Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Application of Combined Superficial Femoral Artery Stenting and Deep Femoral Artery Profundoplasty in Chinese Patients With Lower Extremity Artery Disease

Objective: Lower extremity artery disease (LEAD) increases sharply with age and results in severe burden in individuals and in society. This study aimed to compare the efficiency of simple superficial femoral artery stenting (SFAS) and the hybrid operation, such as combined SFAS and deep femoral artery profundoplasty (DFAP), in the treatment of Chinese patients with LEAD, classified as Rutherford grades 3–5.Methods: There were 200 patients with LEAD classified as Rutherford grades 3–5 included in the simple SFAS group (n = 100) and the combined SFAS and DFAP group (n = 100).Results: All the patients had median age of 71 years, and there were 143 males (71.5%). Not only the increase rate of ankle brachial index (ABI), but also reduction rate of Rutherford grade, were significantly higher after surgery in the combined SFAS and DFAP group than in the simple SFAS group (P < 0.05 for all). The patency rate of patients in the combined SFAS and DFAP group was significantly higher than that of patients in the simple SFAS group during the follow-up (P < 0.05). Proportion of amputation and claudication distance <200 m had no significant difference between the two groups during the 2-year follow-up (P > 0.05 for all).Conclusion: This study demonstrated that, compared with SFAS, combined SFAS and DFAP improved not only the ABI and the Rutherford grade after surgery but also the patency rate during the follow-up in Chinese patients with LEAD. Hybrid operation has significant value in alleviating clinical symptoms after surgery, and, thereby, improving vascular prognosis in Chinese patients.

UNAMID: A Path Towards Hybrid Peacekeeping?

ABSTRACT In 2007, the United Nations - African Union Hybrid Operation in Darfur (UNAMID) was established as the first joint peacekeeping operation (PKO) of the United Nations (UN), with the African Union (AU) in Darfur, Sudan, which became known as the first hybrid PKO, bringing together two of the largest international organizations and taking over AMIS (African Union Mission in Sudan). In this paper, we want to understand the purpose of this bilateral relationship, since this hybrid operation opened a window of opportunity for future operations to adopt this typology. Firstly, the responsibility of managing certain conflicts is distributed among other regional organizations, giving them more autonomy and responsibility. Secondly, the “burden” – human and financial – of the UN is somehow eased. To this end, we will gather and process the data relating to the strengths and weaknesses of this PKO typology, with the help of a SWOT analysis, to find clues and bring evidence to light that demonstrate the possibility of this model being replicated in future situations, while respecting the due differences inherent to each mission and each country and region. We concluded that the hybridization of more PKOs could be a reality, albeit dependent on a greater investment by regional organizations in adapting to UN procedures, namely through diverse types of training. In addition, it will always be necessary a prior and careful analysis regarding the implementation of a PKO of this typology, with a concrete and clear definition of the roles of each organization. KEYWORDS: hybrid peacekeeping; United Nations; peacekeeping operations; UNAMID; African Union.

Hybrid repair of aberrant right subclavian artery with aortic dissection caused by Kommerell diverticulum

Background Aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum (KD) is a rare congenital aortic disease. KD patients have a high risk of rupture, dissection, and compression of adjacent structures. Although several treatment options have been proposed (traditional surgery, hybrid operation, and endovascular intervention), a consensus regarding optimal surgical management has not yet been established. Case presentation A case of successful hybrid repair of distal aortic arch dissection aneurysm by dissecting KD and ARSA with debranching of right and left common carotid arteries, left subclavian artery, and stent grafting was presented. Conclusions The hybrid operation is suitable for elderly patients or those with high risks. Along with intervention, the hybrid operation needs to be developed as a minimally invasive method.

A Modified Hybrid Operation:The Retroperitoneoscopic Nephroureterectomy Without Intraoperative Patient Repositioning

Purpose: To describe the oncological safety and validity of the modified hybrid operation without intraoperative patient repositioning for upper urinary tract urothelial carcinoma (UTUC) patients. Materials and Methods: We collected and retrospectively analyzed the clinical data of 63 consecutive patients underwent the modified hybrid operation for localized UTUC at The Second Hospital of Tianjin Medical University between July 2018 and July 2019. Details of the modified operating technique were summarized and described. Results: All procedures were successful and no reposition or re-sterilization occurred during these operations. The operative time was 135 mins (IQR:125-145) and estimated blood loss was 35 ml (IQR:30-45.5), the time of distal ureter and bladder cuff resection was only 40 mins (IQR:35-47.5). No positive margins were found by pathological investigation. No complication related to the modified position was detected. Follow-up period after surgery was 24 months (IQR:19.5-27) and 12 cases (19.05%) had recurrence.Conclusion: The modified hybrid technique eliminated the need for patients repositioning during the extravesical bladder cuff excision and permitted the continuity of the operation. It minimizes the operative time and eliminates the distortion of the surgeon's lower back. This technique can be safely reproduced with surgical outcomes comparable to other established techniques.

Hybrid vascular interventin for multilevel peripheral arterial disease

Objective To increase the effectiveness of intervention for the lower limb arteries multilevel lesion (MPAD) in patients with type C and D lesions by TASC II classification. Materials and methods 87 hybrid vascular reconstructions (74 male and 13 female, 59% (n=52) smokers) for MPAD were performed from 2017 to 2020. The average age was 64,6±8,1y. CLI was diagnosed in 47% (n=41) by Fontaine- Pokrovsky classification. Following concomitant disease were diagnosed: stage 2–3 of CHF by HYHA classification 33% (n=29), COPD 23% (n=20), arterial hypertension stage 2–3 54% (n=47), CAD 66% (n=58), postinfarction cardiosclerosis 29% (n=26). Registered lesion of iliac-femoral segment type A/B=44 (51%) and C/D=43 (49%); registered lesion of femoro-tibial segment A/B=14 (16%), C/D=73 (84%) by TASC-II classification. Common femoral artery (CFA) bifurcation was most important to perform hybrid intervention. Through CFA with patented method (RU 2621395C) we performed remote endartherectomy from external iliac or superficial femoral arteries, that allowed us to remove a total prolonged occlusion (>15–20 cm), reducing the time and complexity of the endovascular stage. The key note is that we perform CFA plasty with using an autovenous patch with a “trunk” through which we provide endovascular stage of hybrid intervention on natural blood flow, restored after open endartherectomy. This technique allows you to change the direction of introducer in both distal and proximal direction without the need for extra punctures or temporary clamping of the arteries. Results Technical success rate was 98%. Local aneurysm of EIA was found in one case that restricted to provide the loop endarterectomy. The average duration of hybrid operation was 223,7±88,2 min (134,2±72,3 min for open and 89,9±52,9 for endovascular stages). Average blood loss was 225,3±130,7 ml. ICU staying duration was 20,6±2,8 hours. 30-days patency was 98,8%, 12 and 36 months primary patency was 98% and 88,5% respectively. There were no deaths within 30 days after hybrid operation. The following complications occurred: bleeding n=2 (2,3%), acute thrombosis n=1 (1,2%), surgical site infection n=1 (1,2%) but cured safely. Limb salvage in critical ischemia was in 100% of patients for 20 months. Conclusion Hybrid surgery of MPAD is highly effective, reduces operation trauma, improves its results and limb salvage. By reducing trauma of surgical intervention reduces admition in ICU, postoperative risks, especially in patients with severe concomitant pathology. FUNDunding Acknowledgement Type of funding sources: None.