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Morse taper junction tribocorrosion is recognized as an important failure mode in total hip arthroplasty. Although taper junctions are used in almost all shoulder arthroplasty systems currently available in the United States, with large variation in design, limited literature has described comparable analyses of taper damage in these implants. In this study, taper junction damage in retrieved reverse total shoulder arthroplasty (RTSA) implants was assessed and analyzed.Fifty-seven retrieved RTSAs with paired baseplate and glenosphere components with Morse taper junctions were identified via database query; 19 of these also included paired humeral stems and trays or spacers with taper junctions. Components were graded for standard damage modes and for fretting and corrosion with a modified Goldberg-Cusick classification system. Medical records and preoperative radiographs were reviewed. Comparative analyses were performed assessing the impact of various implant, radiographic, and patient factors on taper damage.Standard damage modes were commonly found at the evaluated trunnion junctions, with scratching and edge deformation damage on 76% and 46% of all components, respectively. Fretting and corrosion damage was also common, observed on 86% and 72% of baseplates, respectively, and 23% and 40% of glenospheres, respectively. Baseplates showed greater moderate to severe (grade ≥ 3) fretting (43%) and corrosion (27%) damage than matched glenospheres (fretting, 9%; corrosion, 13%). Humeral stems showed moderate to severe fretting and corrosion on 28% and 30% of implants, respectively; matched humeral trays or spacers showed both less fretting (14%) and less corrosion (17%). On subgroup analysis, large-tapered implants had significantly lower summed fretting and corrosion grades than small-tapered implants (P .001 for both) on glenospheres; paired baseplate corrosion grades were also significantly lower (P = .031) on large-tapered implants. Factorial analysis showed that bolt reinforcement of the taper junction was also associated with less fretting and corrosion damage on both baseplates and glenospheres. Summed fretting and corrosion grades on glenospheres with trunnions (male) were significantly greater than on glenospheres with bores (female) (P .001 for both).Damage to the taper junction is commonly found in retrieved RTSAs and can occur after only months of being implanted. In this study, tribocorrosion predominantly occurred on the taper surface of the baseplate (vs. glenosphere) and on the humeral stem (vs. tray or spacer), which may relate to the flexural rigidity difference between the titanium and cobalt-chrome components. Bolt reinforcement and the use of large-diameter trunnions led to less tribocorrosion of the taper junction. The findings of this study provide evidence for the improved design of RTSA prostheses to decrease tribocorrosion.

Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type.From 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74 years (interquartile range, 70-78 years). More than one-half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (n = 9 grafts), Cook Zenith (n = 8), Endologix AFX (n = 7), Medtronic Endurant (n = 5), and Medtronic Talent (n = 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2 years, although ranging widely (interquartile range, 2.6-5.1 years), but similar between index and nonindex explants (4.2 years vs 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8 days. The median intensive care unit length of stay was 3 days, without significant differences in nonindex explants (4 days vs 3 days) and partial explants (4 days vs 3 days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P = .12).Explants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.

The primary purpose of this study was to compare 2-year anatomic total shoulder arthroplasty (TSA) functional and radiographic outcomes between Walch type A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique.We performed a multicenter retrospective review of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient-reported outcomes and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology; preoperative and postoperative glenoid version, glenoid inclination, and posterior humeral head subluxation; and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications.A total of 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (P .001), range-of-motion measures (forward elevation, external rotation at 0°, external rotation at 90°, internal rotation by spinal level, and internal rotation at 90°; P .001), and strength measures (Constant, external rotation, and modified belly press; P .001). There were no clinically meaningful differences in functional outcomes or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed that glenoids with a cemented central peg had the worst radiographic outcomes based on Lazarus scoring.Patients undergoing TSA with a hybrid in-line pegged glenoid have excellent clinical outcomes at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.

In revision total knee arthroplasty, zonal fixation methods with a combination of augments, press-fit stems, and sleeves are popular. We hypothesized that high distal femoral augmentation with diaphyseal press-fit stems leads to an increased rate of early aseptic loosening and that femoral metaphyseal sleeves improve implant survival. Therefore, we retrospectively investigated implant survival in relation to augment heights and sleeves.A total of 136 patients with mean clinical follow-up of 50 months (range, 28-85) who underwent modular total knee arthroplasty and revision total knee arthroplasty with semiconstrained implants between January 2012 and July 2018 were retrospectively evaluated. Implant survival with 4, 8, and 12 mm distal femoral augments was compared to no distal augmentation. Subsequently, a subgroup analysis was performed for femoral sleeve implantation.We observed an implant survival rate of 97.0%, 87.5%, and 69.2% for 4, 8, and 12 mm distal femoral augmentation, respectively (P = .73; P = .19; P = .008). The implant survival rate with femoral sleeves was 95.8% for the 8 mm augments and 85.7% for the 12 mm augments (P = .42; P = .96). Without femoral sleeves, the implant survival rate was 78.3% with the 8 mm augments and 50.0% with the 12 mm augments (P = .02; P.001).Higher rates of aseptic femoral loosening were identified for distal femoral augmentation of 8 mm or more without metaphyseal sleeve fixation in semiconstrained implants. Thus, in cases with femoral metaphyseal bone damage requiring high distal femoral augmentation, metaphyseal sleeves should be used to avoid early aseptic femoral loosening.

The treatment of proximal interphalangeal joints (PIP) after a traumatic injury has produced disappointing outcomes. The objective of this study was to evaluate the functional results of emergency hinged or gliding arthroplasty for destroyed PIP joints. A two-center retrospective study was carried out in 24 patients with open and closed trauma of the PIP joint of the fingers from 2007 to 2019. Fifteen hinged silicone implants (NeuFlex®) and nine gliding implants (Tactys®) were used. Pain on a visual analog scale (VAS), stability and total active motion (TAM), grip and pinch strength (Jamar®), QuickDASH and PRWE and satisfaction were assessed, and X-rays were performed. With a mean follow-up of 48 months, 24 patients aged 58 years on average were reviewed. Pain on VAS was 0.2/10, the TAM was 72% of the contralateral side, the QuickDASH was 15.6/100 and the PRWE was 24.5/100. PIP flexion was ≥50% of the contralateral side in 75% of patients. PIP and DIP extensor lag of 9° was significantly larger with the Tactys® than with the NeuFlex®, with no significant difference in the TAM. Three clinodactylies in fingers with the NeuFlex® and three reducible swanneck deformities in fingers with the Tactys® were noted. Three-quarters of patients were very satisfied or satisfied with the outcome. Emergency PIP arthroplasty with Tactys® seems to provide functional results that are as good as with NeuFlex®. Clinodactyly was found with NeuFlex® use. A significant PIP and IPD extensor lag of 9° and swan-neck deformities were found with Tactys® without significant functional impairment.

Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA.This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA.A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%.Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data.

Revision total hip arthroplasty (THA) for adverse local tissue reactions (ALTRs) secondary to head-neck taper corrosion is associated with a high complication rate. Diagnosis of ALTR is based on risk stratification using the patient's history and examination, implant risk, serum metal ion levels, and imaging. The purpose of this study was to determine if stratification using similar risk factors is predictive of outcomes following revision THA for metal-on-polyethylene (MoP) ALTR.We performed a retrospective review on 141 patients revised for ALTR due to head-neck taper corrosion. Pain outcomes following surgery were analyzed using a generalized linear mixed model. Complications were defined as instability/dislocation, infection, fracture, nerve palsy, leg-length discrepancy, or reoperation.The overall complication rate was 17.7%. The odds of having pain decreased by 44% after revision surgery (Odds Ratio = 0.56, 95% Confidence Interval: 0.324 to 0.952). There was no significant difference in instability/dislocation based on either increased or decreased head-neck offset (P = .67) or magnetic resonance imaging findings of abductor loss, effusion size, and degree of ALTR (P = .73). Increased serum cobalt (P = .31) and chromium (P = .08) levels did not predict complications; however, a decreased cobalt-chromium ratio was associated with postoperative complications (2.8 versus 3.5; P = .002).These findings are the first to suggest that patients who have ALTR after MoP THA undergoing revision surgery demonstrated major pain relief. Increasing femoral head offset did not change rates of instability/dislocation. In clinical scenarios where preoperative cobalt-chromium femoral head offsets were greater than available ceramic head offsets, a mandatory decrease in femoral head offset did not increase rates of instability/dislocation.

