The Mini-Craniotomy for cSDH Revisited: New Perspectives

Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow.

Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR.

Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months.

Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.

Gimme' the Loop: Modifications to the Squid-Capture Technique for Laser-Fenestrated Thoracic Endografting

PURPOSE

Laser-fenestrated thoracic endovascular aortic repair (LfTEVAR) in the aortic arch with covering of the left subclavian artery (LSA) orifice is challenging. To optimize fenestration, the so-called squid-capture technique has been introduced. We present here a modification to the technique that may help improve time-efficiency and safety.

TECHNIQUE:

During the originally proposed squid-capture maneuver, the stent-graft is deployed in a preset snare wire loop, which is used to pull the stent graft toward the penetration device during in-situ fenestration. In preparation, the guidewire needs to be passed through the loop inside the aortic arch, which can be difficult and may predispose for embolic events. We propose here the creation of a "guidewire-through-snare-loop" configuration outside the body, which can then be reliably transferred into the aortic arch. The modified technique was successfully applied in a patient undergoing LfTEVAR for penetrating aortic ulcers.

CONCLUSION

The proposed modification may help facilitate the squid-capture technique for LfTEVAR while saving time and resources. Given that LfTEVAR is becoming more frequently used, it is important to ensure technical success and safety of the procedure.

Left ventricular restrictive physiology in kids with atrial septal defects: Something unexpected!

Atrial septal defect (ASD) associated with left ventricular (LV) diastolic dysfunction (DD) is rare in children. DD is common in elderly patients undergoing ASD closure. Restrictive physiology among children undergoing percutaneous ASD closure is something unexpected that has not been described before in the literature. Hence, we report a child referred to our center for ASD closure in whom an LV DD has been unmasked with a balloon occlusion test and has been managed with pharmacological preconditioning and subsequent ASD closure with good outcome. Albeit rare, LV DD can occur in children undergoing ASD closure.

A Clinical Evaluation of Cone-beam Computed Tomography: Implications for Endodontic Microsurgery

INTRODUCTION

Cone-beam computed tomographic (CBCT) imaging is a valuable diagnostic tool for endodontics. Some studies report that CBCT images have limitations in representing the true clinical presentation. This prospective, in vivo study compared limited field of view (LFOV) CBCT measurements with clinical measurements made during endodontic surgery.

METHODS

Eighty-seven subjects requiring endodontic surgery and LFOV CBCT acquisition of the surgical site were enrolled. Data collection involved clinicians answering standardized questions during the radiographic and surgical assessment. Intraoperatively, data were collected and photographically documented. Postoperatively, CBCT scans were evaluated by 3 calibrated, board-certified specialists: 2 endodontists and 1 oral and maxillofacial radiologist. The 2 subsets of data were compared through statistical analysis to quantify their relationship.

RESULTS

The subjects included 65 maxillary and 29 mandibular teeth from 87 subjects: 25 women and 62 men with an average age of 42 years old. The CBCT evaluators correctly identified the presence or absence of buccal plate fenestrations with 91.0% accuracy (95% confidence interval, 83.1-96.0) with 89.4% sensitivity and 92.9% specificity. The area of fenestrations measured clinically (mean = 19.6 ± 33.4 mm²) was generally larger than the area measured by CBCT imaging (mean across CBCT evaluators = 12.2 ± 19.1 mm²). Fenestration size in the maxillary arch was more likely to be underestimated than in the mandibular arch (P < .0001). Vertical bone height was also underestimated when measured on CBCT imaging.

CONCLUSIONS

Based on the findings of this study, LFOV CBCT imaging accurately identifies the presence or absence of buccal plate fenestrations, yet, when a fenestration is present, underestimates its area.

Evaluation of facial and palatal alveolar bone thickness and sagittal root position of maxillary anterior teeth on cone beam computerized tomograms

Background

Amount of bone covering the facial and palatal surface of the root and the sagittal root position are important parameters while considering an immediate implant placement.

