using Kaplan-Meier analysis. Results: Of the total 229 patients, 96 (41.9%) were identified as post-dialysis euvolemic hypertensive. Final samples of 88 (40.1%) patients were randomized into standard (n = 44) and intervention arms (n = 44), and 36 (81.8%) patients in each arm completed a follow-up of 12 months. A total of eight patients passed away during the 12-month follow-up period (6 deaths among standard arm and 2 in intervention arm). However, the probability of survival between both arms was not significant (p = 0.13). Cox regression analysis revealed that chances of survival were higher among the patients in the intervention (OR 3.17) arm than the standard arm (OR 0.31); however, the survival was found not statistically significant. Conclusion: There was no statistical significant difference in 1 year survival of post-dialysis euvolemic hypertensive patients when treated with losartan 50 mg.

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Radiation Pneumonitis Risk after Bleomycin Toxicity in Hodgkin Lymphoma Patients

Blood ◽

10.1182/blood.v126.23.1511.1511 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1511-1511

Author(s):

Zeinab A Abou Yehia ◽

George Mikhaeel ◽

Grace Smith ◽

Chelsea C Pinnix ◽

Sarah A Milgrom ◽

...

Keyword(s):

Hodgkin Lymphoma ◽

Respiratory Symptoms ◽

Cox Regression ◽

Radiation Pneumonitis ◽

Radiation Treatment ◽

Cox Regression Analysis ◽

Significant Difference ◽

To Receive ◽

Median Interval

Abstract Introduction: Combined modality treatment with Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD) chemotherapy followed by consolidative radiation to start within 3-4 weeks is the current accepted approach in the treatment of patients with early stage Hodgkin lymphoma (HL). Bleomycin pulmonary toxicity (BPT) is a well-known complication of treatment in HL patients. We undertook this study to investigate the risk of radiation pneumonitis (RP) in the setting of BPT and to determine the need for delay or omission of radiation in these patients. Methods: We reviewed the records of all HL patients treated with ABVD followed by radiation therapy (RT) to the chest between January 2009 and December 2014. We defined bleomycin toxicity as: the occurrence of clinical respiratory symptoms leading to discontinuation of bleomycin and/or bilateral opacities noted on computed tomography (CT) imaging and/or drop in diffusing capacity of the lung for carbon monoxide (DLCO) by 25%, in the absence of infection. We identified 129 patients, 100 of which received consolidation RT as part of combined modality and are the subject of this report, 29 patients were excluded because they developed relapse before getting RT. We compared patients with and without bleomycin toxicity for the following outcomes:Frequency of RP using the Pearson chi-square test.Interval between BPT and Radiation using Mann-Whitney U test (MWT)Interval between end of chemotherapy and radiation using MWT. We used univariate Cox regression analysis to assess the risk of RP by looking at the time-interval in weeks from end of bleomycin to start of RT. Results: Median follow up was 23 months (6 - 69), Median age was 31 years (18-77), and 60% were females. Per our criteria, 28 patients developed BPT (25.5%). All patients received intensity modulated radiation therapy, radiation dose median was 30.60 Gy (20-42Gy). Mean lung dose (MLD) was a median of 9.4 Gy (2.6- 13.9 Gy). The median interval between chemotherapy and RT was 3 weeks (1- 8 weeks). Median interval from stopping bleomycin, either as a precaution or because of toxicity, to the start of RT was 5 weeks (1-20 weeks). Interval between documented bleomycin toxicity to start of radiation was a median of 8.5 weeks (2-20 weeks). We had 10 cases of RP (10%), 5 of which were ≥ Grade 2. There was no significant difference in RP risk in patients with or without BPT; 10.7% (3/28) versus 9.6% (7/72) respectively, P= 0.82. Patients with BPT versus those without BPT had no significant difference in baseline characteristics. The interval time from chemotherapy to radiation was a median of 3 weeks in both groups with or without BPT showing no difference; P= 0.83. However, Patients with BPT had a significantly longer interval from last bleomycin cycle to start of radiation compared to those without BPT (median 8.5 vs. 5 weeks, p =0.014). The intervals from chemotherapy to radiation treatment and from bleomycin to radiation treatment showed no significant correlation with RP on univariate Cox regression analysis (P= 0.41 and P= 0.12, respectively). This was maintained when adjusted for the number of bleomycin cycles. Treatment of BPT Of the 28 patients, 17 were managed by stopping bleomycin and observation only; 10 patients required a 2 week course of steroids. One patient went into severe respiratory compromise, was started on continuous oxygen and eventually recovered 48 hours later and went on to receive RT beginning 2 weeks after completing his steroid treatment. This patient did not have pulmonary complications after RT. All 28 BPT patients eventually completed their planned course of radiation. At last follow up, all 28 patients were alive and free of respiratory symptoms. Conclusion: In our cohort of Hodgkin lymphoma patients, those patients with bleomycin toxicity who received standard RT had no excess risk of subsequent RP. Moreover, patients were able to receive complete courses of RT to intended conventional radiation doses. Our findings suggest that RT does not need to be delayed following chemotherapy, except to allow for the completion of steroids or clinical recovery from BPT. Table 1. BPT_clinical BPT _imaging BPT_DLCO≥25% Clinical+(CTorDLCO≥25%) BPT per criteria All patients n=100 25 17 10 13 28 RP No n=90 22 15 9 12 25 Yes n=10 3 2 1 1 3 Disclosures No relevant conflicts of interest to declare.

