Plaque composition, as determined by VH-IVUS, only weakly correlates with the degree of cerebral embolization after carotid stenting. Specifically, there is a trend for larger dense calcium volume in patients with distal embolization. Of note, the proportion of necrotic core, which has traditionally been considered the main component of a vulnerable or unstable plaque, is not definitely associated with subclinical cerebral embolization after CAS when a filter device for embolic protection is used. The role of VH-IVUS in evaluating plaque composition during CAS remains unestablished and warrants further investigation.
Purpose: To report a case of severe mpox in a newly diagnosed HIV patient concerning Immune Reconstitution Inflammatory Syndrome (IRIS) and/or tecovirimat resistance and/or tecovirimat resistance and to describe the management approach in the setting of refractory disease. Case: 49-year-old man presented with 2 weeks of perianal lesions. He tested positive for mpox PCR in the emergency room and was discharged home with quarantine instructions. Three weeks later, the patient returned with disseminated firm, nodular lesions in the face, neck, scalp, mouth, chest, back, legs, arms, and rectum, with worsening pain and purulent drainage from the rectum. The patient reported being on 3 days of tecovirimat treatment, which was prescribed by the Florida department of health (DOH). During this admission, he was found to be HIV positive. A pelvic CT scan revealed a 2.5 cm perirectal abscess. Treatment with tecovirimat was continued for 14 days, along with an empiric course of antibiotics for treatment of possible superimposed bacterial infection upon discharge. He was seen in the outpatient clinic and initiated antiretroviral therapy (ART) with TAF/emtricitabine/bictegravir. Two weeks after starting ART, the patient was readmitted for worsening mpox rash and rectal pain. Urine PCR also returned positive for chlamydia, for which the patient was prescribed doxycycline. He was discharged on a second course of tecovirimat and antibiotic therapy. Ten days later, the patient was readmitted for the second time due to worsening symptoms and blockage of the nasal airway from progressing lesions. At this point, there were concerns for tecovirimat resistance, and after discussion with CDC, tecovirimat was reinitiated for the third time, with the addition of Cidofovir and Vaccinia, and showed an improvement in his symptoms. He received three doses of cidofovir and two doses of Vaccinia, and the patient was then discharged to complete 30 days of tecovirimat. Outpatient follow-up showed favorable outcomes and near resolution. Conclusion: We reported a challenging case of worsening mpox after Tecovirimat treatment in the setting of new HIV and ART initiation concerning IRIS vs. Tecovirimat resistance. Clinicians should consider the risk of IRIS and weigh the pros and cons of initiating or delaying ART. In patients not responding to first-line treatment with tecovirimat, resistance testing should be performed, and alternative options should be considered. Future research is needed to establish guidance on the role of Cidofovir and Vaccinia immune globulin and the continuation of tecovirimat for refractory mpox.
Objectives:To compare the outcomes of surgeon-modified fenestrated-branched stent grafts (mFBSG) and abdominal debranching (AD) in patients unfit for conventional open repair of complex abdominal (AAA) and thoracoabdominal aortic aneurysms (TAAA).Methods: We reviewed the outcomes of 35 high-risk patients (30 male, 5 female; median age 75 years) treated for large (7.2Ϯ1 cm) complex AAA and TAAA between 2006 and 2008. Fifteen patients had AD of 43 vessels (26 mesenteric, 17 renal) with aortic stent grafting. Twenty patients had 1 to 4-vessel mFBSG with branch artery stenting of 52 vessels (32 renal, 18 mesenteric, 2 hypogastric). End-points were mortality, morbidity, patency, endoleak and re-intervention rates.Results: mFBSG patients had higher comorbidity scores (16Ϯ5 vs 12Ϯ3; PϽ.03) and more (PϽ.05) stress-induced cardiac ischemia (60% vs 27%), renal insufficiency (65% vs 20%) and trans-renal aneurysm extension (100% vs 67%). The number of target vessels per patient (2.8Ϯ1) was similar in both groups, but AD patients had more thoracic extension (80% vs 32%; PϽ.05). Technical success for branch artery stenting was 98% (51/52). mFBSG required more (PϽ.05) fluoroscopy time (ϩ135Ϯ20 min) and contrast dose (ϩ105Ϯ89 ml), but less operative time (Ϫ151Ϯ49 min), blood loss (Ϫ1Ϯ0.8 L) and fluid requirement (Ϫ7Ϯ2 L). There