The incidence of new permanent pacemaker implantation (PPI) after rapid deployment aortic valve replacement (RDAVR) remains debated. Expertise in this field has significantly increased over the last decade. This study aimed to investigate the need for PPI following implantation of a rapid deployment (RD) valve.Analysis of n=372 patients who underwent Edwards INTUITY (Edwards Lifesciences, Irvine, CA, USA) (n=251) and Perceval (Sorin/LivaNova Group, Saluggia, Italy) (n=121) valve replacement at the current institution between May 2012 and August 2018 was performed. Coronary artery bypass graft procedures were additionally performed in patients with coronary artery disease. Baseline, preoperative and postoperative outcomes were examined regarding correctness and completeness of the procedure. Statistical analysis was performed using SPSS Version 23.0.0 (IBM Corp, Armonk, NY, USA).A total of 372 patients (aged 75±6.3 yrs) with a high grade of aortic valve stenosis underwent either Edwards INTUITY (67%) or Perceval (33%) valve replacement. Seventy-six (76) patients (20%) presented with preoperative conduction disorders. Sixty (60) patients (16%) underwent PPI, which in most cases was performed during the first month after the initial operation. Follow-up was performed up to 9 years, presenting a persistent pacemaker dependency rate of 50% among all patients who underwent PPI. Twenty (20) (40%) PPI recipients showed no dependency on pacemaker, while 10 (10%) required temporary pacemaker support. Mean length of ICU stay was 4±5.1 days and in-hospital stay was 8.2±7.6 days.The incidence of PPI after RD valve implantation still remains high compared with conventional aortic valve replacement. However, this study shows that this phenomenon appears to be transient in a significant proportion of the patients undergoing RD valve replacement. These findings might contribute to the scientific discussion and should be taken into consideration for the indication of RD valve replacement.

Revision surgery is usually required for complications associated with total hip arthroplasty (THA). Significant morbidity can be associated with revision THA and thus some may only revise the liner of the original metal back component if it is found to be well fixed. We compare the long-term survivorship of cemented and uncemented head-liner THA exchange surgeries and possible causes.Between 2000 and 2018, we reviewed cases from our arthroplasty database who underwent THA revision for head-liner exchange. We stratified our cohort into 2 groups: cemented and uncemented liners. Patients were followed clinically and radiographically to determine survivorship of the exchanges for both cemented and uncemented liners. Implant survivorship was measured using a competing risk analysis considering death and patients lost to follow-up as competing risks.A total of 84 patients (85 hips) underwent head-liner exchange surgery during the study period (21 cemented and 64 uncemented liners). The mean follow-up time was 6.9 years, with 75.3% and 24.7% of patients having been revised due to non-dislocation and dislocation causes, respectively. Two cemented liners (9.5%) and 11 uncemented liners (17.2%) required revision. The survival analysis of all head-liner revision was 86.4% at 18 years. Survival estimates liner exchanges due to dislocation versus non-dislocation groups were 57.3% versus 82.7% respectively (P = .034).The present study shows improved survivorship of head-liner exchanges performed due to non-dislocation etiology compared to dislocation etiology, but no difference in survivorship between cemented and uncemented head-liner exchange.Level III.

Although complete bioresorbable vascular scaffold (BVS) resorption has been demonstrated at 5-year follow-up, whether corresponding vasomotor function restoration occurs remains unknown. The objective was to simultaneously assess the structural healing response along with vasomotor responses at 5-year follow-up of BVS implantation. We studied consecutive patients treated with ABSORB-BVS at 5-year follow-up (n = 31), who were recruited from a multicenter registry and were contacted to undergo a research protocol-driven repeat coronary angiogram involving intracoronary optical coherence tomography (OCT) and invasive coronary endothelial function testing. Epicardial endothelium-dependent vasomotion was defined as any vasodilatation after intracoronary acetylcholine (ACh), whereas endothelium-independent vasomotion was defined as any vasodilatation after intracoronary nitroglycerine (NTG), using quantitative coronary angiography. The mean implantation time point was 60.5 ± 4.6 months. OCT imaging demonstrated complete scaffold resorption in all patients. New coronary lesions (stenosisgt;50%) were found in 5 patients (16.1%), 3 of them underwent ad hoc percutaneous revascularization (9.7%). Intracoronary ACh (27 patients) and NTG testing (30 patients) was performed. Quantitative coronary angiography analysis demonstrated vasoconstriction after ACh administration and lack of response to NTG in BVS segments (mean lumen diameter = 2.00 ± 0.61 mm at baseline vs 1.74 ± 0.70 mm post-ACh, plt;0.001; 2.05 ± 0.54 mm at baseline vs 2.03 ± 0.50 mm post-NTG, p = 0.69). OCT lumen analysis demonstrated similar vasoconstrictive responses to ACh (mean lumen area = 5.31 ± 2.26 mmsup2/supat baseline vs 5.12 ± 2.55 mmsup2/suppost-ACh, p = 0.007) but had a vasodilatory response to NTG (5.96 ± 2.35 mmsup2/supat baseline vs 6.17 ± 2.55 mmsup2/suppost-NTG, plt;0.001). In conclusion, complete ABSORB-BVS resorption was demonstrated at 5-year follow-up. However, this healing response was associated with endothelium-dependent vasomotor dysfunction within the BVS segment.

During anatomic total shoulder arthroplasty (aTSA), the humeral head can be resected with or without the use of an intramedullary cutting guide, the former referred to as intramedullary (IM) resection and the latter referred to as freehand (FH) resection. Outcomes following aTSA are predicated upon the restoration of the native humeral anatomy, which can be more challenging with stemless implants. To date, no studies have determined which method of humeral head resection is superior in restoring native anatomy. Our purpose was to determine whether FH or IM resection was superior in restoring native anatomy during aTSA with stemless implants.A review of all patients who underwent aTSA using the stemless Tornier Simpliciti Shoulder System at two academic institutions by two separate surgeons between January 2017 and June 2020 was performed. One surgeon at one institution performed stemless aTSA using the IM resection technique, while the second surgeon utilized the FH resection technique. Patients were excluded if they underwent surgery for an indication other than glenohumeral osteoarthritis, if they received a short-stem or standard-stem implant, or if they lacked adequate preoperative and postoperative Grashey radiographs. One hundred eleven patients across both institutions (51 IM, 60 FH) were included for the final radiographic assessment. The humeral head height (HH) and neck-shaft angle (NSA) were measured on preoperative and postoperative Grashey radiographs. The centers of rotation (CORs) were measured on postoperative Grashey radiographs. Patients were classified as having acceptable restoration of their native anatomy if the change (Δ) in COR or HH was ≤3 mm and ≤ 5 mm, respectively, or if the postoperative NSA was ≥130°.IM resection had the greatest acceptable restoration of COR (90.2% IM versus 70% FH, P = .009), HH (96.1% IM vs. 63.3% FH, P .001), and NSA (96.1% IM vs. 78.3% FH, P = .006) relative to FH resection. The mean postoperative NSAs for the IM and FH cohorts were 134.4° (±2.1°) and 133.8° (±5.4°), respectively (P = .208). The mean ΔCORs for the IM and FH groups were 1.2 (±1.5) and 2.3 (±1.2) mm, respectively (P .001). Finally, the mean ΔHHs for the IM and FH cohorts were 1.7 (±1.4) and 4.4 (±2.9) mm, respectively (P .001).Restoration of the native humeral anatomy following stemless aTSA occurred at a significantly higher rate when using IM vs. FH resection.

