Surgical Treatment of a Neglected Thumb Volar Plate Injury in an 11-Year-Old Girl: A Case Report

BACKGROUND Volar plate injuries are rare and difficult to diagnose and treat. Only a few cases have been described on the thumb, especially in children, that resulted in swan-neck type deformity. Conservative treatment has been suggested as first-line management, but surgical reconstruction utilizing flexor digitorum superficialis tenodesis has been described for refractive cases. Only a few attempted surgical repairs of the volar plate have been reported, since it is a technically demanding procedure. CASE REPORT We present the case of a neglected thumb volar plate injury in an 11-year-old girl after a thumb hyperextension injury. The patient presented 2 months after her injury with functional disability of her thumb. Magnetic resonance imaging had been performed, with no signs of volar plate injury, and she was consequently treated with an extension-blocking splint, with no effect. Clinical examination raised the suspicion of a thumb volar plate injury, which was confirmed during surgical exploration. Therefore, fixation with a bone anchor was performed, and the metacarpophalangeal joint was immobilized in 20° flexion with a percutaneously inserted Kirschner wire. After splinting for 3 weeks, the patient had 10 sessions of physical therapy. At 6-week follow-up, she presented with excellent active and passive range of motion and absence of pain. CONCLUSIONS Magnetic resonance imaging did not have high sensitivity. Six weeks after surgery, full range of motion was achieved, with no stiffness or tenderness at the first metacarpophalangeal joint, suggesting that a thumb volar plate injury had been managed surgically with a suture anchor with excellent results.

Intersection of the Academic Research Consortium – high bleeding risk criteria in patients undergoing PCI for acute coronary syndromes: insights from a high-volume single centre registry

Introduction

Patients presenting for percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS) often have overlapping bleeding and ischaemic risk factors that offset the long-term success of PCI and limit the post stenting therapeutic options. Aiming at improving outcomes following PCI, the Academic Research Consortium (ARC) recently published a set of major and minor criteria that identify, a priori, patients at high bleeding risk (HBR). Indeed, knowledge of these risk factors will help in optimization of pre-procedural therapy and minimization of post intervention complications. Nonetheless, the actual prevalence of these criteria among patients undergoing PCI for ACS is not well known.

Purpose

To determine the intersection and distribution of ARC-HBR major and minor criteria in a real-world ACS population presenting for PCI.

Methods

In this analysis, we included all patients who presented with ACS to a high-volume PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent (DES) implantation. Patients were then classified as HBR if they met ≥1 major or ≥2 minor criteria according to the ARC-HBR definition. Baseline clinical and procedural characteristics were extracted from each patient electronic health records. The most common exclusive intersections of ARC-HBR major and minor criteria were quantitatively visualized using an Upset Plot.

Results

Only 44.6% (n=2,717) of ACS patients (n=6,097) fulfilled the ARC-HBR definition. There were significant differences in baseline clinical characteristics between HBR and non-HBR groups: age (71.4±11.5 vs. 60.9±10.3 years, p<0.001), females (40.7% vs. 25.5%, p<0.001), cerebrovascular disease (19.5% vs. 3.9%, p<0.001), and diabetes (55.4% vs. 42.1%, p<0.001). The prevalence of active smoking, a major risk factor for bleeding, was higher in the non-HBR group (20.6% vs. 9.9%, p<0.001). The most frequent major and minor criteria were severe anemia (n=1,072) and age ≥75 (n=1,264), respectively. The top five criteria intersections were: severe anemia (n=215), age ≥75 and moderate chronic kidney disease (CKD) (n=145); moderate CKD and mild anemia (n=142); age ≥75 and mild anemia (n=140); age ≥75, moderate CKD, and mild anemia (n=130) (Figure 1).

Conclusion

Among patients who have undergone PCI for ACS, a significant proportion of individuals fulfilled the ARC-HBR definition. Severe anemia was the most prevalent major criteria. Different combinations of minor criteria, mainly age ≥75, moderate CKD and mild anemia, represented the most common intersections.

Figure 1

Funding Acknowledgement

Type of funding source: None

Are the minor high bleeding risk criteria of the academic research consortium truly minor? Insights from a high-volume tertiary care pci centre

Background

The Academic Research Consortium (ARC) has recently published a consensus-based definition to identify patients at high bleeding risk (HBR), reflected by a BARC 3 or 5 bleeding rate of ≥4% at 1 year after percutaneous coronary intervention (PCI). The HBR criteria included in the definition are divided into minor and major categories, with patients deemed to be at HBR if they fulfill at least one major or two minor criteria. As a result, patients who present with only one minor criterion are categorized as non-HBR.

