Comparing clinical outcomes of Vitamin K antagonists versus Non-Vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis

OBJECTIVE

Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than Vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants.

METHODS

Between Jan 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications.

RESULTS

The median age of the patients was 56 years (46-68) and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs. 6 months in Group 2; p = 0.076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs. 28 months, p = 0.048). No recurrence of mesenteric vein thrombosis related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs. 18 months in Group 2; p = 0.064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (p = 0.075). Regarding bleeding complications, varix bleeding and melena developed in 2 patients in Group 2, and anticoagulation treatment thereafter ceased.

CONCLUSIONS

Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.

Outcomes of Surgical and Endovascular Treatment for Cephalic Arch Stenosis in Proximal Arteriovenous Fistula

Purpose

The cephalic arch is a significant site of stenosis in proximal arteriovenous fistulas (AVFs) that contributes to access dysfunction and thrombosis. This study aimed to evaluate the outcomes of surgical treatment (ST) and endovascular treatment (ET) for cephalic arch stenosis (CAS).

Materials and Methods

A total of 62 patients with proximal AVF who underwent CAS revision using either ST or ET were enrolled between January 2018 and March 2023. In the ET group, only the initial ET following AVF formation was considered, to mitigate bias. In the ST group, central transposition of the native AVF (transposition group) or interposition of the prosthetic graft into the proximal basilic or axillary vein (interposition group) was performed. We evaluated primary and functional patency based on these groups and calculated the number of patency loss events after CAS treatment.

Results

Of the 62 patients, 38 (61%) were male, with a mean age of 66.4 years. ST was performed in 26 (42%) patients, including transposition in 16 and interposition in 10, whereas ET was administered to 36 patients during the study period. Among the ST recipients, 42% had a history of ET for CAS. The incidence of AVF thrombosis was marginally higher in the ST group than in the ET group (39% vs. 19%, P=0.098). The primary patency rates at 6 months, 1 year, and 3 years were 87%, 87%, and 66% in the transposition group; 45%, 23%, and 11% in the interposition group; and 66%, 49%, and 17% in the ET group, respectively. Notably, the primary patency of the transposition group was significantly higher than that of the interposition (P=0.001) and ET groups (P=0.016). The frequency of patency loss events per person-year after the initial revision was 0.40, 0.52, and 1.42 in the transposition, interposition, and ET groups, respectively.

Conclusion

Transposition exhibited the most favorable primary patency rate and the lowest number of subsequent patency loss events during follow-up despite the higher rates of AVF thrombosis and previous ET at presentation. Consequently, transposition should be actively considered in eligible patients with CAS.

Case Report: Popliteal artery entrapment syndrome as a cause of deep vein thrombosis and subsequent popliteal artery occlusion

Background

Popliteal artery entrapment syndrome (PAES) is a relatively rare cause of arterial insufficiency in young and physically active individuals; however, deep vein thrombosis (DVT) can develop in association with PAES.

Case report

A 47-year-old man presented with a 6-day history of left leg swelling and discomfort which was diagnosed as DVT extending to the distal femoral vein and pulmonary embolism on computed tomography (CT). PAES was not suspected at this time, and the patient was administered anticoagulants for 1 year. Two years after the DVT diagnosis, the patient developed sudden-onset left calf claudication for 1 week. Repeat CT angiography showed popliteal artery (PA) occlusion caused by PA displacement from an abnormally lateral insertion of the medial gastrocnemius head. A retrospective review of the initial CT scan confirmed this, as well as compression of the popliteal vein between the displaced medial head and the normal lateral head of the gastrocnemius. The patient eventually underwent myotomy and resection of the PA with an interposition graft.

Conclusion

This case underscores the potential of PAES as a rare etiology of DVT, emphasizing the importance of considering it in the differential diagnosis of DVT in younger patients lacking common predisposing factors.