New-generation drug-eluting stents (DES) strongly reduce restenosis and repeat revascu- larization compared with bare-metal stents (BMS) for percutaneous coronary interven- tion. There is residual uncertainty as to whether other prognostically relevant outcomes are affected by DES versus BMS concerning initial presentation (chronic coronary syn- drome [CCS] vs acute coronary syndrome [ACS]). We performed an individual patient data meta-analysis of randomized trials comparing new-generation DES versus BMS (CRD42017060520). The primary outcome was the composite of cardiac death or myocar- dial infarction (MI). Outcomes were examined at maximum follow-up and with a 1-year landmark. Risk estimates are expressed as hazard ratio (HR) with 95% confidence inter- val (CI). A total of 22,319 patients were included across 14 trials; 7,691 patients (34.5%) with CCS and 14,628 patients (65.5%) with ACS. We found evidence that new-generation DES versus BMS consistently reduced the risk of cardiac death or MI in both patients with CCS (HR 0.83, 95% CI 0.70 to 0.98, p

The aim of this study was to compare the stem alignment and the quality of cement mantle of collarless polished tapered cemented stems inserted through the direct anterior approach (DAA) and the direct lateral approach (DLA).A comparative retrospective study of 232 hybrid total hip arthroplasties using a cemented collarless polished tapered stem through either the DAA (n = 147) or DLA (n = 85) was performed. Radiographic evaluation included stem alignment, cement mantle quality, and cement mantle thickness.On anteroposterior radiographs, stems implanted through the DLA were more likely to be in neutral alignment, than those implanted through the DAA (83.5%[n = 71] versus 71.4% [n = 105]; P = .001). No difference between approaches was noted for stem alignment on lateral radiographs or cement mantle quality. Multivariate analysis revealed factors associated with suboptimal cement mantle and included Dorr type B or C femur as well as male gender. A mean cement mantle thickness ≥2mm was achieved in all Gruen zones for both approaches.In our series, the DAA was associated with a higher incidence of coronal plane stem malalignment compared to the DLA when using cemented tapered polished femoral components for total hip arthroplasty. No difference in lateral stem alignment or cement mantle quality was found.

Transcatheter heart valve technology has rapidly progressed since initial approval in the United States. There are currently two widely available transcatheter heart valve delivery systems approved in the US; however limited data exist on optimal device selection for various patient populations. This review explores the characteristics of currently approved transcatheter heart valve systems and scenarios where one valve system may be favored over others. We provide a simplified decision tree for selecting the optimal transcatheter valve system for specific patient-centered characteristics.

The Supera (Abbott Vascular, Santa Clara, CA) stent is an interwoven nitinol, shape-memory stent with high strength and flexibility characteristics which are purported to increase resistance to kinking and compression. The purpose of this study was to review single-center outcomes of the use of this stent in the femoropopliteal segment.We performed a single-center, retrospective analysis of patients who underwent Supera stent placement for femoropopliteal occlusive disease from 2016-2019. Data was collected on patient demographics and procedural details. Follow-up imaging data, including duplex imaging and ankle-brachial indices, and clinical data were abstracted from encounter notes.Sixty-two patients with 72 unique Supera stent placements were identified. Mean age was 76 and 69% were male. 56% of patients had severe calcification and 11% had moderate calcification. 48% of lesions were Trans-Atlantic Inter-Society Consensus Document C or D lesions. Primary patency rates at 12, 24, and 36 months were 85%, 82%, and 75%, respectively. Primary patency was not affected significantly by lesion length, degree of calcification, number of outflow vessels, concomitant interventions, or stent size.These results demonstrate sustained primary patency with the Supera stent over a 3-year interval in treatment of patients with femoropopliteal occlusive disease, including in the setting of severely calcified vessels.

In-stent restenosis (ISR) remains a potential complication after percutaneous coronary intervention, even in the era of drug-eluting stents, and its treatment remains suboptimal. Neoatherosclerosis is an important component of the pathology of ISR and is accelerated in drug-eluting stents compared with bare-metal stents. Coronary angiography is the gold standard for evaluating the morphology of ISR, although computed tomography angiography is emerging as an alternative noninvasive modality to evaluate the presence of ISR. Drug-coated balloons and stent reimplantation are the current mainstays of treatment for ISR, and the choice of treatment should be based on clinical background and lesion morphology.

Emergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting, physician-modified endografts, double-barrel/reversed iliac branch device, and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAAs and TAAAs.A retrospective review of patients who underwent endovascular repair of ruptured SRAAAs and TAAAs from July 2014 to March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared with those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia.Forty-two patients underwent endovascular repair for ruptured SRAAAs and TAAAs, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive before surgery, compared with 46% of the patients who underwent repair using non-ISF techniques (physician-modified endografts, parallel grafting, or double-barrel/reversed iliac branch device). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. Compared with the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P = .048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly used technique later in the study period.Although emergent endovascular repair of ruptured SRAAAs/TAAAs remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a fivefold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up are needed to validate these initial results and assess durability.

Stent grafts (SG) and drug eluting stents (DES) have emerged to combat intimal hyperplasia. It remains unclear which type of stent yields superior outcomes in femoropopliteal (FP) arterial lesions. This study compared the clinical data between the VIABAHN SG and the Eluvia DES two years after endovascular treatment.In this retrospective multicentre study, 504 cases with a lesion length10 cm treated either with SG or DES were analysed. Ankle brachial index (ABI) measurements were conducted before and after the endovascular procedure, and every three months thereafter. When the ABI dropped ≥ 0.15 compared with the baseline value, a duplex ultrasound was conducted to check stent patency. The outcome measures were stent patency rates, freedom from target lesion revascularisation (TLR), stent thrombosis, and acute limb ischaemia (ALI) accompanying loss of patency rates. Propensity score matching (PSM) was performed to adjust for confounding baseline characteristics.PSM extracted 219 limbs in the SG group and 109 limbs in the DES group. Compared with the SG group, the DES group had statistically significantly higher rates of freedom from TLR (86.0 ± 4.2% vs. 73.1 ± 4.8%, p = .040), and ALI accompanying loss of patency (98.9 ± 1.1% vs. 93.5 ± 1.8%, p = .029) at two years. Primary patency (75.9 ± 5.9% vs. 69.5 ± 5.9%, p = .087) and freedom from stent thrombosis (90.4 ± 3.3% vs. 81.2% ± 3.0%, p = .11) were not statistically significantly different. For lesions ≤ 15 cm, primary patency in the DES group was statistically significantly better than the SG group.FP lesions treated with Eluvia DES had a higher primary patency rate in lesions ≤ 15 cm, freedom from clinically driven TLR and ALI accompanying loss of patency than the VIABAHN SG.

