Stent grafts improved patency of ruptured hemodialysis vascular accesses

This study aimed to compare stent graft with balloon tamponade for ruptured dialysis access during percutaneous transluminal angioplasty. Patients over an 8-year period (2010–2018) were identified from a database of 11,609 procedures. The primary endpoint was target lesion primary patency at 12 months. A total of 143 patients who had rupture dialysis access were enrolled, of whom 52 were salvaged by stent grafts and 91 were salvaged by balloon tamponade. The 6-month target lesion primary patency was greater in the stent graft group than in the balloon tamponade group (66.7% vs. 29.5%, P < 0.001). The benefit of stent grafts was sustained for 12 months (52.5% vs. 9.0%, P < 0.001). The stent grafts increased the median time from the index procedure to the next intervention in the ruptured area by 171 days (260 vs. 89 days) at 12 months. There was no significant difference in the access circuit patency rates at 6 months (25.5% vs. 19.8%, P = 0.203) and 12 months (12.0% vs. 5.8%, P = 0.052). The patency results of the stent grafts remained after the multivariable adjustment analysis. Compared to balloon tamponade alone, stent grafts provided superior target lesion primary patency at 6 and 12 months. The access circuit patency rates were similar.

Treatment of cephalic arch stenosis in dysfunctional arteriovenous fistulas with paclitaxel-coated versus conventional balloon angioplasty

Background Treatment of cephalic arch stenosis (CAS) with standard plain old balloon angioplasty (POBA) in dysfunctional arteriovenous fistulas (AVF), is associated with early re-stenosis and higher failure rates compared to other lesions. Paclitaxel-coated balloons (PCB) may improve patency rates. This is a retrospective cohort study. Patients who underwent POBA or PCB for CAS over a 3-year period were included. Outcomes compared were circuit primary patency rates (patency from index procedure to next intervention), circuit primary assisted-patency rates (patency from index procedure to thrombosis), and target lesion (CAS) patency rates (stenosis > 50%) at 3, 6 and 12 months. Results Ninety-one patients were included. Sixty-five (71.4%) had POBA, while 26 (28.6%) had PCB angioplasty. There were 62 (68.1%) de-novo lesions. CAS was the only lesion that needed treatment in 24 (26.4%) patients. Circuit primary patency rates for POBA versus PCB groups were 76.2% vs. 60% (p = 0.21), 43.5% vs. 36% (p = 0.69) and 22% vs. 9.1% (p = 0.22) at 3, 6 and 12-months respectively. Circuit assisted-primary patency rates were 93.7% vs. 92% (p = 1.00), 87.1% vs. 80% (p = 0.51) and 76.3% vs. 81.8% (p = 0.77), whilst CAS target lesion intervention-free patency rates were 79.4% vs. 68% (p = 0.40), 51.6% vs. 52% (p = 1.00) and 33.9% vs. 22.7% (p = 0.49) at 3, 6 and 12-months respectively. Estimated mean time to target lesion intervention was 215 ± 183.2 days for POBA and 225 ± 186.6 days for PCB (p = 0.20). Conclusion Treatment of CAS with PCB did not improve target lesion or circuit patency rates compared to POBA.

EP.TH.855Hartmanns reversal - Laparoscopic Vs Open, UHNM experience over the last 3 years

Aim Reversal of hartmanns is still an operation associated with significant morbidity. Although various studies have tried to assess the best time for attempting reversal after the primary operation, there is still no consensus. The aim of our study was to look at our experience over the last three years to find any possible factors which determine the duration between primary operation and reversal and compare laparoscopic vs open approach. Methods Prospective cohort including consisting of patients who underwent hartmanns reversal in 3 years was analysed (January-2017 to December-2019). Data was collected retrospectively from clinical notes. Results Among the patients (n = 50) there was equal distribution of males (52%) and females (48%). Although the initial operation was open in 74% patients, reversal was attempted laparoscopically in 46% with a conversion rate of 43.4%. Median duration between initial operation and reversal was 433 days. There was no significant association between duration before reversal and patient comorbidities or the indication for the index procedure. Also there was no statistical difference in postoperative hospital stay or immediate postoperative morbidity between laparoscopic and open hartmanns reversal. Conclusion There was no difference in immediate postoperative outcomes between patients who had laparoscopic or open hartmanns reversal. There was no determining factor which made the surgeon prefer laparoscopic over open approach nor was there a difference in duration between primary operation and reversal based of patient factors or method of approach. Hence timing of hartmanns reversal and the method of approach still depends on surgeon preference and experience.