Refining dietary metabolisable energy and crude protein levels in relation to duck performance and behaviour

1. The study evaluated the effect of dietary metabolisable energy (ME) content and crude protein (CP) level on the growth performance and behaviour of ducks.2. A total of 720, Cherry Valley ducks were allocated to 36 pens in groups of 20 birds. For the initial period, from 1 to 21 d age, six diets, containing a standard (SME), low (LME) and high (HME) ME of 12.14, 11.93 and 12.35 MJ/kg, and standard (SCP) or high (HCP) CP contents of 210 or 220 g/kg diet, respectively, were mixed. For the period from 22 to 42 d age, the diets contained ME of 12.98 (SME), 12.77 (LME), 13.19 (HME) MJ/kg and the levels of CP were 170 (SCP) or 180 (HCP) g/kg, respectively.3. An ME by CP interaction was seen from 1 to 21 d age in ducks fed HME + HCP diet, which had greater weight gain than those fed LME + SCP (P < 0.05). Compared to LME + SCP, dietary HME decrease feeding but increased walking behaviour compared to LME + SCP and SME + SCP (P < 0.05). High CP in LME and SME diets increased drinking behaviour (P < 0.05), but there was no change in HME diet. Compared to LME, feeding HME reduced ground pecking (P < 0.05). Feeding HME reduced feeding behaviour (P < 0.05) from 22 to 42 d age. During the same period, standing behaviour was reduced in HCP + LME (P < 0.05). Drinking was reduced in LME + SCP compared to SME + HCP and HME + HCP (P < 0.05).4. A diet formulated with HME and HCP is effective for enhancing growth performance of ducks aged 1-21 d and saving time for feeding or ground pecking, which may induce spending more time on other activities.

Surgical Strategies and Long-Term Outcomes for Complex Coral Reef Aorta with Multisegmental Involvement: A Case Report

Coral reef aorta (CRA) is a rare condition characterized by the distribution of rock-hard calcifications in the visceral part of the aorta, leading to potentially life-threatening symptoms, such as hypertension, congestive heart failure, and limb and visceral ischemia. The patient was a 54-year-old female who presented with leg claudication and was diagnosed with CRA using computed tomography. CRA affected the descending thoracic and abdominal aortas, including the visceral portion, leading to reduced perfusion of both limbs and the left kidney. The surgical intervention involved bypass surgery from the descending thoracic aorta proximal to the CRA to the aortic bifurcation, including reimplantation of the left renal artery. Postoperative recovery was successful and the symptoms resolved. However, the patient experienced decreased right renal function due to CRA progression three years postoperatively. Given the uncertainty regarding the optimal surgical approach for CRA, long-term considerations are crucial for its management.

Popliteal Artery Entrapment Syndrome Presented with Popliteal Artery Pseudoaneurysm: A Case Report

Popliteal artery entrapment syndrome (PAES) is a rare vascular disorder characterized by the compression of the popliteal artery behind the knee, primarily affecting physically active individuals. This is a case of a 36-year-old man who presented with a 1-week history of sudden-onset left leg pain. Diagnostic evaluation, including physical examination, color duplex ultrasonography, computed tomography, and magnetic resonance imaging, revealed a popliteal artery pseudoaneurysm caused by type 5 PAES. The patient underwent surgical exploration to release the entrapment, followed by an interposition graft with the ipsilateral great saphenous vein. Patient postoperative recovery was uneventful, with significant symptomatic improvement. This case underscores the significance of considering PAES as a differential diagnosis in young patients with popliteal artery aneurysms and highlights the necessity for prompt diagnosis and treatment to prevent limb-threatening complications.