Purpose

To compare the differences in baseline characteristics and 1-year bleeding and ischaemic outcomes between non-HBR patients undergoing PCI that present with only one minor HBR criterion versus those that do not fulfill any HBR criteria.

Methods

The study population consisted of all consecutive patients who underwent PCI with stent implantation in a single high-volume centre from January 2014 to December 2017. Patients were classified as non-HBR if they did not fulfill at least one major or two minor ARC-HBR criteria. The outcomes of interest were major bleeding (composite of peri-procedural and post-discharge bleeding), all-cause death, and myocardial infarction (MI) at 1 year. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Of the 9,623 patients included in the analysis, 5,345 were classified as non-HBR. Within the non-HBR patients, 2,078 (38.9%) presented with only one minor HBR criterion and 3,267 (61.1%) presented with no HBR criteria. Non-HBR patients with one minor criterion were more often female, significantly older, with a higher burden of comorbidities such as diabetes mellitus, hypertension and hyperlipidaemia, and more likely to have multivessel disease as well as a history of prior MI and revascularisation, while non-HBR patients with no criteria were more likely to be smokers and have a higher BMI. Distribution of the minor HBR criteria within the group presenting with one minor criterion are illustrated in the figure. Non-HBR patients with only one minor criterion had a numerically higher rate of major bleeding compared to non-HBR patients with no criteria (3.6% vs. 2.9%, p=0.09). While the rate of all-cause death was significantly higher in the group with only one minor criterion (1.2% vs. 0.4%, p=0.004), there was no difference in the rate of MI between the two groups (2.1% vs. 1.9%, p=0.83). Hazard ratios comparing the two groups are presented in the figure.

Conclusions

Non-HBR patients presenting with only one minor criterion had a numerically higher rate of post-PCI bleeding and significantly higher mortality compared to those without any criteria. Nonetheless, the major bleeding rates of both groups at 1 year were less than the 4% cutoff to qualify as HBR according to the ARC definition, thereby supporting their inclusion as “minor” criteria in the recent ARC-HBR definition.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of high-density lipoprotein levels in males and females undergoing percutaneous coronary intervention with drug eluting stents

Background/Introduction

Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in multiple epidemiological studies. Evidence regarding the role of HDL in males and females with established coronary artery disease undergoing percutaneous coronary intervention (PCI) with drug eluting stents (DES) is scarce.

Purpose

We sought to investigate the impact of low HDL levels on 1-year cardiovascular outcomes in males and females undergoing PCI with DES.

Methods

We screened all patients undergoing PCI in our center from 2012 to 2017. Exclusion criteria were: unavailable baseline HDL measurement, age <18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, coexisting neoplastic disease and treatment without a stent or with a bare metal stent. The final population was divided by gender and further stratified to the high or low HDL group according to baseline HDL levels. Cut-offs were 40mg/dL in males and 50mg/dL in females, per the most recent ACC/AHA guideline recommendations. The primary endpoint of the analysis was major adverse cardiovascular events (MACE) at 1 year, defined as death, MI or target vessel revascularization (TVR). To account for potential clinical and anatomical confounders the outcomes were also adjusted for age, Caucasian ethnicity, hypertension, diabetes mellitus (DM), body mass index, smoking, prior MI, multi-vessel disease and type B2/C lesions.

Results

Out of the 10,843 patients included, 7,718 (71.2%) were male and 3,125 (28.8%) were female. Low HDL was noted in 58.5% of males and 63.8% of females. Patients with low HDL were younger and had a higher prevalence of DM, prior MI, smoking and multi-vessel disease. When comparing low to high HDL groups in terms of 1-year MACE a borderline significant difference was shown in males (7.4% vs. 6.0%; p-value=0.08) but not in females (7.7% vs 8.1%; p-value=0.90) [Panel A]. The numerically higher incidence of MACE in males with low HDL was primarily driven by TVR (5.4% vs 3.7%; p-value=0.005) while the rates of Death (1.4% vs. 1.3%; p=0.96) and MI (2.0% vs. 1.8%; p-value=0.89) were similar between the two groups. After adjustment the male low HDL subgroup remained at a higher risk for 1-year TVR but not 1-year MACE compared to the male high HDL subgroup [Panel B]. No difference for any individual component of MACE was shown between low and high HDL subgroups in females [Panel C].

Conclusion(s)

High HDL levels were associated with a lower incidence of TVR and borderline reduction of MACE in male but not female patients undergoing PCI with DES. No difference was demonstrated in terms of death or MI between the high and low HDL subgroups at 1-year follow-up.

