Applying Runthrough Guidewire To Transseptal Puncture Without Iodinated Contrast Agent

Aims: Conventional transseptal puncture(TSP) relies on fluoroscopy and iodinated contrast agent to distinctly position the transseptal needle at the left atrium, however, there exists great challenges in clinic in patients with contrast hypersensitivity or allergy-like reactionsin the procedure. This study aimed to evaluate a novel approach to TSP assisted by Runthrough guidewire and fluoroscopy without use of iodinated contrast agent. Methods: Sixty patients with paroxysmal atrial fibrillation undergone radiofrequency catheter ablation were enrolled from February 2021 to October 2021, and randomised to routine TSP group and Runthrough guidewire assisted group. The two groups were compared regarding the total operative time, length of fluoroscopy exposure, difference of radiation dose in X-ray, and the safety was evaluated in the patients undergone TSP without iodinated contrast agent. Results: There were no differences in baseline demographics or clinical characteristics between the two groups. Although the total procedure time[(1.98±0.29) min vs.(2.11±0.14) min, P<0.04],length of fluoroscopic exposure [(1.83±0.30) vs.(1.98±0.14), P<0.19] and radiation dose in X-ray[(27.83±3.21) uGym2vs.(29.13±1.57) uGym2, P<0.30] were somewhat statistically different between groups, yet the difference was insignificant. No complications, including pericardial tamponade and aortic perforation, occurred in all patients. Conclusion: Iodine-free TSP under the guidance of Runthrough guidewire and fluoroscopy can be a simple, safe, economical and effective approach to TSP, and may be reproduced as a novel option for TSP in patients with contrast hypersensitivity or allergy-like reactions.

2450 MHz Microwave Ablation for Liver Metastases Under 3.0T Wide-bore Magnetic Resonance Guidance: a Pilot Study

Purpose: To investigate the feasibility and effectiveness of 3.0T wide-bore magnetic resonance (MR)-guided microwave ablation (MA) for liver metastases (LM).Patients and methods: From October 2018 to May 2020, 39 patients with 63 LM were treated with 3.0T wide-bore MR-guided 2450 MHz MA therapy. The procedure parameters, technical success, complications, biochemical indexes changes, local tumor response, local tumor progression (LTP) and overall survival were recorded and analyzed.Results: The mean tumor maximum diameter and total procedure time were 3.0 cm and 55.2 min, respectively. Technical success was 100% but 5 cases (12.8%) with grade-1 complications. Alanine transaminase, aspartate transaminase and total bilirubin showed slight a transient increase on day 3 (P<0.05) and returned to normal by day 30 (P>0.05). The complete ablation rate for ≦ 2.5 and >2.5 cm lesions were 100 % and 92.5 %, respectively, during the median followup of 12.0 months, LTP rate was 4.8 % (3/63), and the 6-, 12- and 18-month overall survival were 100%, 92.2%, 76.4% , respectively.Conclusion: 3.0T wide-bore MR-guided MA for LM is a safe and effective approach, especially for small LM.

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

Objectives: Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA. Methods: This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims. Results: This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods. Conclusion: It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Automating Endoscope Motion in Robotic Surgery: A Usability Study on da Vinci-Assisted Ex Vivo Neobladder Reconstruction

Robots for minimally invasive surgery introduce many advantages, but still require the surgeon to alternatively control the surgical instruments and the endoscope. This work aims at providing autonomous navigation of the endoscope during a surgical procedure. The autonomous endoscope motion was based on kinematic tracking of the surgical instruments and integrated with the da Vinci Research Kit. A preclinical usability study was conducted by 10 urologists. They carried out an ex vivo orthotopic neobladder reconstruction twice, using both traditional and autonomous endoscope control. The usability of the system was tested by asking participants to fill standard system usability scales. Moreover, the effectiveness of the method was assessed by analyzing the total procedure time and the time spent with the instruments out of the field of view. The average system usability score overcame the threshold usually identified as the limit to assess good usability (average score = 73.25 &gt; 68). The average total procedure time with the autonomous endoscope navigation was comparable with the classic control (p = 0.85 &gt; 0.05), yet it significantly reduced the time out of the field of view (p = 0.022 &lt; 0.05). Based on our findings, the autonomous endoscope improves the usability of the surgical system, and it has the potential to be an additional and customizable tool for the surgeon that can always take control of the endoscope or leave it to move autonomously.