Case Report: Hybrid approach as a Rescue Treatment in a patient with vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos Syndrome (vEDS) is a rare connective tissue disorder associated with COL3A1 gene mutation encoding type III collagen. Given the possible fatal prognosis if not treated timely, it is important to suspect and diagnose as soon as possible. Despite advances in endovascular technique, access point complications remain a serious challenge in patients with vEDS. Here, we describe a 30-year-old male patient who was diagnosed with vEDS after consecutive events of bilateral iliac vessels at an interval of 3 months: (1) spontaneous dissecting aneurysm of right iliac artery and (2) arteriovenous fistula between left internal iliac artery (IIA) and left common iliac vein. This patient was treated with iliac stent-grafts and overlapping femoral interposition graft (Dacron) in the 1st operation and access artery repair with surgical dissection after coil embolization of IIA and stent-graft insertion into left common to external iliac arteries in the 2nd operation. The patient has been treated with beta-blockers and anticoagulants for the management of vEDS and postoperative deep vein thrombosis, respectively. The stent-grafts in both iliac arteries and the access sites have been well-tolerated without any adverse effects for 14 months following the 2nd operation. In conclusion, given the vascular fragility and the potential for future events, additional vascular manipulation should be avoided unless it is in a life-threatening condition. In particular, meticulous hybrid interventions can be effective treatments.

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair

Purpose

This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications.

Materials and Methods

Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors.

Results

IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication.

Conclusion

The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Recurrent C3 Glomerulonephritis along with BK-Virus-Associated Nephropathy after Kidney Transplantation: A Case Report

C3 glomerulonephritis (C3GN) is a rare cause of end-stage kidney disease and frequently recurrent in allografts following kidney transplantation (KT). Herein, we describe the case of a kidney transplant recipient who developed recurrent C3GN along with BK-virus-associated nephropathy (BKVAN) following KT. A 33-year-old man diagnosed with membranoproliferative glomerulonephritis 17 years ago underwent preemptive KT with a donor kidney from his aunt. Proteinuria gradually increased after 3 months following KT, and graft biopsy was performed 30 months after KT. Histopathological examination revealed recurrent C3GN. The dosages of triple immunosuppressive maintenance therapy agents were increased. Subsequently, serum C3 levels recovered to normal levels. However, at 33 months following KT, the BK viral load increased and graft function gradually deteriorated; a second graft biopsy was performed at 46 months following KT, which revealed BKVAN and decreased C3GN activity. The dosages of immunosuppressive agents were decreased; subsequently, BKVAN improved and graft function was maintained with normal serum C3 levels at 49 months following KT. This case indicates that C3GN is highly prone to recurrence following KT and that immunosuppressive therapy for C3GN increases the risk of BKVAN.

Below-Knee Prosthetic Bypass Is a Viable Option for Limb Salvage in Patients with Extensive Femoropopliteal Occlusive Disease

Purpose

This study aimed to (1) evaluate the outcomes of below-knee prosthetic bypass (BKPB) in the absence of the great saphenous vein, and (2) identify risk factors associated with these outcomes.

Materials and Methods

This study included 37 consecutive patients who underwent BKPB with or without distal modification between 2010 and 2022. We further assessed the following treatment outcomes: primary patency (PP), secondary patency (SP), limb salvage (LS), and amputation-free survival (AFS) rates. The risk factors for PP were also examined.

Results

Most patients (n=31) were male. In 32 (86.5%) patients, BKPBs were performed for chronic limb-threatening ischemia. At the time of initial admission, two (5.4%) early deaths and three (8.1%) major amputations were noted. At 1 year after BKPB, the overall PP, SP, LS, and AFS rates were 78%, 85%, 85%, and 70%, respectively; at 3 years, they were 58%, 70%, 80%, and 52%, respectively; and at 5 years, they were 35%, 58%, 62%, and 29%, respectively. Notably, PP was significantly lower in limbs with ≤1 patent tibial arteries than in limbs with ≥2 patent artery (hazard ratio [HR], 3.80; 95% confidence interval [CI], 1.14-12.69 for overall; and HR, 12.97; 95% CI, 2.15-78.08 for distal anastomosis to below-knee popliteal artery). However, the PP was unaffected by the distal modification.