Impact of HDL levels according to gender

Funding Acknowledgement

Type of funding source: None

Long-term outcomes in high-bleeding risk patients undergoing PCI for acute coronary syndromes: results from a large single-center pci registry

Introduction

Current clinical guidelines recommend prolonged dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS). However, an extended DAPT duration in high-bleeding risk (HBR) patients amplifies the risk of post procedural complications. Hence, clinicians often face the dilemma of prolonging DAPT duration to prevent recurrent ischaemic events at the expense of increasing the incidence of bleeding in high-risk patients. The actual incidence of ischaemic and bleeding events in this particular population is not well elucidated.

Purpose

To evaluate one-year ischemic and bleeding outcomes following PCI for ACS in a real-world HBR population as defined by the Academic Research Consortium (ARC) consensus document.

Methods

We included all patients who presented with ACS to a high-volume single PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent implantation. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the recent ARC-HBR consensus. The outcomes of interest were major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR), and major bleeding events, including both peri-procedural and post-discharge bleeding. All outcomes were assessed at 1-year follow-up. The Kaplan-Meier method was used for time-to-event analyses.

Results

Out of 6,097 ACS patients included in this analysis, 2,717 (44.6%) fulfilled the ARC-HBR definition. Compared to non-HBR group, HBR patients were more frequently female, older, more likely to have cardiovascular risk factors (e.g., diabetes, hypertension, and hyperlipidemia) and complex coronary artery disease (e.g., multi-vessel disease, bifurcation lesions, and calcification). The 1-year incidence of MACE was significantly higher in HBR patients (16.3% vs. 8.1%, HR 2.16, 95% CI [1.81–2.59], p<0.001) (Figure 1A). This finding was driven by higher rates of all-cause death and MI (Figure 1B). The 1-year incidence of major bleeding was also significantly higher in HBR patients compared to non-HBR (11.1% vs. 3.1%, HR: 3.92, 95% CI 3.10–4.95; p<0.001).

Conclusions

HBR patients undergoing PCI for ACS are not only subject to bleeding complications but are also at an increased risk for ischemic events and all-cause mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials

Background

The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated.

Purpose

Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI.

Methods

In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO.

Results

We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group.

Conclusions

In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality.

Funding Acknowledgement

Type of funding source: None

Carcinoid: modern aspects on its therapy

In the past two years two patients with carcinoid tumours have been operated in Chios General Hospital. These two cases gave rise to our review of the literature concerning the therapy and follow-up of colorectal carcinoid tumours. We demonstrate the differences among surgeons concerning the acceptable and relevant indications for a hemicolectomy in appendiceal carcinoids and the prevailing aspects in the therapy of carcinoid of the colon and rectum. Finally we present the imaging techniques and the biochemical examinations that are proven of value and therefore should be used in the post-surgery follow-up.

Secondary orbital melanomas: analysis of 15 cases

Orbital melanomas comprise a heterogeneous group of pigmented tumours originating from melanocytes of the ophthalmic tissues, or represent distant metastases of cutaneous melanomas to the orbit. They can be classified into primary and secondary orbital melanomas. Whereas primary orbital melanomas are extremely rare, secondary orbital melanomas are seen more often and usually represent massive extrascleral extensions of uveal melanomas. Their diagnosis is difficult and controversy exists both about the treatment policy and regarding the prognosis. In an effort to clarify some of the aspects of the biological behaviour of these intriguing lesions, we retrospectively reviewed all orbital melanomas treated in our departments during the last eight years. The records of 15 patients with massive secondary orbital melanomas treated surgically were reviewed and analysed. Eleven of the patients were female and four were male. The mean age at the time of surgery was 68 years. Presenting features included unilateral orbital mass, often with painless proptosis, conjuctival bleeding, acute glaucoma crisis, decreased visual acuity and intermittent diplopia. The site of origin was the uveal tract in nine cases, the conjunctiva in three, the eyelids in two and the skin of the lower extremity in one patient. All patients were treated surgically with various types of orbital exenteration. Additional treatment included radiotherapy and chemotherapy. Two patients died from intracranial extension of the disease and 10 died from distant metastases. Three patients are alive with no evidence of disease. The longest survival was 33 months and the mean survival was 16.6 months. Early diagnosis and proper management of ocular melanoma prevents orbital extension and prolongs patient survival. Surgical treatment of secondary orbital melanoma with or without adjuvant radiotherapy and/or chemotherapy does not seem to improve patient survival when compared with conservative treatment used in other reports. However, orbital exenteration is effective for local control of the disease.