During fenestrated endovascular repair (FEVAR), mesenteric vessels may be incorporated with a scallop or fenestration. The benefits/harms of techniques to incorporate the coeliac axis (CA) have not been assessed for their impact on procedural complexity vs. peri-operative and longer term outcomes; this assessment may instruct a balanced operative strategy for the CA and complex FEVAR, minimising adverse intra- or peri-operative events, and maximising durability.This was a retrospective cohort study. Patients undergoing fenestrated or scalloped CA incorporation during FEVAR for a juxtarenal/pararenal/suprarenal aortic aneurysm (January 2015 - December 2019) were reviewed (n = 159) for demographics, intra-procedural/peri-operative outcomes, and re-interventions to five years. Mean follow up for all groups was 3.28 years. The primary outcome of CA instability (occlusion/stenosis/endoleak/re-intervention) was assessed. CA specific re-intervention, re-intervention free survival, and all cause mortality were assessed against incorporation strategy. Secondarily, the harm of CA stenting, comprising intra-operative harms and peri-operative adverse outcomes was interrogated.The CA was incorporated with a stented fenestration (n = 74), an unstented fenestration (n = 59), and a minority with scallop (n = 26). There were no between group differences in operative indication, or anatomical aneurysm/CA features. Fenestrated stented and unstented patients had longer aortic coverage but the same primary technical success. At follow up, three CA endoleaks occurred in stented fenestrated patients, although scallop patients more often had type 3 endoleaks at the SMA and renal fenestrations (23%). Elevated CA instability in fenestrated unstented patients was driven by CA occlusion (16.9%), but not associated with CA re-intervention, worse re-intervention free survival, or all cause mortality. Regression analysis for visceral branch instability revealed predictors of CA non-stenting and diminished aortic coverage.In the present authors' experience, the practice of not stenting a CA fenestration does not pose peri-operative or long term clinical harm. At follow up, not stenting the CA is associated with CA instability; however, both fenestration groups are preferable to a shorter (scalloped) endograft as increasing aortic coverage reduces non-CA branch vessel instability.

Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches.Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes.Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke.This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.

Postoperative conduction disorders are serious adverse events in patients undergoing aortic valve replacement, and may prolong the duration of hospitalization and require pacemaker insertion.Our aim was to evaluate the rate of pacemaker insertion after implantation of an Edwards Intuity sutureless aortic valve (Edwards Lifesciences, Irvine, CA, USA) compared with a standard surgical bioprosthesis.This retrospective single-centre study included patients who underwent aortic valve replacement with an Intuity sutureless aortic valve or a standard bioprosthetic valve between 4 June 2014 and 27 June 2016. The main outcome criterion was the rate of postoperative pacemaker insertion. Secondary outcome criteria included the rate of new conduction disorders, the rate of atrial arrhythmia or paroxysmal conduction disorders, mortality and duration of hospital stay.Ninety-three patients received an Intuity sutureless aortic valve (median age 76 years, interquartile range 71-80 years), and 176 were implanted with a standard biological aortic valve (median age 73 years, interquartile range 68-79 years; P=0.007). The rate of postoperative pacemaker insertion, after adjustment, was 22.44% in the Intuity group and 5.66% in the standard aortic valve group (P=0.030). The main indications for postoperative pacemaker insertion were complete atrioventricular block and left bundle branch block with prolongation of the H-V interval. The rate of new postoperative left bundle branch block conduction disorders was significantly higher in patients implanted with an Intuity valve (odds ratio 5.28, 95% confidence interval 1.59 to 23.05; P=0.012).Higher rates of pacemaker insertion and new conduction disorders were observed in patients implanted with an Intuity sutureless bioprosthesis compared with those who received a standard surgical aortic valve.

Transcatheter aortic valve implant (TAVI) is gaining momentum in the treatment of severe, symptomatic aortic valve stenosis, and its indication is expanding to lower surgical risk individuals, who are generally younger and have a long life expectancy. Therefore, transcatheter bioprostheses durability appears of critical importance. Aim of the present study is to evaluate mid-term outcomes of TAVI in a high-volume single center cohort.We analyzed all consecutive patients (n = 408) who underwent transfemoral TAVI at a single, high-volume center, between 2007 and 2014. Study objectives were all-cause death and bioprosthetic valve failure (BVF) at long term follow-up. Structural valve deterioration (SVD), BVF and valve-related death were defined according to current international standards. Follow-up was performed by in person visit and transthoracic echocardiography, which was obtained only in a minority of patients, or phone call as per patient preference.At a median follow-up of 1821 days, overall mortality was 64.5%, with cardiovascular disease accounting for roughly half of total deaths. Valve-related deaths occurred in 10 patients. Seventeen patients were diagnosed with BVF, and 15 required repeat intervention. Moderate and severe SVD were observed in 10 and 7 patients, respectively. In the subgroup of patients with echocardiographic mid-term follow-up (n = 76), no significant increase of transprosthetic gradients nor increase of significant regurgitation was detected.In the present unselected, all-comers cohort, TAVI bioprostheses appeared to have excellent durability at long-term follow-up.

Loosening remains one of the most common reasons for revision total knee arthroplasty (TKA). Cement viscosity has a potential role in reducing revision rates for loosening. The aim of this study was to assess the outcome for loosening of the 5 most used cemented knee prostheses by constraint type, based on the cement viscosity type used.There were 214,708 TKA procedures performed between 1999 and 2020 for a diagnosis of osteoarthritis using the 5 most commonly used minimally stabilized, posterior stabilized, and medial pivot design cemented tibial components. Only procedures with a cemented tibial component were included. Outcomes for two different cement viscosities, 140,060 high viscosity and 74,648 low viscosity cement, were compared for each fixation type within each of the three stability groups.There was no difference in a risk of all-cause revision when high viscosity cement was used compared to low viscosity cement for minimally stabilized prostheses (hazards ratio [HR] 1.07 [95% CI 0.99-1.15], P = .09), posterior stabilized prostheses (HR 1.03 [95% CI 0.95-1.11], P = .53), and medial pivot design prostheses (HR 1.06 [95% CI 0.80-1.41], P = .67). No difference was observed between cement viscosity types for any of the prosthesis constraint types when aseptic loosening was assessed.We found no difference in the risk of revision for any reason, or for loosening, with cement viscosity for the most commonly used minimally stabilized, posterior stabilized, and medial pivot TKA. The role of cement viscosity in the risk of TKA revision remains unclear and further research is required.Level III Retrospective comparative study.

Objective To evaluate clinical outcomes of a trifocal intraocular lens using femtosecond laser-assisted cataract surgery (FLACS), digital tracking (DT), and intraoperative aberrometry (IA). Setting One site (Abbotsford, B.C., Canada) Design Retrospective, single-surgeon study. Methods This was a retrospective, single-surgeon study examining 200 eyes of 100 bilaterally implanted patients. Eligible participants were those presenting with visually significant cataracts or as a candidate for clear lens extraction who were interested in implantation of a diffractive toric or non-toric intraocular lens. Preoperative and postoperative data were collected for manifest refraction spherical equivalent (MRSE), refractive astigmatism (RA), and monocular uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA). Results Mean postoperative manifest refraction spherical equivalent (MRSE) was 0.006 ± 0.27 D. The absolute prediction error was 0.50 D or less in 88.0% (176/200) of eyes. Postoperative RA was 0.50 D or less in 98.5% (197/200) of eyes. Postoperative UDVA was 0.10 logMAR or better in 86% (172/200) of eyes, and 66.0% (132/200) of eyes were 0.00 logMAR or better. Postoperative UIVA was 0.10 logMAR or better in 99.5% (199/200) of eyes, and 95.0% (190/200) of eyes were 0.00 logMAR or better. Postoperative UNVA was 0.10 logMAR or better in 91.5% (183/200) of eyes, and 73.5% (147/200) of eyes were 0.00 logMAR or better. Conclusion The results demonstrate that trifocal implantation with FLACS, DT, and IA can provide excellent refractive and visual outcomes.