Conclusion

BKPB is a viable option for LS in patients with extensive femoropopliteal disease. Tibial runoff was significantly correlated with patency; therefore, decision-making for BKPB and follow-up must involve careful evaluation of the outflow arteries.

Right Gastroepiploic Artery Transposition for a Common Hepatic Artery and Proper Hepatic Artery Aneurysm Repair

Although hepatic artery aneurysms (HAAs) are uncommon, they are associated with risk of rupture. HAAs >2 cm in diameter require endovascular or open surgical repairs. For HAAs involving the proper hepatic artery or gastroduodenal artery, which is a collateral artery from the superior mesenteric artery, hepatic arterial reconstruction is especially important to avoid ischemic liver injury. In this study, right gastroepiploic artery transposition was performed in a 53-year-old man after a 4 cm common hepatic artery and proper hepatic artery aneurysm was identified. The patient was discharged without any complications on postoperative day 8.

Type Ic Endoleak after LifeStream Balloon-Expandable Stent Graft and Zenith Iliac Branch Device Placement

Considering the recent advancements in endovascular management of aortoiliac aneurysms, the use of an iliac branch device (IBD) to preserve pelvic blood flow and reduce complications caused by embolization of the internal iliac artery (IIA) is recommended by various guidelines. Although the outcomes reported following IBD placement are mainly positive and durable, IBD-specific complications such as a type Ic endoleak and associated reintervention may occur. Moreover, only one IBD device and one type of balloon-expandable bridging stent graft for IIA are currently available on the domestic market. Here we present two cases of type Ic endoleak following IBD placement. In both cases, IIA diameter was slightly larger than the basic instructions for use. Notably, the initial procedures were considered successful; however, type Ic endoleaks were detected on 1-month follow-up imaging. This finding emphasizes the need for a precise preoperative evaluation, intraoperative manipulation, and postoperative follow-up.

Pretransplant C-reactive protein-to-albumin ratio predicts mortality in kidney transplant recipients: a retrospective cohort study

Background

The C-reactive protein (CRP)-to-albumin ratio (CAR) is a more effective prognostic indicator than CRP or albumin alone in various diseases. This study aimed to evaluate the predictive value of the CAR for mortality in kidney transplant recipients (KTRs).

Methods

A total of 924 patients who underwent their first kidney transplantation at Kyungpook National University Hospital during 2006-2020 were enrolled and classified into quartile (Q) groups according to their pretransplant CAR values. A Cox regression analysis was conducted to analyze the hazard ratios (HRs) of mortality.

Results

Fifty-nine patients died during the posttransplant period (mean, 85.2±44.2 months). All-cause mortality (Q1, 3.0%; Q2, 4.8%; Q3, 7.8%; Q4, 10.0%; P for trend <0.001) and infection-related mortality increased linearly with an increase in CAR (P for trend=0.004). The Q3 and Q4 had higher risks of all-cause mortality than Q1 after adjusting for confounding factors (Q3 adjusted HR [aHR] 2.49, 95% confidence interval [CI] 1.04-5.99, P=0.041; Q4 aHR 3.09, 95% CI 1.31-7.27, P=0.010). Q4 was also independently associated with infection-related mortality (aHR 5.83, 95% CI 1.27-26.8, P=0.023). The area under the curve of the CAR for all-cause and infection-related mortality was higher than that of CRP or albumin alone. There was no association between CAR and death-censored graft failure or acute rejection.

Conclusions

A higher pretransplant CAR increases the risk of posttransplant mortality, particularly infection-related, in KTRs. Pretransplant CAR can be an effective and easily accessible predictor of posttransplant mortality.

Prospective, Multicenter Study of Rotational Atherectomy with Antirestenotic Therapy for Infrainguinal Arterial Disease

BACKGROUND

Thrombi are common in steno-occlusive lesions of infrainguinal atherosclerotic diseases. Despite the easy passage of guidewires through these lesions, conventional ballooning or stenting cannot effectively treat them, and patients are at risk of distal embolization. This study aimed to investigate the clinical outcomes of using a rotational aspiration atherectomy system to treat infrainguinal atherosclerotic disease.