Aims

This study measures the distance from cement-enamel junction (CEJ) to alveolar crest and thickness of alveolar bone of maxillary anterior teeth facially and palatally at 5 different points.

Materials and Methods

CBCT scans of 79 systemically healthy patients were evaluated by two calibrated and independent examiners. Measurements like: 1) distance from CEJ to Crest. 2) Thickness of facial and palatal alveolar bone at five different points a) Crest, b) 2 mm from the crest, c) mid root level, d) apical 3^rd, e) apex. 3) Sagittal root position. 4) Labiopalatal distance at the apex. 5) Length of the bone from apex to the nasal floor for incisors. 6) Presence of fenestrations and dehiscences were assessed.

Results

Healthy maxillary anteriors were evaluated and less than 2 mm bone was seen at all five points, 0.5 to 1 mm bone is seen in all anteriors at crest, 2 mm from crest, midroot, apical 3^rd level. 1 to 2 mm is seen at apex. Labiopalatal width at apex ranged from 3 mm to 13 mm with a mean of 7.45 ± 2.24 mm for centrals, 7.69 ± 2.14 mm for lateral incisors, and 6.76 ± 2.42 mm for canines.

Conclusion

The present study supports the finding of very thin facial bone over maxillary anteriors and frequent occurrence of fenestrations and dehiscences. Pre-treatment evaluation of alveolar bone surrounding the maxillary anteriors is important to avoid complications during implant placement.

Is gelfoam sealing necessary in stapes surgery?

BACKGROUND

Sealing the oval window around the piston after fenestration with Gelfoam^® is a common practice in stapes surgery for otosclerosis.

OBJECTIVES

To analyse the effect of using or not using Gelfoam^® as a sealing material.

METHODS

A retrospective study was performed on 418 patients who underwent stapes surgery from 2013 until 2019. Data were collected from medical records in a tertiary centre. 215 cases in the Gelfoam group and 203 cases in the control group without sealing were included. The main comparisons were made between these two groups in terms of vestibular (primary outcome) and audiological outcomes and complications.

RESULTS

The patients' mean age was 47 years with a mean follow up of 50 months and a female predominance (65.6%, p = .049). There was no significant difference in terms of postoperative vertigo (11.6% vs 8.4%) or audiological outcomes in between Gelfoam and control group respectively. The average postoperative air-bone gap in the Gelfoam group was 4.6 dB vs. 5.3 dB in the control group (p = .634).

CONCLUSION AND SIGNIFICANCE

No difference were identified in vestibular or audiological outcomes during stapes surgery when using or not using Gelfoam^® in the middle ear.

The vascular endothelial growth factor signaling pathway regulates liver sinusoidal endothelial cells during liver regeneration after partial hepatectomy

INTRODUCTION

Liver regeneration after partial hepatectomy is a very complex and well-regulated procedure. It utilizes all liver cell types, which are associated with signaling pathways involving growth factors, cytokines, and stimulatory and inhibitory feedback of several growth-related signals. Liver sinusoidal endothelial cells (LSECs) contribute to liver regeneration after partial hepatectomy. Vascular endothelial growth factor (VEGF) has various functions in LSECs. In this review, we summarize the relationship between VEGF and LSECs involving VEGF regulatory activity in the vascular endothelium.

AREAS COVERED

Maintenance of the fenestrated LSEC phenotype requires two VEGF pathways: VEGF stimulated-NO acting through the cGMP pathway and VEGF independent of nitric oxide (NO). The results suggest that VEGF is a key regenerating mediator of LSECs in the partial hepatectomy model. NO-independent pathway was also essential to the maintenance of the LSEC in liver regeneration.

EXPERT OPINION

Liver regeneration remains a fascinating and significative research field in recent years. The liver involved of molecular pathways except for LSEC-VEGF pathways that make the field of liver further depth studies should be put into effect to elaborate the undetermined confusions, which will be better to understand liver regeneration.