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Early and Midterm Outcome of TEVAR for Thoracic Aortic Pseudoaneurysm

10.21203/rs.3.rs-659146/v1 ◽

2021 ◽

Author(s):

Hui Wang ◽

Tun Wang ◽

Hao He ◽

Xin Li ◽

Yuan Peng ◽

...

Keyword(s):

Risk Factors ◽

Clinical Outcome ◽

Cardiac Disease ◽

Cox Regression ◽

Cox Regression Analysis ◽

Aortic Pseudoaneurysm ◽

Significant Difference ◽

Independent Risk Factors ◽

The Mean

Abstract Backgrounds: The prognosis of thoracic aortic pseudoaneurysm (TAP) after thoracic endovascular aortic repair (TEVAR) remains unclear. This study investigates the early and midterm clinical outcome as well as relevant risk factors of TAP patients following TEVAR therapy.Methods: From July 2010 to July 2020, 37 eligible TAP patients who underwent TEVAR were selected into our research. We retrospectively explored their baseline, perioperative and follow-up data. Fisher exact test and Kaplan-Meier method were applied for comparing difference between groups. Risk factors of late survival were discerned using Cox regression analysis.Results: There were 29 men and 12 women, with the mean age as 59.5±13.0 years (range, 30-82). The mean follow-up time was 30.7±28.3 months (range, 1-89). For early result, early mortality (≦30days) happened in 3(8.1%) zone 3 TAP patients versus 0 in zone 4 (p= 0.028); acute arterial embolism of lower extremity and type II endoleak respectively occurred in 1(2.7%) case. For midterm result, survival at 3 months, 1 year and 5 years was 88.8±5.3%, 75.9±7.5% and 68.3±9.9%, which showed significant difference between zone 2/3 versus zone 4 group (56.3±14.8% versus 72.9±13.2%, p= 0.013) and emergent versus elective TEVAR groups (0.0±0.0% versus 80.1±8.0%, p= 0.049). On multivariate Cox regression, lesions at zone 2/3 (HR 4.605, 95%CI 1.095-19.359), concomitant cardiac disease (HR 4.932, 95%CI 1.086-22.403) and emergent TEVAR (HR 4.196, 95%CI 1.042-16.891) were significant independent risk factors for worse late clinical outcome. Conclusions: TEVAR therapy is effective and safe with satisfactory early and midterm clinical outcome for TAP patients. Lesions at zone 2/3, concomitant cardiac disease and emergent TEVAR were independent risk factors for midterm survival outcome.

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Bilateral internal thoracic artery grafting in haemodialysis patients with diabetic nephropathy

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivaa208 ◽

2020 ◽

Vol 31 (6) ◽

pp. 774-780

Author(s):

Kohei Hachiro ◽

Takeshi Kinoshita ◽

Tomoaki Suzuki ◽

Tohru Asai

Keyword(s):

Diabetic Nephropathy ◽

Internal Thoracic Artery ◽

Cox Regression ◽

Statistical Significance ◽

Artery Bypass ◽

Myocardial Revascularization ◽

University Hospital ◽

Deep Sternal Wound Infection ◽

Significant Difference

Abstract OBJECTIVES To compare postoperative outcomes in patients with diabetic nephropathy receiving haemodialysis and undergoing isolated coronary artery bypass grafting (CABG) using bilateral or single skeletonized internal thoracic artery (ITA). METHODS Among 1441 consecutive patients undergoing isolated CABG between 2002 and 2019 at our university hospital, we retrospectively analysed data for 107 patients with diabetic nephropathy receiving haemodialysis. After inverse probability of treatment weighting, we found no statistically significant differences regarding patients’ preoperative characteristics. RESULTS All patients underwent myocardial revascularization using the off-pump technique. There was no statistical significance in postoperative deep sternal wound infection (P = 0.902) and 30-day mortality (P = 0.755). However, the bilateral ITA group had a lower rate of postoperative stroke versus the single group (0% vs 5.5%, respectively; P = 0.021). Follow-up was completed in 95.3% (102/107) of the patients, and the mean follow-up duration was 3.3 years. Thirty-eight deaths occurred in the bilateral ITA group and 18 in the single ITA group. There was no significant difference in all-cause death (P = 0.558) and cardiac death rates (P = 0.727). Multivariable Cox regression models showed that the independent predictors of all-cause death were age [hazard ratio (HR) 1.031; P = 0.010], previous percutaneous intervention (HR 1.757; P = 0.009) and gastroepiploic artery grafting (HR 0.582; P = 0.026). CONCLUSIONS Bilateral ITA grafting in patients with diabetic nephropathy receiving haemodialysis did not improve mid-term outcomes.