METHODS

Patients underwent revascularization of target lesions using the Jetstream™ Atherectomy System. The primary endpoint was the freedom from clinically driven target lesion revascularization (CD-TLR) 12-month after the procedure. Outcomes were evaluated according to the clinical severity, lesion type, use of drug-coated balloons (DCBs), and lesion length, characteristics, and sites. Survival analysis for CD-TLR over time was plotted. All statistical analyses were performed using SPSS version 22 (IBM; Armonk, NY, USA). P-values <0.05 were considered statistically significant.

RESULTS

In total, 150 patients (91.2% male; mean age, 69.8 years; 66.2% with diabetes) with de novo or restenotic infrainguinal lesions were enrolled. The mean lesion length was 17.2 cm, 75.0% were occlusive, and 38.2% had severe calcification. The lesion types were sclerotic (64.7%), thrombosclerotic (20.6%), thrombotic (8.8%), and in-stent (5.9%). Adjunctive DCB was used in 86.8% of patients. The 12-month primary patency rate (PPR) and CD-TLR rates were 81.6% and 90.1%, respectively. The 12-month CD-TLR rate was significantly better in the sclerotic and thrombosclerotic groups than in the thrombotic group (100% and 100% vs. 66.7%; P = 0.001). The 12-month PPR was significant better in TransAtlantic Inter-Society Consensus (TASC) A and B groups than TASC C and D groups (P = 0.02). The 12-month PPR is significantly better after using a DCB or stent placement than after using a simple balloon (P = 0.01). There were no major adverse events, including procedure-related death, myocardial infarction, or major amputation.

CONCLUSIONS

The results of this study demonstrated the safety and effectiveness of the Jetstream atherectomy device for complex infrainguinal lesions. This system functions optimally with TASC A/B lesions and sclerotic or thrombosclerotic lesions.

Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report

INTRODUCTION

Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients.

PATIENT CONCERNS

A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup.

DIAGNOSES

Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length.

INTERVENTIONS

After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD.

OUTCOMES

The stent grafts were patent without endoleak at the 6-month follow-up.

LESSONS

In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Significance of collateral circulation in managing persistent sciatic artery: Two case reports

Persistent sciatic artery (PSA) is a rare congenital anomaly considered an embryologic remnant of the internal iliac artery. Traditionally, the classification systems categorized PSA based on the completeness of PSA and superficial femoral artery (SFA) alongside the origin of PSA. The most common class has been known as type 2a in Pillet-Gauffre classification, meaning complete PSA with incomplete SFA. The mainstay of these patients with limb ischemia has been surgical bypass alongside excision or ligation of PSA aneurysm if present. However, the current PSA classification system does not account for collateral blood flow. Herein, we described two cases of type 2a PSA with distal embolization and explored therapeutic choices for PSA based on collateral presence. The first patient was treated with thromboembolectomy and patch angioplasty, and the second with conservative management. Despite distal embolization in both patients, bypass surgery was avoided, and distal circulation was maintained via collaterals from deep and superficial femoral arteries without increased risk of recurrent embolization. Thus, carefully examining collateral circulation and customized strategy is essential for managing PSA.

Preliminary outcomes of the LifeStream balloon-expandable stentgraft in Zenith Iliac branch device to preserve pelvic circulation: A Korean multicenter study

BACKGROUND

To evaluate early outcomes of aortoiliac or isolated iliac artery aneurysm repair using the Zenith® Bifurcated Iliac Side (ZBIS) stent graft combined with the LifeStream™ Balloon Expandable Vascular Covered Stent as a bridging stentgraft.