Previous studies have demonstrated that decreased impingement-free range of motion (ROM) can adversely influence clinical outcomes following reverse shoulder arthroplasty (RSA). Inferior placement of the glenosphere is thought to minimize impingement and its associated sequelae. This study evaluated the relationship between inferior overhang of the glenosphere and clinical outcomes in patients undergoing primary RSA using a lateralized humeral implant design.By use of a prospectively collected shoulder arthroplasty database, all primary RSAs performed at our institution between 2007 and 2015 with a single implant design (lateralized humerus and medialized glenoid) and minimum 2-year follow-up were evaluated. Glenosphere overhang in relation to the inferior rim of the glenoid was measured in millimeters on postoperative Grashey radiographs of the shoulder and categorized into tertiles (low,7.1 mm; medium, 7.1 to 9.9 mm; and high,9.9 mm). Clinical outcomes of interest comprised the changes between preoperative and postoperative values in the following ROM and outcome score measures: active forward elevation (aFE), active external rotation, American Shoulder and Elbow Surgeons score, Constant-Murley score, Shoulder Pain and Disability Index score, and Simple Shoulder Test score. Random-effects linear models were used to assess univariate and multivariable associations between overhang tertile and change in patient outcomes. Differences in outcomes were further compared using the minimal clinically important difference (MCID).The study identified 284 shoulders in 265 patients. The median follow-up period was 36 months (range, 24-108 months). The median glenosphere inferior overhang was 8.4 mm, with an interquartile range of 6.3-10.6 mm. Plots demonstrated nonlinear relationships between overhang and outcome scores and between overhang and ROM. Patients with high overhang experienced a significantly greater improvement in aFE compared with patients with low overhang (P = .019), which exceeded the MCID. No other differences in ROM and outcome scores between overhang groups exceeded the MCID. For other outcome scores and ROM measurements, there was no significant relationship with glenosphere overhang. Increased overhang was associated with a significantly lower incidence of scapular notching (P = .005).Patients undergoing RSA using a lateralized humerus design with greater inferior overhang of the glenosphere demonstrated a significantly greater improvement in aFE and lower rate of notching compared with those with low overhang. No ideal glenosphere overhang range was identified to maximize function in this study.

Both cones or sleeves have been developed to address metaphyseal bone loss in revision total knee arthroplasty (TKA), but few studies have directly compared the outcomes. The purpose of this study was to compare the survivorship and aseptic revision rates between metaphyseal cones and sleeves at intermediate follow-up.We reviewed a consecutive series of 1,172 revision TKA patients between 2009 and 2018 with a minimum two-year follow-up on all patients. We compared demographics, surgical indication, stem fixation, constraint, rates of rerevision, and Short-Form-12 scores between patients with cones and sleeves. A multivariate analysis was performed to identify the effect of cones and sleeves on aseptic rerevision. Kaplan-Meier curves were generated to compare aseptic survivorship of cones and sleeves.There were 194 tibial cones (17%), 107 tibial sleeves (9%), 31 femoral cones (3%), and 135 femoral sleeves (12%) with a mean follow-up of 6.5 years (range: 2-12 years). There was no difference in demographics, indication, stem fixation, or constraint (P.05). Although overall aseptic failure rates may be lower for tibial sleeves, there were no significant differences in survivorship over a one-year, two-year, and five-year follow-up when both tibial and femoral sleeves were directly compared to cones.Both tibial and femoral sleeves and cones perform well at an intermediate-term follow-up. Further investigation of these two are required to better understand their survivorship relative to each other.

High degree cardiac conduction disturbances (HDCD) remain a major complication after transcatheter aortic valve replacement (TAVR), especially with self-expandable valves (SEV). Our aim was to investigate peri-procedural and in-hospital modification of atrioventricular and intracardiac conduction associated to new generation SEV implantation, and the development of new HDCD resulting in permanent pacemaker implantation (PPM) in patients undergoing TAVR.Three-hundred forty-four consecutive patients with severe aortic stenosis who underwent TAVR with a new generation SEV [Evolut-R/Pro (n = 130), Acurate-neo (n = 79), Portico (n = 75) and Allegra (n = 60)] were included. An analysis of baseline, post-TAVR and pre-discharge ECG and procedural aspects were centrally performed. A significant increase in baseline PR interval (169.6 ± 28.2 ms) and QRS complex width (101.7 ± 25.9 ms) was noted immediately post-TAVR (188.04 ± 34.49; 129.55 ± 30.02 ms), with a partial in-hospital reversal (179.4 ± 30.1; 123.06 ± 30.94 ms), resulting in a net increase at hospital discharge of 12.6 ± 38.8 ms and 21.4 ± 31.6 ms (p 0.001), respectively. The global incidence of new onset persistent HDCD at hospital discharge was 46.3%, with 17.7% of patients requiring PPM. Independent predictors of new onset HCDC at hospital discharge were valve recapture (OR: 2.8; 95% IC: 1.1-7.2, p = 0.033) and implantation depth ≥ 6 mm (OR: 1.9 05% IC 1.1-3.3, p = 0.015), while higher implantation (3 mm (OR: 0.3, 95% IC 0.1-0.7, p = 0.014) and use of Acurate-Neo valve (OR: 0.4; 95% IC 0.2-0.8, p = 0.009) were protective factor.New generation self-expanding aortic valves were associated with a significant increase in PR and QRS interval at hospital discharge leading to a very high rate of HDCD. While valve recapture and implantation depth were independent predictors for the occurrence of HDCD, use of Accurate-Neo valve was a protective factor.

The differences in long-term outcomes of aortic valve replacement for aortic stenosis between stentless and stented bioprostheses are controversial.Between 2007 and 2018, 1173 patients underwent aortic valve replacement for aortic stenosis, including 559 treated with a stentless valve and 614 with a stented valve. A propensity score matched cohort with 348 pairs was generated by matching for age, sex, body surface area, bicuspid aortic valve, chronic lung disease, previous cardiac surgery, coronary artery disease, renal failure on dialysis, valve size, concomitant procedures, and surgeon. The primary endpoints of the study were long-term survival and incidence of reoperation.Immediate postoperative outcomes were similar between the stentless and stented groups with an overall operative mortality of 2.9% (P = .19). Kaplan-Meier estimation for long-term survival was comparable between the stentless and stented valves in both the whole cohort and the propensity score matched cohort (10-year survival 59% vs 55%, P = .20). The hazard ratio of stentless vs stented valve for risk of long-term mortality was 1.12 (P = .33). The 10-year cumulative incidence of reoperation due to valve degeneration was 5.5% in the stentless group and 4.7% in the stented group (P = .25). The transvalvular pressure gradient at 5-year follow-up was significantly lower in the stentless group (7 vs 11 mm Hg, P.001).Both stented and stentless valves could be used in aortic valve replacement for aortic stenosis. We recommend stented valves for aortic valve replacement in patients with aortic stenosis for their simplicity of implantation.

A critical step in the endovascular treatment of complex aortic aneurysms is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR).Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or nonchallenging TV.Fifty-three patients (median age 73 (Q1, Q3 (68-80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n = 26; 49%), juxtarenal aneurysms (n = 23; 43.5%) and penetrating aortic ulcers (PAU) (n = 4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of 3 TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus nonchallenging TV (P = 0.457). One patient died within 30 days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36 months, the survival rate was 87%, 87%, and 81%, respectively. Primary patency after 12 months was 98.6%, and 97.9% of vessels remained FFR during follow-up.Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.

The US Food and Drug Administration (FDA) was created with the intent to ensure the safety of consumers in the United States. During the 1970s, this mandate was expanded to include medical devices. Aortic endografts, implanted since the 1990s, fall under this purview. Industry-sponsored and physician-sponsored investigation of the efficacy and safety of these devices is critical to the ongoing development of interventions for complex aortic anatomy. This research, in accordance with federal rules and regulation, must be conducted in coordination and with the approval of the FDA. The FDA has designed a process for which manufacturers or investigators may conduct efficacy and safety research using new or modified devices with oversight by the federal government. To conduct this type of research, an investigational device exemption must be obtained from the FDA. An investigational device exemption, although useful from a regulatory perspective, places a large time and financial responsibility on the investigator. As it stands now, the regulatory environment limits research into fenestrated and branched endovascular aortic repair to only those physicians and manufacturers able to provide the significant number of resources required to complete the laborious pre-application, application, and ongoing reports associated with obtaining and maintaining an investigational device exemption.