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Intraoperative Assessment of Coronary Resistances: A New Quality Marker and Potential Tool to Predict Early Graft Failure after Coronary Artery Bypass Grafting?

Journal of Cardiovascular Development and Disease ◽

10.3390/jcdd8120163 ◽

2021 ◽

Vol 8 (12) ◽

pp. 163

Author(s):

Antonino Salvatore Rubino ◽

Fabrizio Ceresa ◽

Liborio Mammana ◽

Giuseppe Vite ◽

Gianluca Cullurà ◽

...

Keyword(s):

Graft Failure ◽

Coronary Revascularization ◽

Artery Bypass ◽

Graft Patency ◽

Graft Occlusion ◽

Additional Tool ◽

Intraoperative Assessment ◽

Early Graft ◽

Early Graft Failure

Intraoperative assessment of graft patency is pivotal for successful coronary revascularization. In the present study we aimed to propose a new, easy to perform tool to assess anastomotic quality intraoperatively, and to investigate its potential reliability in predicting early graft failure. Intraoperative graft flowmetry of 63 consecutive patients undergoing CABG were prospectively collected. Transit time flowmetry and its derivatives were recorded. Coronary resistances were calculated according to Hagen–Poiseuille equation both during cardioplegic arrest and after withdrawal from cardiopulmonary bypass. Angiographic evidence of graft occlusion at follow-up was cross-checked with intraoperative recordings. After a mean follow-up of 10.4 ± 6.0 months, 22 grafts were studied, and occlusion was documented in five (22.7%). Occluded grafts showed lower flows and higher resistances recorded during aortic cross-clamping. Coronary resistances, recorded during aortic cross-clamping, greater than 2.0 mmHg/mL/min, showed a sensitivity of 80% and a specificity of 100% to predict graft failure. We propose the routine recording of coronary resistances during aortic cross-clamping as an additional tool to overcome the acknowledged limitation of TTF to predict graft occlusion at 1 year.

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Transit time flow measurement predicts graft patency in off-pump coronary artery bypass grafting upon 5-year angiographic follow-up

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01716-3 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Caiwu Zeng ◽

Xiaomi Li ◽

Yan Dai ◽

Ye Zhou ◽

Chenglong Li ◽

...

Keyword(s):

Coronary Artery ◽

Graft Failure ◽

Artery Bypass ◽

Bypass Graft ◽

Graft Patency ◽

Bypass Grafts ◽

Off Pump ◽

Time Flow ◽

Pump Coronary Artery Bypass

Abstract Objective This retrospective study sought to evaluate the efficacy of transit time flow measurement (TTFM) as a means of predicting bypass graft patency as assessed by coronary artery angiography upon 5-year follow-up. Methods Of 311 patients undergone isolated off-pump coronary artery bypass graft surgery from January 2014 through December 2014, 202 (65%) underwent both intraoperative TTFM and angiography at follow-up. 610 grafts, 202 left internal mammary artery grafts and 408 saphenous vein grafts were checked. Any grafts that exhibited Fitzgibbon type B or O lesions upon angiographic evaluation were considered to be failing. Receiver operating characteristic curves were used to identify the optimal TTFM values for predicting graft patency. Results A total of 610 grafts were included in this analysis, including 202 LIMA grafts and 408 SV grafts, of which 107, 129, 129, and 43 anastomosed to DIAG, OM, PDA, and PLA, respectively. LIMA, DIAG, OM, PDA, and PLA bypass grafts had overall patency rates of 95.0%, 74.8%, 73.6%, 71.5%, and 74.4%, respectively, upon 5-year follow up. No significant differences in TTFM values (MGF, PI, and DF) were observed when comparing outcomes associated with individual or sequential SV grafting. MGF was found to be predictive of graft failure regardless of the target vessel (P < 0.05). While PI was found to predict LIMA, OM, and PDA graft failure (P < 0.05), it was not associated with the failure of grafts associated with DIAG and PLA vessels. Similarly, DF was found to predict OM and PDA graft failure (P < 0.05), but was not significantly associated with the failure of grafts associated with LIMA, DIAG, or PLA vessels. Conclusion LIMA bypass grafts were associated with better 5-year graft patency relative to SV bypass grafts. Similar graft patency rates were observed for both individual and sequential bypass grafts. MGF was able to predict bypass graft failure in patients that underwent off-pump CABG surgery.