METHODS

Between August 2018 and February 2020, 38 patients (37 male, mean age 72.7 years) received 46 LifeStream stents in conjunction with 38 ZBIS stent grafts to bridge hypogastric arteries for aneurysm repair in six university hospitals in Korea. The primary outcomes were technical success rate and procedure-related complications. Secondary outcomes were bridging stent graft patency and re-intervention.

RESULTS

All procedures were performed as elective standard endovascular aortic aneurysm repair (EVAR) and unilateral iliac branch device (IBD). Mean follow-up was 13.1 months, and patient overall survival rate was 96.7%. Technical success rate was 76.3% (n = 29). Causes of failure included seven total endoleaks; six type Ic and one type IIIc from the IBD junction, one unintentional IIA coverage, and one failure to deploy the IIA stent graft. Procedure-related complications occurred in two patients: one LifeStream migration and one ZBIS stent graft migration. Overall patency rates for the LifeStream and ZBIS stents were 97.4% and 97.2%, respectively.

CONCLUSION

This multicenter preliminary experience with the LifeStream™ Balloon Expandable Vascular Covered Stent in IBD demonstrated good patency; however, an unexpectedly high rate of type Ic endoleaks was observed. Combined use of the LifeStream stent with the ZBIS stent graft is safe and feasible to preserve pelvic circulation with good patency and a low rate of device-related reintervention.

Outcomes of Isolated Endarterectomy and Patch Angioplasty of the Common Femoral Artery According to Current Inclusion Criteria for Endovascular Treatment

Purpose

This study aimed to evaluate the outcomes of isolated common femoral endarterectomy with patch angioplasty (IFEA) in the endovascular era.

Materials and Methods

In 2012-2022, 189 limbs underwent femoral endarterectomy with patch angioplasty. Of them, 45 IFEAs were included. We evaluated safety based on early complications; efficacy with primary patency (PP) and reintervention, above-ankle amputation, or stenosis (RAS)-free survival. We also evaluated lesion characteristics and outcomes according to the inclusion criteria (IC) of vascular mimetic implant-common femoral artery (VMI-CFA) stenting trial.

Results

Forty-one patients were male, and 30 IFEAs were required for claudication. No cases of early mortality occurred. Ten limbs (22%) developed local/nonvascular complications (hematoma, 3; lymphocele, 5; wound infection, 2), of which 8 resolved spontaneously. The overall PP and secondary patency rates were 100% at 1 year and 87% and 97% at 3 years, respectively. Twenty-one lesions (47%) did not meet the IC. The PP within the IC was 100% at 1 and 3 years, and the PP outside the IC was 100% at 1 year and 73% at 3 years (P=0.068). The overall RAS-free survival rates were 91% at 1 year and 81% at 3 years. All cases of RAS occurred in lesions outside the IC. The multivariate analysis showed that dialysis was associated with poor RAS-free survival (adjusted odds ratio, 8.56; 95% confidence interval, 1.9-35.5; P=0.005).

Conclusion

The recent VMI-CFA trial results should be interpreted with caution. IFEA is a low-risk and durable procedure; however, careful follow-up is warranted in patients undergoing dialysis.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

Background

It is unclear whether and how diabetes mellitus may aggravate myocardial fibrosis and remodeling in the pressure-overloaded heart. We investigated the impact of diabetes on the prognosis of aortic stenosis (AS) patients and its underlying mechanisms using comprehensive noninvasive imaging studies and plasma proteomics.

Methods

Severe AS patients undergoing both echocardiography and cardiovascular magnetic resonance (CMR) (n=253 of which 66 had diabetes) comprised the imaging cohort. The degree of replacement and diffuse interstitial fibrosis by late gadolinium enhancement (LGE) and extracellular volume fraction (ECV) was quantified using CMR. Plasma samples were analyzed with the multiplex proximity extension assay for 92 proteomic biomarkers in a separate biomarker cohort of severe AS patients (n=100 of which 27 had diabetes).