The aim of this study was to compare the 2-year outcomes of de novo versus postendovascular lesion treatment of femoropopliteal occlusions included in a national, multicenter, observational, prospective registry based on the treatment of critical Limb-threatening IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE) registry.From January 2018 to December 2019, 541 patients from 43 centers have been enrolled in the LIMBSAVE registry. Of these patients, 460 were included in the present study: 341 (74.1%) with de novo lesions (DN group) and 119 (25.9%) with postendovascular treatment lesions (PE group). Initial outcome measures were assessed at 30 days after treatment. Furthermore, at the 2-year follow-up, the estimated outcomes of primary patency, primary-assisted patency, secondary patency, and limb salvage were analyzed with Kaplan-Meier curves and compared between groups with the log-rank test.Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation. However, compared with DN group, more patients in PE group had a great saphenous vein diameter of less than 3 mm (11.1% vs 21%; P = .007). Intraoperatively, both groups showed similar distal anastomosis sites: below-the-knee popliteal artery (63% DN group, 66.4% PE group) and tibial vessel (37% DN group, 33.6% PE group) (P = .3). The overall mean duration of follow-up was 11.6 months (range, 1-24 months). At the 2-year follow-up, there were no differences between the two groups in terms of primary patency (66.3% DN group vs 74.1% PE group; P = .9), primary-assisted patency (78.2% DN group vs 79.5% PE group; P = .2), secondary patency (85.1% DN group vs 91.4% PE group; P = .2), and limb salvage (95.2% DN group vs 95.1% PE group; P = .9).The LIMBSAVE registry did not show a worsening of overall patency and limb salvages rates at the 2-year follow-up in patients undergoing in situ saphenous bypass after a failed endovascular approach for long femoropopliteal occlusive disease. This finding is in contrast with what has been published in literature.

Current guidelines provide recommendation for transcatheter aortic-valve replacement (TAVR) in severe aortic stenosis without emphasis on valve systems. The comparative performances of balloon-expandable valves (BEV) and self-expanding valves (SEV) remain unclear. We aim to compare the early (30-day) and midterm (1-year) mortality and cardiovascular outcomes of BEV with SEV.PubMed, CENTRAL, and EMBASE were searched from inception to February 13, 2020 for randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. Odds ratios (ORs) for binary outcomes and mean differences for continuous outcomes were pooled using random-effect models (DerSimonian-Laird method) with Hartung-Knapp-Sidik-Jonkman variance correction. Primary outcomes were early and midterm all-cause mortality.We included 3 RCTs (1418 patients) and 12 PSM studies (36,540 patients). Compared with SEV, BEV was associated with significantly lower mortality at 30 days (OR 0.76, 95% CI 0.67-0.85, p 0.001, I2 = 0) and 1 year (OR 0.87, 95% CI 0.77-0.99, p = 0.04, I2 = 20.4%) in PSM studies, but not RCTs with insufficient power. Similar findings were found in subgroups analysis based on valve generations and SEV types. The 30-day and 1-year cardiovascular mortality, 30-day incidences of moderate to severe paravalvular leak, procedural contrast agent volume, and procedure time were lower, but transvalvular pressure gradient was higher in BEV than SEV in PSM studies. The 30-day incidences of permanent pacemaker implantation (PPI), acute kidney injury, stroke, major bleeding, major vascular complications, and rehospitalization were not statistically different between BEV and SEV. Early-generation SEV was associated with a higher 30-day PPI risk than corresponding BEV comparators. PPI risk was lower in ACURATE neo (Boston Scientific, Natick, MA) but higher in Evolut R SEV (Medtronic Inc., Minneapolis, MN), both compared with SAPIEN 3 BEV (Edwards Lifesciences, Irvine, CA).PSM studies suggest lower early and midterm mortality in BEV than SEV, but the contribution of unmeasured confounders cannot be excluded. Results from adequately powered RCTs with long-term follow-up are critically needed to confirm these findings.

BACKGROUND: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created. RESULTS: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation. CONCLUSIONS: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation. ispartof: ANNALS OF THORACIC SURGERY vol:114 issue:3 pages:758-+ ispartof: location:Netherlands status: published

Transcatheter aortic valve replacement (TAVR) is increasingly being performed in younger and lower surgical risk patients. Given the longer life expectancy of these patients, the bioprosthetic valve will eventually fail, and aortic valve reintervention may be necessary. Although currently rare, redo-TAVR will likely increase in the future as younger patients are expected to outlive their transcatheter bioprosthesis. This review provides a contemporary overview of the indications, procedural planning, implantation technique, and outcomes of TAVR in failed transcatheter bioprosthetic aortic valves.

Fenestrated-branched endovascular aortic repair (FB-EVAR) has gained widespread acceptance in patients with complex aortic aneurysms. It has evolved from an alternative to treat elderly and higher risk patients to the first line of treatment in most patients with suitable anatomy, independent of the clinical risk. Currently, these devices are available off-the-shelf (ready to use) and tailored to the patient anatomy with the options of fenestrated, branched and mixed fenestrated, and branched designs. Reports from single and multicenter experiences and systematic reviews have shown lower mortality and morbidity for FB-EVAR compared with historical results of open surgical repair. The main advantages are noted on mortality, respiratory complications, acute kidney injury, and length of hospital stay. The purpose of this article is to review the advances in the endovascular repair of complex aortic aneurysms exploring the indications for treatment, preoperative evaluation, patient selection, device design, and implantation technique.

The article describes contemporary indications, techniques, and outcomes of physician-modified endografts (PMEGs) for the treatment of complex aortic aneurysms. Physician-modified endografting has been performed with high technical success rates and lower complication rates compared with traditional open surgery for complex aortic aneurysms. Various techniques have been reported for the design, modification, and implantation of PMEGs, using different off-the-shelf devices. Although PMEGs are used more commonly for urgent and emergent repair of symptomatic or ruptured complex abdominal and thoracoabdominal aortic aneurysms in patients who do not have access to manufactured devices, some centers have reported utilization of PMEGs in elective cases under the aegis of the US Food and Drug Administration-approved Investigational Device Exemption protocols. Although the initial outcomes of PMEGs are promising, continued surveillance remains a crucial component to determine long-term durability. All treatment options for complex abdominal and thoracoabdominal aortic aneurysms should be considered carefully, with PMEGs reserved for those cases unsuitable for other repair alternatives, and at centers with the volume and expertise to execute the procedure with high technical success and low morbidity and mortality rates. With the continued evolution of endovascular technology, the role and indications for PMEGs are expected to change.

Cemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies.Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma.Of the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups.There is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.

The ability of a group of high-volume arthroplasty surgeons to simultaneously change their preferred primary total knee arthroplasty (TKA) implant of choice to another, has not been explored in the literature to date. The main hypothesis was that such a change could be made with no significant impact on clinical outcomes.This is a retrospective cohort study comparing the last 500 consecutive TKAs implanted of a routinely used TKA implant (NexGen; Zimmer, Warsaw, IN) with the first 500 consecutive TKAs implanted of a newly adopted TKA implant (Triathlon; Stryker, Mahwah, NJ) at an institutional level. Primary outcomes of importance included all complications that occurred either intraoperatively or early postoperatively, early all-cause revision rate, and early reintervention rate.There was a 1.2% (n = 6) complication rate in the NexGen cohort compared to 0.8% (n = 4) in the newly adopted Triathlon cohort (P = .75). The rate of intraoperative fracture was 1% in the NexGen cohort and 0.6% in the Triathlon cohort (P = .72). The early all-cause revision rate for the NexGen TKA was 1% (n = 5) compared to 0.8% (n = 4) in the Triathlon cohort (P = 1.0). The manipulation under anesthesia (MUA) rate in the NexGen cohort was 2.4% compared to 4.6% in the Triathlon cohort (P = .058). The only predictor variable associated with MUA rate was American Society of Anesthesiologists grade, where there was a significantly lower rate of MUA with a higher American Society of Anesthesiologists grade (P = .042).It is possible to implement the institution-wide adoption of an established, high-performing TKA implant without any negative implications in relation to early revision rates, perioperative complication rates, and reintervention rates. This study is the first of its kind to be reported in the literature.