LSI guided-high power short duration is safe and improves pulmonary vein isolation efficiency

Introduction High-power short-duration (HPSD) is an increasingly used ablation strategy for pulmonary vein isolation (PVI) procedures, but Lesion Index (LSI)-guided HPSD radio-frequency (RF) application has not been described in this clinical setting. Purpose We evaluated the procedural efficiency and safety of an LSI-guided HPSD strategy for atrial fibrillation (AF) ablation. Methods Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled and divided in two groups, according to the ablation power used. The LSI-HP Group included patients ablated with a RF power of 50 Watts and the LSI-LP Group included patients ablated with 35 Watts. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance &lt;6 mm. Procedural efficiency parameters were compared between groups. Results Forty-six patients with AF (60% paroxysmal) were prospectively enrolled, 25 in the LSI-HP Group and 21 in the LSI-LP Group. They were usually male (78%) with a low-intermediate CHA2DS2-Vasc score (1.8±1.1), a preserved ejection fraction (60±6%) and moderate left atrial dilatation (45±6 mm). Baseline clinical characteristics resulted comparable between groups (p=NS). PVI was successful in all patients. RF time (30.22±9.04 vs 47.85±11.87 min, p&lt;0.0001), total procedure time (138.7±33.2 vs 177.6±49.77, p=0.006) and fluoroscopy time (13.92±5.34 vs 23.14±10.97 min, p=0.006) were significantly lower in the LSI-HP Group. No complication or steam pops was seen in either group. Conclusions LSI-HP AF ablation significantly improves procedural efficiency, reducing ablation time, total procedural duration and fluoroscopy use, while maintaining a comparable safety profile as lower powers. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Double kissing – crush technique to treat coronary bifurcation lesions: analysis of success rate, procedural times and device usage

Background The Double Kissing Crush (“DK Crush”) technique is one of the recommended planned 2-stent techniques to treat true coronary bifurcation lesions (Medina 1–1-1, Medina 0–1-1). While some trials demonstrated superiority to other techniques, DK Crush requires a sequence of specific and potentially technically challenging steps. No data exists on the procedural difficulty of the various steps required for DK Crush. We therefore analyzed procedural times and device usage in a systematic fashion. Methods and results 54 patients (42 male, mean age 67±12 years) intended for treatment with DK Crush were enrolled. Detailed procedural characteristics including exact times and device usage for each step of DK Crush were prospectively measured and analyzed. DK Crush was successful in 48/54 patients (89%). In two patients stenting technique was changed to T- or TAP-stenting due to anatomical reasons at the moment of positioning of the SB stent. In one patient no balloon could cross the lesion and in another the procedure had to be modified due to coronary perforation directly after pre-dilatation. True failure of DK Crush was observed in two cases: In one case, the first rewiring of the SB, in the other, placement of a balloon for first kissing balloon (KB) maneuver in the SB was not possible. These 6 patients were excluded from further analysis. Median times for each step were: 1:21min (IQR 0:52min-1:50min) for wiring SB, 1:18min (IQR 0:47min-1:42min) for wiring MV, 1:30min (IQR 0:54min-2:15min) for stent placement in the SB, 0:40min (IQR 0:29min-1:21min) for balloon placement in the MV. First rewiring of the SB after SB stent crush required 1:30min (IQR 0:37min-2:05min), 1st KB placement in the SB took 1:42min (IQR 1:00min-3:13min) and 1st KB placement in the MV required 0:45min (IQR 0:27min-1:19min). Stent placement in the MV required 1:34min (IQR 1:09min-2:40min) and 2nd rewiring of the SB 1:21min (IQR 0:55min-2:04min), 2nd KB placement of the SB 2:08min (IQR 1:01min-3:36min) and 2nd KB placement of the MV 0:50min (IQR 0:34min-1:01min). Final POT was performed in all cases. Median total procedure time was 52:35 min (IQR 00:42:54h-1:01:37h). Additional devices were needed in 10% (3x1, 2x2 balloons) for stent placement in the SB; in 46% (20x1, 1x4 wires) for the first rewiring of the SB and in 49% (20x1, 3x2 balloons) for 1st KB placement in the SB. The 2nd rewiring of the SB required additional wires in 32% (13x1, 2x2 wires) and 54% of the patients required additional balloons for the 2nd KB placement in the SB (20x1, 2x2, 1x3, 2x5 balloons). Final TIMI flow was III in 97.9%. Complications occurred in 6% (n=3), each showing coronary dissection with TIMI III flow in 2 patients and TIMI I flow in 1 patient after placement of additional stents. Conclusion DKMC has a high success rate but is a time-consuming and material-intensive technique. The placement of the 2nd KB in the SB requires most of the procedural time and resources. FUNDunding Acknowledgement Type of funding sources: None.