Results

In the imaging cohort, diabetic patients were older (70.4±6.8 vs. 66.7±10.1 years) and had a higher prevalence of ischemic heart disease (28.8% vs. 9.1%), with more advanced ventricular diastolic dysfunction. On CMR, diabetic patients had increased replacement and diffuse interstitial fibrosis (LGE% 0.3 [0.0–1.6] versus 0.0 [0.0–0.5], p=0.009; ECV% 27.9 [25.7–30.1] versus 26.7 [24.9–28.5], p=0.025) (Figure 1).

Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) are significantly elevated in diabetic AS patients (Figure 2). Pathway over-representation analyses of the plasma proteomics with Gene Ontology terms indicated that pathways related to inflammatory response and extracellular matrix components were enriched, suggesting that diabetes is associated with systemic effects that evoke proinflammatory and profibrotic response to the pressure-overloaded myocardium.

During follow-up (median 6.3 years [IQR 5.2–7.2]) of the imaging cohort, 232 patients received aortic valve replacement (AVR) with 53 unexpected heart failure admissions or death. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and AVR (hazard ratio 1.88, 95% confidence interval 1.06–3.31, p=0.030).

Conclusion

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory and profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Research Foundation of Korea

Integrating wearables and modelling for monitoring rehabilitation following total knee joint replacement

BACKGROUND AND OBJECTIVE

Wearable inertial devices integrated with modelling and cloud computing have been widely adopted in the sports sector, however, their use in the health and medical field has yet to be fully realised. To date, there have been no reported studies concerning the use of wearables as a surrogate tool to monitor knee joint loading during recovery following a total knee joint replacement. The objective of this study is to firstly evaluate if peak tibial acceleration from wearables during gait is a good surrogate metric for computer modelling predicted functional knee loading; and secondly evaluate if traditional clinical patient related outcomes measures are consistent with wearable predictions.

METHODS

Following ethical approval, four healthy participants were used to establish the relationship between computer modelling predicted knee joint loading and wearable measured tibial acceleration. Following this, ten patients who had total knee joint replacements were then followed during their 6-week rehabilitation. Gait analysis, wearable acceleration, computer models of knee joint loading, and patient related outcomes measures including the Oxford knee score and range of motion were recorded.

RESULTS

A linear correlation (R² of 0.7-0.97) was observed between peak tibial acceleration (from wearables) and musculoskeletal model predicted knee joint loading during gait in healthy participants first. Whilst patient related outcome measures (Oxford knee score and patient range of motion) were observed to improve consistently during rehabilitation, this was not consistent with all patient's tibial acceleration. Only those patients that exhibited increasing peak tibial acceleration over 6-weeks rehabilitation were positively correlated with the Oxford knee score (R² of 0.51 to 0.97). Wearable predicted tibial acceleration revealed three patients with a consistent knee loading, five patients with improving knee loading, and two patients with declining knee loading during recovery. Hence, 20% of patients did not present with satisfactory joint loading following total knee joint replacement and this was not detected with current patient related outcome measures.

CONCLUSIONS

The use of inertial measurement units or wearables in this study provided additional insight into patients who were not exhibiting functional improvements in joint loading, and offers clinicians an 'off-site' early warning metric to identify potential complications during recovery and provide the opportunity for early intervention. This study has important implications for improving patient outcomes, equity, and for those who live in rural regions.

Elderly kidney transplant recipients have favorable outcomes but increased infection-related mortality

Background

The number of elderly patients with end-stage kidney disease has been increasing, but the outcomes of kidney transplants (KT) remain poorly understood in elderly patients. Therefore, we evaluated the clinical outcomes of elderly KT recipients and analyzed the impact of elderly donors.

Methods

This retrospective cohort study included patients who underwent KT between 2000 and 2019. KT recipients were divided into four groups according to a combination of recipient and donor age (≥60 or <60 years); elderly recipients: old-to-old (n = 46) and young-to-old (n = 83); young recipients: old-to-young (n = 98) and young-to-young (n = 796). We compared the risks of mortality, graft failure, and acute rejection between groups using Cox regression analysis.