Connective tissue disease (CTD) syndromes involve the ascending, aortic arch, and thoracoabdominal aorta and are associated with higher risk of aortic aneurysm or dissection. Currently, vascular societies generally recommend open repair as the first option for aortic disease in patients with CTD. However, the implementation of endovascular techniques for patients with CTD with aortic pathologies seems to have increased in recent years, mainly in patients of high surgical risk or in urgent situations. Endovascular treatment of aortic arch pathologies in patients with CTD have been feasible in experienced centers; however, the evidence is scarce. Thoracic endovascular aneurysm repair in patients with CTD is more evident; in 15 studies, 304 patients with CTD were treated with thoracic endovascular aneurysm repair with high technical success rates (88% to 100%) and a low early mortality rate (1.6%). During the median follow-up, 33 patients died and 64 patients underwent a re-intervention. In 6 studies, 26 patients with CTD were treated with fenestrated/branched endovascular aneurysm repair for thoracoabdominal aortic aneurysm, with a technical success rate of 100%, without early mortality and morbidity. The endovascular approach to thoracoabdominal aortic aneurysm, especially in post-dissection patients, mandates adjunctive techniques to achieve false lumen thrombosis with various approaches; in our experience, the Candy-Plug technique has been proven to be technically feasible with good outcomes. Endovascular treatment of aortic pathologies in patients with CTD seems to be feasible and safe in high-risk and urgent patients. Re-intervention remains an issue. The constant development of endovascular techniques and devices may provide improved mortality and morbidity outcomes.

To analyze the outcomes of Supera stent deployment in Chinese patients with atherosclerotic femoropopliteal artery (FPA) disease in a real-world setting.This retrospective cohort study collected and analyzed the medical records of 246 consecutive patients who received Supera stents for FPA disease at the China Academy of Chinese Medical Sciences Xiyuan Hospital between February 2017 and December 2019. All study patients underwent balloon angioplasty and were treated with Supera stents (Abbott Vascular, Santa Clara, CA, USA). The primary outcome was the rate of primary patency 12 months after discharge.The analyses included 246 consecutive patients and 260 lesions. The mean ± SD age was 73.2 ± 9.9 years and most patients (60.2%) were males. Of the 260 treated lesions, Supera stents were deployed in eight (3.1%) cases after a previous stent fracture. Critical limb ischemia was diagnosed in 87.3% of the limbs, and 84 (32.3%) and 83 (31.5%) cases were classified as TransAtlantic Inter-Society Consensus (TASC) C and D, respectively. Most of the lesions were in situ (80.8%) and located in the superficial femoral artery (45.0%) or the FPA (45.8%). The mean lesion length was 147.7 mm. Nominal deployment (-10 to 10% compression) was the most common deployment scenario (84.1%). The 1-year primary patency rate was 80.6%. Lesions that occurred as restenosis (odds ratio [OR]: = 3.34, 95% confidence interval [CI]: 1.03-10.85, P = 0.045) or in-stent restenosis (OR: = 2.88, 95% CI: 1.03-8.07, P = 0.045) were independently associated with occlusion or stenosis after stent deployment. No stent fracture was observed in this study.Our study indicates that the use of Supera stents is feasible for the treatment of Chinese patients with FPA disease. The long-term results reveal high primary patency.

Conventional polyethylene (CPE) was used widely in the past as a bearing surface in total hip arthroplasty (THA). As CPE THAs age and the revision burden continues to grow, it is increasingly important to understand the durability and failure mechanisms of this bearing material. Currently, such long-term data remain limited, particularly in younger, more active patients in whom wear issues are of greater concern.We retrospectively reviewed 90 hips (77 patients) that underwent primary THA with CPE bearings on cobalt chrome femoral heads at age ≤50 years at 20-year minimum follow-up (mean 21.6 [20-23]). We analyzed polyethylene wear rates, clinical outcomes (modified Harris Hip Score, University of California, Los Angeles Activity Score), and implant survivorship.Wear analysis revealed a median linear wear rate of 0.113 mm/y (95% CI 0.102-0.148) and a median volumetric wear rate of 41.20 mmWear-related issues developed at increasingly high rates after 15 years, suggesting the need for surveillance after this time. The long-term wear and survivorship data of this study may be used as a benchmark when evaluating the performance of contemporary bearings in young, active THA patients.

Over the last two decades there has been a significant shift towards the use of bioprostheses in the context of surgical aortic valve replacement, despite the well-known process of structural valve deterioration (SVD). This process has been extensively evaluated even though with many different definitions and methods, thus, the true long-term durability of surgical bioprostheses is not yet fully elucidated. Following the increasing implementation of the transcatheter aortic valve implantation (TAVI) technology, a better understanding of the long-term durability of transcatheter bioprostheses has become increasingly important as well, despite the limited availability of such data compared to the surgical experience. This lack of knowledge is a major barrier to the use of TAVI platforms to treat relatively younger patients. We thus aimed at providing an overview on long-term actual data concerning the durability of bioprostheses focusing on definition, incidence, and subsequent management of SVD of both surgical and transcatheter bioprosthetic aortic valves.

Endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms has become increasingly common, with some specialized centers using fenestrated and branched endografts as a first-line therapy, given the decreased early morbidity and mortality compared with open surgical repair. However, the long-term durability of fenestrated and branched endovascular aortic repair remains in question, given the high rate of secondary interventions. Contraindications, complications, and causes of secondary interventions after fenestrated and branched endovascular aortic repair are often related to the anatomic factors of the aorta, target arteries, and access vessels. This article provides an overview of anatomic factors that should be considered when determining eligibility, as well as designing and executing fenestrated and branched endovascular aortic repair procedures.

Fenestrated-branched endovascular repair has been disseminated worldwide from a technique used to treat high-risk patients to a valid alternative in almost any patient who is anatomically suitable and has complex abdominal and thoracoabdominal aortic aneurysms. As with any new procedure, there is a steep learning curve that goes beyond proficiency with deployment. Ultimately, patient selection, team performance, surgeon's ability to adapt to unexpected events, and the constant evolution of improvements in technical aspects all affect the early outcomes and durability of the repair. This article reviews the importance of the learning curve, evolution of complex endovascular techniques, and factors affecting outcomes of complex endovascular aneurysm repair.

To compare gait biomechanics of the Northwestern University Flexible Sub-Ischial Vacuum (NU-FlexSIV) Socket to the ischial containment (IC) socket.Randomized crossover trial with 2, 7-week periods.Private prosthetic clinics and university research laboratory.A total of 30 enrolled (n=30); 25 participants completed the study with full (n=18) or partial data (n=7).Two custom-fabricated sockets (IC and NU-FlexSIV), worn full-time for 7 weeks, with testing at 1, 4, and 7 weeks after socket delivery.Gait analyses were conducted at 1, 4, and 7 weeks post socket delivery. Differences between sockets in selected gait variables related to hip motion and coronal plane socket stability were assessed.For participants with data for both sockets at week 7 (n=19), there were no significant differences in any gait variables between sockets at self-selected normal walking speed. However, when all participants and all study time points were assessed (n=25), there was a significant main effect of socket (P=.013), with prosthetic side sagittal plane hip range of motion being significantly greater for the NU-FlexSIV Socket at self-selected normal walking speed. There were no other significant effects.The results suggest that, compared to the IC socket, the NU-FlexSIV Socket did not alter gait biomechanics related to hip motion and coronal plane socket stability in people with unilateral transfemoral amputation.