Zero-fluoroscopy ablation in patients with cardiac electronic implantable devices

Introduction: Utilizing a 3-dimensional (3-D) mapping system and intracardiac echocardiography (ICE) has allowed ablation procedures with less or without fluoroscopy; however, there is limited data for patients with cardiac electronic implantable device (CIED) leads regarding the suspected risk of lead injury. Therefore, we sought to explore technics to perform safe trans-septal approach and catheter manipulation technique in patients with CIED leads. Methods and Results: This study comprised 68 consecutive patients (45 [66.2%] males, median [interquartile range] 73 [68–77] years old) with CIED who underwent catheter ablation for supraventricular tachycardia, 16 without fluoroscopy (zero-fluoro group) and 52 with fluoroscopy (conventional-fluoro group), between July 2019 and April 2021. All procedures were performed under a 3-D mapping system and ICE guidance. We compared the differences in treatment and development of complications between the two groups. The procedures were mainly atrial fibrillation (73.6%) and atrial tachycardia. The median time from venipuncture to trans-septal procedure (zero-fluoro vs. conventional-fluoro group: 27.0 min vs. 23.5 min, P=0.71) and total procedure time (215 min vs. 172 min, P=0.55) were not different between the two groups. The acute procedural success rate (100% vs. 98.1%, P=1.00) and reduction of atrial high-rate episodes at 6 months (3.2 [0.3–93.9]% vs. 1.0 [0.0–14.9]%, P=0.33) did not differ between the two groups. No patient showed lead-related complications in both groups. Conclusions: Zero-fluoro ablation for supraventricular arrhythmia using 3-D mapping and ICE in patients with CIED leads was feasible under careful catheter manipulation.

Diagnostic Performance of Endoscopic Ultrasound-Guided Tissue Acquisition by EUS-FNA versus EUS-FNB for Solid Pancreatic Mass Without ROSE: A Retrospective Study.

Background: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fineneedle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. Thus, we aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size (22 gauge), respectively, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). Methods: All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single center university hospital were retrospectively reviewed. The procedure was performed without an onsite cytologist. After macroscopic onsite evaluation (MOSE), the endoscopist finished the procedure. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. Results: A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, gender, mass location, tumour size and disease stage from imaging were not significantly different. The diagnostic performance was dramatically higher in EUS-FNB (100%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was less in FNB (34.7 minutes) than in FNA (41 minutes). The adverse event rate between FNB and FNA was not significantly different. Conclusions: The diagnostic performance for solid pancreatic mass without ROSE was significantly higher in FNB than in FNA. The number of needle passes and the total procedure time was also lesser in FNB.

Early Results of a Novel Gutter-Free Chimney Stent-Graft System to Treat Aortic Arch Dissection: Single-Center Data from a Prospective Clinical Trial

Aims: Discuss the clinical value, technique characteristics, and early follow-up results of a newly designed gutter-free chimney stent-graft system for aortic arch pathology. Methods and Results: About 13 patients with aortic arch dissection were enrolled in a clinical trial testing a novel gutter-free stent-graft between February 2019 and December 2020. All 13 patients were male, age 52.6±10.4 years. The implantation time was 14.0±6.9 minutes; total procedure time was 89.5±19.8 minutes. The volume of contrast was 79.6±7.2 ml. And 15 aortic stent-grafts were implanted, and all 13 patients had chimney branch stent-grafts implanted into the left subclavian artery (LSA). There were 3 (23.1%) cases of immediate type Ιa endoleak after thoracic endovascular aortic repair (TEVAR), and 7.7% type Ιa endoleaks occurred in delayed fashion. Survival at 2 years was 100%, and the 2-year patency of chimney stent-grafts was 100%. Conclusions: This study reports early success with good freedom from endoleak using a novel stent-graft designed for chimney TEVAR to treat aortic arch dissection. Postoperative survival and patency of the branch stent-grafts were excellent. Additional data from this multicenter clinical trial will be forthcoming.

Pedunculated colorectal polyps with heads ≤ 1 cm in diameter can be resected using cold snare polypectomy

Background and study aims : Cold snare polypectomy (CSP) is not recommended for the resection of pedunculated colorectal polyp. The aim of this study was to examine the adequacy of CSP compared to hot snare polypectomy (HSP) for the complete resection of pedunculated polyps with heads ≤ 1 cm in diameter. Patients and methods : This was a retrospective study of a cohort of consecutive outpatients who had resection of pedunculated polyps with heads 6-10 mm in diameter using either dedicated CSP or HSP from 2014 through 2019. The primary outcome measure was occurrence of delayed bleeding. Secondary outcome measures included total procedure time, en bloc resection rate, immediate bleeding, and number of clips used. Results : 415 patients with 444 eligible polyps were enrolled; the CSP group (363 patients; 386 polyps) and HSP group (52 patients; 58 polyps). Patient characteristics, polyp characteristics and en bloc resection rate were similar between groups. The mean total procedure time and mean number (range) of hemostatic clips/patient used were significantly lower with CSP than with HSP (18± 8 min vs. 25± 9 min, P<0.001; 1.1 ± 0.6 (1-3) vs.3.1 ± 1.6 (1-5), respectively, P<0.001). Delayed bleeding occurred significantly less frequently in the CSP, 0% (0/363 vs.3.8% (2/52) in the HSP group (P<0.001), although immediate bleeding was significantly higher in CSP than HSP (84% (325/386) vs. 12% (7/58), P<0.001). Conclusion : Pedunculated colorectal polyps with heads ≤ 1 cm can be removed using CSP, which has several advantages over HSP.