was 1 (5%) operative death after mFBSG and 3 (20%) after AD (Pϭ0.19). Patients treated with mFBSG had less complications (40% vs 73%; PϽ.05), similar paraplegia rate (5% vs 13%; Pϭ.39) and decreased hospital stay (Ϫ10Ϯ7 days; PϽ.05). Type I endoleak was noted in 3 mFBSG (2 resolved) and in 4 AD patients (1 resolved). There was no difference in 1-year freedom from endoleak (83Ϯ9% vs 74Ϯ9%), re-intervention (83Ϯ9% vs 58Ϯ9%), target vessel patency (95Ϯ9% vs 98Ϯ2%) and survival (72Ϯ8% vs 71Ϯ9%) in mFBSG vs AD patients. Sac shrinkage (Ͼ 5mm) was noted in 7 of 9 (78%) mFBSG patients with Ͼ6 months follow up, and in none of the AD patients (PϽ.02). There were no migrations, component separations, fractures, or aneurysm ruptures after mFBSG.Conclusion: Surgeon-modified fenestrated and branched stent grafts can be performed with high procedural success in high-risk patients with complex AAA and TAAA. This study supports the use of mFBSG as an alternative to AD in patients who are suitable candidates for both techniques.Background: Growth of small abdominal aortic aneurysms (AAAs) is frequently associated with aortic neck and iliac artery (IA) changes during surveillance. The purpose of this study was to determine the effects of aortic neck and IA changes on anatomic suitability for endovascular aortic aneurysm repair (EVAR ) during long-term follow-up, particularly of small AAAs with marginal neck morphology (length Ͻ 15 mm and diameter Ͼ28 mm).Methods: We studied 62 patients with small AAAs (diameter, 4 cm to 5.4 cm) under surveillance with long-term follow-up by CT angiography and 3D reconstructions. The mean follow-up duration was 36 months (interquartile range [IQR], 16-53 months). AAA morphology and changes w...
Conclusions:The RUC Committee uses information gathered by subjective surveys rather than by prospectively collecting accurate workload data. This unique study demonstrates a real-world experience of reimbursement per unit time and raises questions about the validity of the RBRVS process. The disparity between payments for open and endovascular repair of similar conditions, such as aortic aneurysm and carotid stenosis, are typical of this inequality. These data do not reflect the intangible time of operative planning, administrative matters, or overhead, and these are factors that must be considered when interpreting this information. Regardless, this study suggests that capturing detailed financial data is possible and is a more accurate source for future discussions on reimbursement. Cerebral Microembolization: Open vs Percutaneous Carotid RevascularizationBackground: A cumulative burden of data suggest that microembolization to the brain may result in long-term cognitive dysfunction despite the absence of immediate overt cerebrovascular events. We reviewed a series of patients treated electively with carotid endarterectomy (CEA), carotid stenting with filter (CAS), and carotid stenting with flow reversal (FRS) monitored continuously with transcranial Doppler (TCD) imaging during the procedure to detect microembolization rates.Methods: TCD insonation of the M1 segment of the middle cerebral artery was conducted during 39 procedures (14 CEA, 18 CAS, and 7 FRS) in 38 patients seen at an academic center. One patient had staged bilateral CEAs. TCD detects intraprocedural microemboli as high-intensity transient signals (HITS). Cerebral blood flow dynamics and HITS were monitored ipsilaterally for CEA patients and bilaterally for CAS and FRS patients. Ipsilateral HITS were divided into three phases: preprotection phase (until the internal carotid artery was cross-clamped or shunted, filter deployed, or flow reversal established), protection phase (until clamp/shunt removed, filter removed, or antegrade flow re-established), and postprotection phase (after clamp/shunt removed, filter removed, or antegrade flow re-established). Descriptive statistics are reported as mean Ϯ standard error for continuous variables and number (%) for categoric variables. Differences in ipsilateral emboli counts based on cerebral protection strategy were assessed using nonparametric methods (Kruskal-Wallis test).Results: TCD insonation and procedural success was obtained in 29 procedures (13 CEA, 11 CAS, and 5 FRS). Groups did not differ in baseline demographics. Total ipsilateral HITs were significantly different across all three groups (P Ͻ .001) as well as by separate two-group comparisons: CEA vs CAS (P Ͻ .001), CEA vs FRS (P ϭ .002), and FRS vs CAS (P ϭ .027; Table).
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