Novel cryoballoon to isolate pulmonary veins in patients with paroxysmal atrial fibrillation: one-year outcomes in a multicenter study

Background Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB. Purpose To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF. Methods This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia. Results Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias. Conclusion Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston Scientific

The Epidemiology of Revision Total Knee Arthroplasty

With an expected increase in total knee arthroplasty (TKA) procedures, revision TKA (rTKA) procedures continue to be a burden on the United States health care system. The evolution of surgical techniques and prosthetic designs has, however, provided a paradigm shift in the etiology of failure mechanisms of TKA. This review can shed light on the current reasons for revision, which may lead to insights on how to improve outcomes and lower future revision risks. We will primarily focus on the epidemiology of rTKA in the present time, but we will also review this in the context of various time periods to see how the field has evolved. We will review rTKAs: 1) prior to 1997; 2) between 1997 and 2000; 3) between 2000 and 2012; and 3) in the modern era since 2012. We will further subdivide each of the sections into reasons for early (first 2 years after index procedure) versus late revisions (greater than 2 years after index procedure). In doing so, it was determined that prior to 1997, the most prevalent causes of failure were infection, patella failure, polyethylene wear, and aseptic loosening. After a major shift of failure mechanisms was described by Sharkey et al, polyethylene wear and aseptic loosening became the leading causes for revision. However, with the improved manufacturing technology and implant design, polyethylene wear was replaced with aseptic loosening and infection as the leading causes of failure between 2000 and 2012. Since that time, in the modern era of TKA, mechanical loosening and infection have taken over the most prevalent causes for failure. Hopefully, with continued developments in component design and surgical techniques, as well as increased focus on infection reduction methods, the amount of rTKA procedures will decline.

Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament Reconstruction

Background: Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series. Purpose: To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients. Results: A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care. Conclusion: Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.

1321 Repeat Colonoscopy: Incidence, Etiology, And Suggestions for Improvement

Aim Colonoscopy is an invasive procedure. Repeating such a procedure has many implications in terms of risks, costs, increased workload and strains on hospital resources. The current study reports the incidence and aetiology of repeat colonoscopies and provides recommendations for improvement. Method The current study was conducted at North Cumbria Integrated Care (NCIC) hospitals over a period of 1 year (January 1st to December 31st, 2019). All patients with a label of “Repeat” by JAG software system, were included in the primary analysis. Patients with colonoscopy after 52 weeks of the index procedure, were excluded. Two authors manually assessed the validity of the data and determined “True repeat rate” and aetiology. Results During the study period, 4717 colonoscopies were performed, where 187 were recorded as a repeat. Manual validation showed that true repeat cases were 355/4717 (7.52%). Moreover, 5% of the system labelled cases where not true repeats rather were escalated from sigmoidoscopy to colonoscopy. Analysis of the first 1000 colonoscopies detected 72 cases. Male to female ratio was 47:25 with a mean age of 66.26 ± 11.75(SD). The causes included further management of polyps (n = 30); poor bowel preparation(n = 22); inability to proceed (n = 9); anticoagulation (n = 8) and others (n = 3). Subgroup analyses of the polyp group showed that the reasons for repeating colonoscopy in such cases were appropriate. Conclusions An operational definition of the ‘Repeat coloscopy’ should be clearly established. Although most of the repeat colonoscopies for “further management of polyps” are appropriate, repeat due to poor bowel preparation and anticoagulation are clearly preventable.

Risks of Recurrent Cardiovascular Events and Mortality in 1-Year Survivors of Acute Myocardial Infarction Implanted with Newer-Generation Drug-Eluting Stents

Current treatments for acute myocardial infarction (AMI) have dramatically improved clinical outcomes during the first year after AMI. Less is known, however, about the subsequent risks of recurrent cardiovascular events and mortality in patients who survive 1 year after AMI. The purpose of the present study is to evaluate long-term clinical outcomes in 1-year AMI survivors who were implanted with newer-generation drug-eluting stents (DESs) since 2010. The COREA-AMI (CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI) registry consecutively enrolled AMI patients who underwent percutaneous coronary intervention (PCI), and patients who received newer-generation DESs since 2010 were analyzed. The primary endpoint was major adverse cardiovascular events (MACEs), and secondary endpoint was all-cause mortality. Of 6242 AMI patients, 5397 were alive 1 year after the index procedure. The cumulative incidence of MACEs and all-cause death 1 to 7 years after AMI were 28.4% (annually 4–6%) and 20.2% (annually 3–4%), respectively. Multivariate analysis showed that uncontrolled systolic blood pressure (SBP) and serum low-density lipoprotein cholesterol (LDL-C) concentration, as well as traditional risk factors, were associated with MACEs and all-cause death. Recurrent non-fatal myocardial infarction, ischemic stroke, and bleeding events within 1 year were significantly associated with all-cause death. The risks of adverse cardiovascular events and death remain high in AMI patients more than 1 year after the index PCI with newer-generation DESs. Traditional risk factors, uncontrolled SBP and LDL-C, and non-fatal adverse events within 1 year after the index procedure strongly influence long-term clinical outcomes.