Renal Artery Aneurysm Due to Fenestration of a Branch of the Renal Artery: A Case Study

Artery fenestration is a congenital vascular malformation, often of the intracranial arteries, that causes an aneurysm. However, there have been no reports of artery fenestration causing renal aneurysm. We present the case of a 58-year-old man who developed renin-dependent hypertension. He was aware of heaviness of the head, and his blood pressure was 196/134 mm Hg on 5 mg of amlodipine. Laboratory tests showed hypokalemia, hyperreninemia, and hyperaldosteronemia. An enhanced 3-dimensional computed tomography scan showed a 19-mm renal aneurysm in a branch of the left renal artery, and renal arteriography showed a fenestration in the aneurysm-forming branch. Coil embolization was performed on the central side of the artery forming the aneurysm and fenestration, after which blood pressure, serum potassium, and plasma renin levels improved. The patient in the present case had renin-dependent hypertension as a result of decreased renal blood flow caused by the renal aneurysm and fenestration, which is considered an extremely rare etiology of hypertension.

Laparoscopic transdiaphragmatic pericardial fenestration in palliative care: how I do it

BACKGROUND

The optimal therapeutic strategy for drainage of malignant pericardial effusion is not yet determined. Several techniques are described, with different benefits and disadvantages. The literature suggests that surgical drainage of pericardial effusions has less effusion recurrence; however, randomized controlled trials are not available. Due to the nature of the disease, quality of life should always be considered while making treatment decisions.

METHODS

A retrospective analysis of all consecutive patients from November 2016 until June 2019 of our institution in the Netherlands was performed. All patients underwent laparoscopic pericardial fenestration after echocardiography and request for operative treatment by the cardiologist. The same operation technique was performed in every case.

RESULTS

Four out of five of our patients needed pericardial fenestration because of oncological diseases. No hemodynamically instability was noted during this fast technique, achieving direct relief of symptoms. No treatment-related morbidity or mortality, nor the need for re-intervention was encountered. We compared the outcome of our five patients with the existing evidence in the literature.

CONCLUSIONS

In this article, we highlight the laparoscopic transdiaphragmatic pericardial fenestration as a treatment of preference in a non-acute palliative setting. This laparoscopic approach is safe, and can be a valuable alternative among the other well-known approaches.

Multiple Anterior and Posterior Circulation Intracranial Fenestrations presenting With Aneurysmal Subarachnoid Hemorrhage

Background and Importance: Intracranial artery fenestrations are very rare, however, when found, there is a high association with cerebral aneurysms.

Clinical Presentation: This report describes a patient with multiple anterior and posterior circulation intracranial artery fenestrations and an anterior communicating artery aneurysm presenting with a thunderclap headache found to have a subarachnoid hemorrhage (SAH). The patient was treated with open surgery via clipping after a diagnostic angiography and did very well.

Conclusion: There is an association between cerebral fenestrations and aneurysms, but it has not been studied in a prospective manner. This case is unusual in that the patient had both anterior and posterior circulation fenestrations, which is uncommon. Clinicians should have a high index of suspicion in patients being evaluated for SAH who have a cerebral artery fenestration with no aneurysm found.

Management of true lateral infected radicular cyst as well as associated mucosal fenestration that occurred postoperatively through an interdisciplinary approach: A rare case report

A radicular cyst (RC) is one of the types of inflammatory cyst of odontogenic origin. It is usually associated with nonvital teeth and is mostly observed in males. It is routinely treated by nonsurgical endodontic therapy; however, if the cystic lesion does not respond to endodontic therapy, then surgical intervention with or without regeneration is the treatment of choice, depending upon the size, location of lesion, the bone integrity of the cystic lesion wall, proximity to vital structures and residual bone defect elicit after enucleation, etc., We hereby present successful interdisciplinary management of rare true lateral RC in the interproximal site with respect to teeth number 21 and 22 as well as associated mucosal fenestration that was occurred postoperatively other than its apparent etiology and diagnosis.