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Abstract 16023: Network Meta-analysis of Randomized Controlled Trials for Graft Patency of a Second Conduit for Coronary Artery Bypass Surgery

Circulation ◽

10.1161/circ.142.suppl_3.16023 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Yujiro Yokoyama ◽

Hisato Takagi ◽

Toshiki Kuno

Keyword(s):

Coronary Artery ◽

Graft Failure ◽

Internal Thoracic Artery ◽

Meta Analysis ◽

Artery Bypass ◽

Graft Patency ◽

Controlled Trials ◽

Randomized Controlled ◽

The Right

Background: It has been well documented that the use of the left internal thoracic artery (LITA) to graft the left anterior descending (LAD) artery has a significant benefit in coronary artery bypass graft (CABG) surgery. However, what graft is the best as a second conduit to complement LITA-LAD anastomosis remains uncertain. We thus conducted a network meta-analysis of RCTs to compare graft patency of the radial artery (RA), the right internal thoracic artery (RITA), the right gastroepiploic artery (RGEA), and saphenous vein (SVG) as a second conduit in CABG. Methods: MEDLINE and EMBASE were searched through February 8th, 2020 to identify randomized controlled trials (RCTs) that investigated graft patency of a second conduit in CABG. From each study, we extracted the incidence rate ratios (IRR) of the outcome. Results: A total of 11 RCTs were identified, including 3,434 patients and 2,171 angiographic results. There was no significant difference of IRR in graft failure among the 4 groups (vs. SVG: RA, IRR [95%CI] =0.66 [0.41-1.07]; RGEA, IRR [95% CI] =2.12 [0.54-8.38]; RITA, IRR [95% CI] =0.71 [0.32-1.60]). (Figure) Sensitivity analyses restricting trials with ≥3 years angiographic follow-up time or ≥5 years angiographic follow-up time showed no significant differences of IRR in graft failure among the four groups in both analyses. Conclusion: In a network meta-analysis of the updated outcomes from RCTs, no significant differences were observed in graft patency with the use of RA, RITA, RGEA or SVG as a second conduit in CABG.

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Prognostic Significance of Blasts in the Cerebrospinal Fluid Without Pleiocytosis or a Traumatic Lumbar Puncture in Children With Acute Lymphoblastic Leukemia: Experience of the Dutch Childhood Oncology Group

Journal of Clinical Oncology ◽

10.1200/jco.2005.03.9727 ◽

2006 ◽

Vol 24 (15) ◽

pp. 2332-2336 ◽

Cited By ~ 64

Author(s):

D. Maroeska W.M. te Loo ◽

Willem A. Kamps ◽

Anna van der Does-van den Berg ◽

Elisabeth R. van Wering ◽

Siebold S.N. de Graaf

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Lumbar Puncture ◽

Cox Regression ◽

Lymphoblastic Leukemia ◽

Prognostic Significance ◽

Event Free Survival ◽

Free Survival ◽

Cox Regression Analysis ◽

Significant Difference

Purpose To determine the significance of blasts in the CSF without pleiocytosis and a traumatic lumbar puncture in children with acute lymphoblastic leukemia (ALL). Patients and Methods We retrospectively studied a cohort of 526 patients treated in accordance with the virtually identical Dutch protocols ALL-7 and ALL-8. Patients were classified into five groups: CNS1, no blasts in the CSF cytospin; CNS2, blasts present in the cytospin, but leukocytes less than 5/μL; CNS3, blasts present and leukocytes more than 5/μL. Patients with a traumatic lumbar puncture (TLP; > 10 erythrocytes/mL) were classified as TLP+ (blasts present in the cytospin) or TLP− (no blasts). Results Median duration of follow-up was 13.2 years (range, 6.9 to 15.5 years). Event-free survival (EFS) was 72.6% (SE, 2.5%) for CNS1 patients (n = 304), 70.3% (SE, 4.7%) for CNS2 patients (n = 111), and 66.7% (SE, 19%) for CNS3 patients (n = 10; no significant difference in EFS between the groups). EFS was 58% (SE, 7.6%) for TLP+ patients (n = 62) and 82% (SE, 5.2%) for TLP− patients (n = 39; P < .01). Cox regression analysis identified TLP+ status as an independent prognostic factor (risk ratio, 3.5; 95% CI, 1.4 to 8.8; P = .007). Cumulative incidence of CNS relapses was 0.05 and 0.07 in CNS1 and CNS2 patients, respectively (not statistically significant). Conclusion In our experience, the presence of a low number of blasts in the CSF without pleiocytosis has no prognostic significance. In contrast, a traumatic lumbar puncture with blasts in the CSF specimen is associated with an inferior outcome.

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