The aim of this study was to evaluate the radiographic and clinical outcomes of a recently introduced metaphyseal cone system for revision TKA.73 revision TKAs in 72 patients were retrospectively reviewed. All patients had a minimum of 2-year clinical follow-up (mean 34.1 months; range 24.0 to 50.3 months). 114 Metaphyseal cones (64 tibial and 50 femoral) of a single manufacturer were implanted. The most common indications for revision were aseptic loosening (56.9%), second stage reimplantation for periprosthetic joint infection (PJI; 26.4%), and instability (12.5%). All femoral and tibial stems were press-fit cementless stems.Ten of 72 patients underwent re-revision: six for infection (8.3%), two for instability (2.8%), one (1.4%) for patellar tendon rupture and one (1.4%) for femoral component loosening (a cone was not utilized at index revision). Two patients had loose cones (one with an isolated tibial cone and one with both femoral and tibial cones) associated with loose implants but declined re-revision. Aseptic survivorship of our patient cohort free from any re-revision surgery was 95.9% at 2 years (95% CI 87.4-98.7%) and 96.5% of cones demonstrated radiographic evidence of osseointegration. At 2-years, the Knee Society Score (KSS) improved from a mean of 17.2 points preoperatively to 57.8 points (p .0001).Porous-coated metaphyseal cones from this manufacturer demonstrate excellent aseptic survivorship and radiographic evidence of osseointegration similar to prior designs when used with cementless stems.

One percent to 3% of contemporary non-cemented total hip arthroplasties (THAs) present with symptomatic mechanically assisted crevice corrosion (MACC). The incidence of this problem, however, as well as the rate of asymptomatic elevations in serum cobalt, is unknown.Cobalt and chromium levels were obtained in conjunction with radiographs at routine 10-year surveillance follow-up of THAs from a single manufacturer with a titanium stem, cobalt alloy femoral head, and cross-linked polyethylene countersurface.Ten-year follow-up of patients with 162 consecutive THAs revealed that 17 patients with 18 hips had died of unrelated causes prior to metal ion testing. Two hips were revised for other reasons, and of the remaining 142 hips, 33 were in patients who were lost, leaving 109 hips (77% of those in alive patients and unrevised for other reasons and 67% of the entire cohort) for investigation. Sixty-three patients (58%) had a serum cobalt less than 1 ppb, and 35 (32%) a cobalt of ≥1 ppb, a cutoff consistent with MACC. Of the 32 hips with definite MACC, 15 of 32 (47%) patients were symptomatic, 16 of 30 (53%) patients had adverse local tissue reaction on magnetic resonance imaging, and 19 of 32 (59%) patients have undergone revision surgery for MACC to date.At 10-year follow-up, a minimum of 22% (35/162) of hips had a cobalt level more than 1 ppb, consistent with MACC. Symptoms and adverse local tissue reactions are each present about one-half of the time, and 59% of those with documented MACC have undergone revision.

The aim of this study was to evaluate outcomes of real-world patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) with the 34 mm Evolut R (Medtronic, Minneapolis, Minnesota).Larger aortic annulus has been associated with increased incidence of paravalvular leaks (PVLs) after TAVR. However, little is known, so far, about the performance of the 34 mm Evolut R in this setting.From the multicenter, international, retrospective Horizontal Aorta in Transcatheter Self-expanding Valves (HORSE) registry, including patients who underwent TAVR for native severe AS, we selected patients treated with the 34 mm Evolut R evaluating procedural characteristics and VARC-2 defined device success. We also compared 34 mm Evolut R with other Evolut R sizes.Among the 4434 patients included in the registry, 572 (13%) received the 34 mm Evolut R valve. Mean age was 80.8 ± 6.5 years and the median STS PROM score was 4 [interquartile range 2-6]. Device success was achieved in 87.4% with 7.7% of PVLs; moreover, the rate of permanent pacemaker implantation (PPMI) was 22.4%. Patients who underwent 34 mm Evolut R implantation experienced more in-hospital permanent pacemaker implantation (22.4% vs. 15%; p 0.001). At multivariate analysis, 34 mm Evolut R did not affect device success (OR: 0.81 [0.60-1.09]; p = 0.151). Device success was consistent with other THVs sizes (87.4% vs. 89.6%; p = 0.157).THV replacement in patients requiring 34 mm Evolut R has an acceptable performance. Compared to other Medtronic sizes it demonstrated to be comparable in terms of device success, despite an increased rate of pacemaker implantation.

The consensus systematic risk stratification algorithm from the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and The Hip Society summarizes clinical challenges in evaluation and treatment of metal-on-polyethylene total hip arthroplasty (THA) patients with adverse local tissue reaction (ALTR) due to mechanically assisted crevice corrosion (MACC), reviews up-to-date evidence, and identifies the areas for future research in order to provide a useful resource for orthopedic surgeons providing care to these patients. A painful THA has various intrinsic and extrinsic causes. ALTR is one of the intrinsic causes in patients with painful THA. The occurrence of ALTR due to MACC at modular junctions is likely to be multifactorial, including implant, surgical, and patient factors. Therefore, a systematic evaluation needs to involve a focused clinical history, detailed physical examination, laboratory tests, and imaging in order to identify potential differential diagnoses. There should be a low threshold to perform a systematic evaluation of patients with painful non-metal-on-metal THA, including patients with metal-on-polyethylene THA, and modular dual-mobility THA with the CoCr metal acetabular insert, as early recognition and diagnosis of ALTR due to MACC will facilitate initiation of appropriate treatment prior to significant adverse biological reactions. Specialized tests such as blood metal analysis and metal artifact reduction sequence magnetic resonance imaging are important modalities in evaluation and management of ALTR in patients with painful THA.

The rationale for advances in implant design is to improve performance in comparison to their predecessors. The purpose of this study was to compare a newer, self-pressurizing peripheral peg glenoid to a traditional polyethylene pegged glenoid through biomechanical evaluation and a retrospective radiographic and clinical review.Three testing conditions (uncemented, partially cemented, and fully cemented) were chosen to assess the 2 component designs in a foam block model. The number of hammer hits to seat the component, amount of time to seat the component, and resistance-to-seat were collected. The implants were then cyclically loaded following ASTM F2028-17 testing standard. Clinically, postoperative radiographs of patients with a self-pressurized glenoid component (n = 225 patients) and traditional glenoid component (n = 206 patients) were evaluated for radiolucent lines and glenoid seating at various timepoints. Clinical outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, and visual analog scale pain scores) and complications were recorded. The presence of radiolucent lines at the bone-cement interface was evaluated using the Modified Franklin Grade and the Lazarus grade.The self-pressurizing glenoid design required significantly more hammer hits than traditional glenoid designs in all groups tested (P .029). Moreover, the self-pressurizing design had significantly more resistance-to-seat than traditional components in both the uncemented and partially cemented group (P .002). No difference in resistance-to-seat was found between designs in the fully cemented group. The uncemented and partially cemented groups did not survive the full 50,000 cycles; however the self-pressurizing design had significantly less motion than the traditional design (P .001). No differences between component designs were found in the fully cemented group at 50,000 cycles. The self-pressurizing glenoid component had 0.005% radiographic radiolucent lines, and the traditional glenoid component had 45% radiographic radiolucent lines, with 38% of the radiolucencies in the traditional glenoid component group being defined as grade E. There were no progressive radiolucencies, differences in clinical outcomes, or complications at 2 years postoperatively.In the fully cemented condition, the 2 component designs had comparable performance; however, the differences in designs could be better observed in the uncemented group. The self-pressurizing all-polyethylene design studied has superior biomechanical stability. Clinically, the improved stability of the glenoid component correlated with a reduction of radiolucent lines and will likely lead to a reduction in glenoid component loosening.