Optimal In Situ Fenestration Technique With Laser Perforation and Balloon Dilation for Aortic Stent-Grafts

PURPOSE

To evaluate the response of various stent-grafts after laser fenestration and dilation with noncompliant balloons to determine the optimal therapeutic combination for this treatment technique.

MATERIALS AND METHODS

Five aortic stent-grafts were evaluated ex vivo: the Bolton RelayPlus, Jotec E-vita Thoracic 3G, Medtronic Valiant, Cook Zenith Alpha, and Vascutek Anaconda. Small holes were created using an excimer laser with the grafts submerged in saline. Five rows of 5 fenestrations were created, 4 holes in each row were dilated once with a 6-, 8-, 10-, or 12-mm-diameter noncompliant balloon to the specified nominal pressure (one hole served as the control). The saline solution from each stent-graft was collected and qualitatively analyzed for debris. The fenestrations were evaluated under light and scanning electron microscopes. The maximum diameter and area for each fenestration were measured. The direction and length of tears were assessed.

RESULTS

The fenestration was feasible and reproducible in all the stent-grafts. The mean area of fenestration ranged from 7.63±1.63 to 14.75±0.73 mm² when using balloons of 6- and 8-mm diameter, respectively. The 10- and 12-mm-diameter balloons caused a significant increase in area, variability, and tearing. The Anaconda graft tended to tear in the weft direction, while the other devices tore in the warp direction when using the 10- and 12-mm-diameter balloons. Dilation of the RelayPlus and Anaconda grafts with 6- and 8-mm-diameter balloons provided minimal tearing and precise fenestrations. Melted fiber remnants were observed after filtration of the saline solution for all devices.

CONCLUSION

Laser fenestration and dilation with noncompliant balloons is a relatively simple and reproducible option for revascularization in urgent, complex aortic endovascular repairs. In our model, large balloons (ie, >10 mm) increased the destruction and tearing of the fabric. The maximum dilation recommended is 6 to 8 mm to avoid significant tears. Development of stent-grafts or novel fabrics designed explicitly for fenestration is needed to reduce potential complications.

Endoscopic treatment of suprasellar arachnoid cysts indenting third ventricle with obstructive hydrocephalus in children: Thirteen cases

Aims

The present study aimed to evaluate the clinical usefulness of endoscopic treatment of suprasellar arachnoid cysts indenting the third ventricle with obstructive hydrocephalus and discuss the clinical features and outcomes of thirteen children treated at our institution.

Method

We treated thirteen pediatric cases of suprasellar arachnoid cysts indenting the third ventricle with obstructive hydrocephalus between January 2012 and September 2018. Five female and eight male patients were enrolled in the study. The patients had increased intracranial pressure symptoms due to hydrocephaly. Endoscopic treatment was performed in all cases.

Results

The patients were followed-up for an average of 36.8 months. The postoperative intracranial pressure findings improved. There was a reduction in the size of the cyst and ventricles and enlargement of the cortical sulci. One patient suffered transient oculomotor nerve deficit. No further surgical interventions, such as shunt placement, were required during the follow-up period. The head circumference of two of the patients with macrocephaly were stable during the follow-up. There were no postoperative recurrences detected.

Conclusions

Endoscopic cyst fenestration and third ventriculostomy are less invasive, safer, and more effective ways to treat suprasellar arachnoid cysts indenting the third ventricle with obstructive hydrocephalus in children with hydrocephaly.

Internal Jugular Vein Fenestration and Duplication: Anatomical Findings, Prevalence, and Literature Review

Background: Comprehensive knowledge of the internal jugular vein (IJV) regarding its anatomical variations and the pattern of its course is valuable for preventing unexpected injuries during surgical procedures or central venous access. IJV anatomical anomalies such as fenestration and duplication are rare, mainly represented by case reports, and intraoperative findings.

Objective: To present two additional cases of IJV anomalies and highlight its clinical presentation, anatomical characteristics, management, and prevalence through an extensive literature review.

