Excimer laser angioplasty can be safely and effectively applied, even in a variety of complex lesions not well suited for percutaneous transluminal coronary angioplasty. These types may include aorto-ostial, long lesions, total occlusions crossable with a wire, diffuse disease and vein grafts. Most recent data show a trend for the selection of predominantly complex lesions and a reduction in the incidence of perforation. This procedure may broaden the therapeutic window for the interventional treatment of selected complex coronary artery disease.
Objectives: Though ablation is a relatively safe procedure for atrial fibrillation (AF) treatment, a rare but potentially fatal complication in the form of cardiac perforation could occur. The aim of this study was to examine the underlying predictors associated with cardiac perforation. Methods: The 2013-2018 Centers for Medicare & Medicaid Services (CMS) Medicare Standard Analytic Files (SAF) data was used for this study. Patients aged $65 years who underwent ablation procedure with a primary diagnosis of AF were identified, with first such occurrence classified as index procedure. The main outcome of interest was the occurrence of cardiac perforation within 30 days of the index ablation. Baseline demographic, comorbid, and procedure-related characteristics were examined. Univariate logistic regression followed by generalized estimating equation (GEE) with logit link and binomial distribution were used to assess the underlying predictors of cardiac perforation. Sensitivity analysis was performed by controlling for hospital ablation volume. Results: The final sample included 102,389 patients. The average age was 71 years, 43.8% were female, and 94.2% were white. Cardiac perforation occurred in 0.61% (n=623) of patients within 30 days of the index ablation procedure. From univariate logistic regression, female gender, prior history of cardiac surgery, non-use of intracardiac echocardiography (ICE), hypothyroidism, obesity, and fluid and electrolyte disorders were identified as significant predictors. When examining these factors together in a GEE model, prior cardiac surgery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.08-0.26), obesity (OR 1.35; 95% CI 1.10-1.65), non-use of ICE (OR 5.06; 95% CI 4.16-6.15), and female gender (OR 1.34; 95% CI 1.15-1.57) emerged as significant predictors of cardiac perforation. Results: were consistent when controlling for hospital ablation volume. Conclusions: One of the strongest predictors of cardiac perforation during ablation for AF was a modifiable factor, i.e., the non-use of ICE.
Background
Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain.
Methods
Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1–4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat.
Results
Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11–34) versus 18 (10–28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups.
Conclusion
Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).
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