Methods and Case Reports: From January 2017 to December 2018, we retrospectively collected data of 221 patients undergoing neck dissection (ND) procedures and identified two patients with IJV anomalies (fenestration and duplication) providing a clinical prevalence of ~0.9%. The IJV fenestration referred to an IJV bifurcation that reunites proximal to the subclavian vein, whereas in the IJV duplication both branches remain separated. In both of our cases, the spinal accessory nerve (SAN) crossed the window between the IJV branches.

Conclusion: Anatomical variations are more likely to be identified intraoperatively or incidentally, and due to the risk of SAN and vascular injury, special attention should be taken to identify them preoperatively in order to reduce the risk of iatrogenic injury and unexpected complications.

Gingival Fenestration Management: A Rarefied Case Entity and Literature Review

Dehiscence and fenestration are commonly confronted alveolar defects. But the combined mucosal and alveolar fenestration is uncommonly reported in the literature as they less often cause pain, and in majority of the cases, only aesthetic complaint is present. This article highlights the case report of a 28-year-old female patient who presented with aesthetic concern about gingival/mucosal fenestration in her right lower central incisor. She had a history of surgical endodontic treatment in the same tooth. In this case, mucosal fenestration was treated with regenerative therapy using bioactive glass with platelet-rich fibrin and free connective tissue graft. The treatment resulted in excellent aesthetic outcome and satisfactory bone healing.

Epilepsy and cognitive deterioration as postoperative complications of the arachnoid cyst fenestration. Case report

OBJECTIVE

With the aim of contributing to the discussion on treatment of patients with arachnoid cysts (AC) and their neuropsychological functioning, we present the case of a patient who has undergone surgery of AC located in the left Sylvian fissure. Case description: The patient had no cognitive deficits and no seizures before the cyst's fenestration. After the procedure, however, occurrences of seizures have been observed. Along with the concomitant epileptic seizures, aphasia and serious memory problems also developed. The initial pharmacological treatment of the seizures brought about unsatisfactory results. The treatment was therefore modified a number of times and ultimately, seizures were brought under control to some extent. Despite the varied efforts at neuropsychological rehabilitation, cognitive impairment was still persistent up to a year after the surgery. Conclusions: 1) While referring patients with AC for surgery, one should always consider both the positive outcomes and the unintended and deleterious consequences. A cyst fenestration could in some cases lead to epilepsy and cause neuropsychological symptoms such as anomic aphasia and cognitive deterioration with memory function impairment. 2) Neurological patients, especially the ones qualified for surgery, should always undergo neuropsychological examination. The lack of data from presurgical neuropsychological examination may impact further treatment of neurosurgical patients.

Supraclinoid Internal Carotid Artery Fenestration with Associated Aneurysm: Case Report and Literature Review

Fenestration of the supraclinoid internal carotid artery (ICA) is extremely rare and may occasionally be associated with saccular aneurysms; nevertheless, the natural history remains unclear. The authors reviewed the cases of fenestration of the supraclinoid ICA and evaluated the clinical characteristics and angioarchitecture with particular focus on the incidence for aneurysm development and rupture. Previously reported 24 cases and 1 new case from our institute were examined for the presence of aneurysms (including size and presence of bleb) leading to subsequent subarachnoid hemorrhage (SAH). Furthermore, 16 cases with sufficient information were classified into one of the three types according to the developmental condition of fenestration and fusion site: Type A (developed fenestration in which the ICA appears to duplicate [two cases]); Type B (hypoplastic fenestration fused to the ICA at the origin of the posterior communicating artery [Pcom] [six cases]); and Type C (hypoplastic fenestration fused to the Pcom itself or appeared to be a duplicated Pcom [eight cases]). In type A, the two cases had an aneurysm (100%), one of which caused SAH (50%). In type B, all six cases had an aneurysm (100%), and one of five led to SAH (20%) (one case lacked information regarding SAH). In type C, five of the eight cases had an aneurysm (62.5%), with no SAH (0%). The result suggested that the extent of development of fenestration and the location of fusion are related to the incidence of aneurysms and risk for rupture.

Cavin1 Deficiency Causes Disorder of Hepatic Glycogen Metabolism and Neonatal Death by Impacting Fenestrations in Liver Sinusoidal Endothelial Cells

It has been reported that Cavin1 deficiency causes lipodystrophy in both humans and mice by affecting lipid metabolism. The ablation of Cavin1 in rodents also causes a significant deviation from Mendelian ratio at weaning in a background-dependent manner, suggesting the presence of undiscovered functions of Cavin1. In the current study, the results show that Cavin1 deficiency causes neonatal death in C57BL/6J mice by dampening the storage and mobilization of glycogen in the liver, which leads to lethal neonatal hypoglycemia. Further investigation by electron microscopy reveals that Cavin1 deficiency impairs the fenestration in liver sinusoidal endothelial cells (LSECs) and impacts the permeability of endothelial barrier in the liver. Mechanistically, Cavin1 deficiency inhibits the RhoA-Rho-associated protein kinase 2-LIM domain kinase-Cofilin signaling pathway and suppresses the dynamics of the cytoskeleton, and eventually causes the reduction of fenestrae in LSECs. In addition, the defect of fenestration in LSECs caused by Cavin1 deficiency can be rescued by treatment with the F-actin depolymerization reagent latrunculin A. In summary, the current study reveals a novel function of Cavin1 on fenestrae formation in LSECs and liver glycogen metabolism, which provide an explanation for the neonatal death of Cavin1 null mice and a potential mechanism for metabolic disorders in patients with Cavin1 mutation.

Combination of F-ASO and Targeted Medical Therapy in Patients With Secundum ASD and Severe PAH

OBJECTIVES

This study was conducted to investigate the combined use of fenestrated atrial septal occluder (F-ASO) and targeted medical therapy (TMT) in patients with secundum atrial septal defect (ASD) and severe pulmonary arterial hypertension (PAH).

BACKGROUND

Treatment of patients with ASD and severe PAH is still challenging.

METHODS

After ethical approval was obtained, 56 consecutive patients with ASD with severe PAH were included (7 men, 49 women; median age 50.5 years; mean ASD size 26.9 ± 4.6 mm). After 3 months of TMT, transcatheter closure was performed using F-ASO in patients with ratios of pulmonary to systemic blood flow ≥1.5. TMT was continued post-operatively together with 6 months of dual-antiplatelet therapy. The hemodynamic variables during baseline, TMT alone, and combined treatment with F-ASO were compared.

RESULTS

After only TMT, systolic pulmonary arterial pressure (-14.5 mm Hg; p < 0.001), pulmonary vascular resistance (-3.9 Wood units; p < 0.001), and exercise capacity (+72.0 m; p < 0.001) improved. Ratio of pulmonary to systemic blood flow increased by 0.9 (p < 0.001), with adverse cardiac remodeling (right ventricular dimension +3.5 mm; p < 0.001). Closure with F-ASO (median size 34.0 mm) led to further decrease in systolic pulmonary artery pressure (-6.0 mm Hg; p < 0.001). Follow-up (median duration 10 months) revealed further improvement in exercise capacity (+60.5 m; p < 0.001), with favorable cardiac remodeling (right ventricular dimension -9.9 mm; p < 0.001). In addition, all fenestrations were stable (p = 0.699), with negligible shunt (median ratio of pulmonary to systemic blood flow 1.1) and no complications. One year later, pulmonary artery pressure was normalized in 8 of 19 patients, and PAH recurred in 5 patients after discontinuation of TMT.

CONCLUSIONS

In patients with ASD and severe PAH, combination of F-ASO and TMT was a safe and effective procedure. Compared with TMT alone, the combined treatment further improved exercise capacity, with favorable cardiac remodeling.

Generation of Functional Liver Sinusoidal Endothelial Cells from Human Pluripotent Stem-Cell-Derived Venous Angioblasts

Liver sinusoidal endothelial cells (LSECs) form a highly specialized microvasculature that plays a critical role in liver function and disease. To better understand this role, we developed a strategy to generate LSECs from human pluripotent stem cells (hPSCs) by first optimizing the specification of arterial and venous angioblasts and derivative endothelial populations. Induction of a LSEC-like fate by hypoxia, cyclic AMP (cAMP) agonism, and transforming growth factor β (TGF-β) inhibition revealed that venous endothelial cells responded more rapidly and robustly than the arterial cells to upregulate LSEC markers and functions in vitro. Upon intrahepatic transplantation in neonates, venous angioblasts engrafted the liver and generated mature, fenestrated LSECs with scavenger functions and molecular profiles of primary human LSECs. When transplanted into the liver of adult mice, angioblasts efficiently gave rise to mature LSECs with robust factor VIII (FVIII) production. Humanization of the murine liver with hPSC-derived LSECs provides a tractable system for studying the biology of this key liver cell type.

Endovascular stent graft repair with chimney technique of an abdominal aortic aneurysm with concomitant horseshoe kidney

A 68-year-old male patient was referred to our clinic for treatment of an infrarenal abdominal aortic aneurysm. Computed tomography angiography revealed a horseshoe kidney overlying the aneurysm. The patient had an accessory renal artery arising from the anterior aspect of the aneurysm. Endovascular aneurysm repair was performed and the accessory renal artery could be revascularized successfully by chimney technique without any morbidity. Postoperative computed tomography angiography revealed complete exclusion of the aneurysm with no endoleak and a patent chimney graft.

Characteristics of Clinical Symptoms, Cerebral Images and Stroke Etiology in Vertebro-Basilar Artery Fenestration-Related Infarction

Cerebral artery fenestration is a rare variant of the vascular architecture, but its existence is well documented. The common site of fenestration is the vertebra-basilar artery and it may be found incidentally with subarachnoid hemorrhage. However, fenestration-related cerebral infarction is rare. We analyzed the clinical characteristics, stroke etiology, and image findings of fenestration-related cerebral infarction of the vertebrobasilar artery. We reviewed our hospital records and previously published reports to find cases of fenestration-related cerebral infarction. We excluded those with unknown clinical features or radiological findings. We retrieved 4 cases of fenestration-related infarction from our hospital, in which vascular change, headache, vertigo/dizziness, and dissection in stroke etiology were detected. In eight previously reported cases of fenestration-related infarction, similar vascular changes were noted, but they were mainly diagnosed as embolic stroke of undetermined source. However, based on the criteria for dissection in this study, dissection as the stroke etiology was suspected in the previously reported cases. Many hypotheses have been proposed for the development of dissection, thrombus, and aneurysms in fenestration. Although an embryological and morphological study is needed, clinicians must consider basilar artery fenestration-related infarction as a differential diagnosis and intensive non-invasive image study is recommended.

On-Site-Modified Sheath to Overcome the Undesirable Catheterization of the Profunda Femoris Artery During Antegrade Femoral Access

Purpose: To present a simple method to avoid favored passage of a guidewire into the profunda femoris artery (PFA) after antegrade puncture of the common femoral artery. Technique: A 6-F conventional introducer sheath with a radiopaque distal marker is placed on the nurse's table with its side port orientated to the 12 o'clock position. A small (2-2.5 mm) oval fenestration is created on the superior aspect of the sheath about 3 cm from its tip with a size 11 surgical blade. The modified introducer is passed over the angled 0.035-inch guidewire into the PFA and gently retrieved until the tip marker is ~3 cm from the femoral bifurcation. The dilator is removed, and the guidewire is withdrawn to the level of the fenestration, manipulated through it, and advanced further into the superficial femoral artery under fluoroscopic guidance. Conclusion: When repeated passage of the guidewire down the PFA persists despite conventional manipulation of the wire or needle, an on-site modification of the sheath is an easy alternative approach for the catheterization of the superficial femoral artery.