Results

The incidence of delayed graft function, graft failure, and acute rejection was not different among groups. Annual mean tacrolimus trough level was not lower in elderly recipients than young recipients during 10-year follow-up. Mortality was significantly higher in elderly recipients (p = 0.001), particularly infection-related mortality (p < 0.001). In multivariable Cox regression analysis, old-to-old and young-to-old groups had increased risk of mortality (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.14–7.32; p = 0.03; aHR, 3.06; 95% CI, 1.51–6.20; p = 0.002). However, graft failure and acute rejection risks were not increased in elderly recipients.

Conclusion

In elderly recipients, graft survival and acute rejection-free survival were not inferior to those of young recipients. However, mortality, especially risk of infection-related death, was increased in elderly recipients. Thus, low immunosuppression intensity might help decrease mortality in elderly recipients.

In Situ Bypass from the Brachial to Radial Artery in the Anatomical Snuffbox for Limb Salvage in End-Stage Renal Disease

Diabetes and renal failure frequently involved in small vessel arteriopathy. With medical advancements, those patients survive longer with an increasing incidence of resultant arterial occlusive disease affecting the distal upper extremity (UE). In patients with ulcers or gangrene in the distal UE, bypass surgery is often complicated by severe atherosclerosis with calcification, resulting in poor distal anastomosis quality. Here we report a patient with a fingertip gangrene who were successfully treated with in situ bypass from the brachial artery below the elbow to the radial artery in the anatomical snuffbox under local anesthesia. Bypass graft patency was maintained during the 18-month follow-up. If the forearm cephalic vein and radial artery in the anatomical snuffbox are of adequate quality, in situ bypass to radial artery in the anatomical snuffbox may be a useful option for limb salvage in selected patients.

Incidence and Risk Factors for Sac Expansion after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms

Purpose

This study aimed to examine the sac changes after endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysms.

Methods

Materials and We examined the aneurysm sac size initially and regularly after surgery in 157 consecutive patients who underwent EVAR in 2009-2019. Contrast-enhanced computed tomography (CT) scans were used as well as ultrasound images with non-enhanced CT scans in the patients with renal insufficiency. Sac expansion (SE) at 3 years was divided into two categories: progressive SE (PSE) defined as continuous sac enlargement of ≥5 mm on serial follow-up images at 1 and 3 years compared with the initial sac and delayed SE (DSE) defined as re-expansion of ≥5 mm compared with the regressed or stable sac at 1 year. The SE rate at 1 and 3 years and the risk factors for SE at 3 years were analyzed using logistic regression.

Results

During a median follow-up of 32.5 months, nine reinterventions in six patients were performed with open conversion (n=5) and endovascular repair (n=4). At 1 year, 112 patients underwent follow-up imaging. SE and sac regression were noted in 4 (3.6%) and 57 (50.9%) patients, respectively. Of the 64 patients with 3-year follow-up images, 16 (25%) exhibited SE (PSE [n=6] and DSE [n=10]). In the multivariable analysis, the risk factors for overall SE at 3 years were endoleaks at 1 year (P=0.006) and renal insufficiency (P=0.003).

Conclusion

During post-EVAR follow-up, patients with any endoleak at 1 year or renal insufficiency must be strictly monitored for SE development.

491 Comparison of Pandemic and Pre-pandemic Practices of Managing Acute Appendicitis

Aim

Acute appendicitis (AA) is a common indication for abdominal surgery, with more than 30,000 appendicectomies performed in England per year. However, SARS-CoV-2 (COVID-19) changed usual surgical practices following advice to minimise laparoscopic surgery, and instead favouring conservative management, or open surgery for AA.

Method

In this study, we compared the management of 50 patients with suspected/confirmed AA during the first wave of the COVID-19 pandemic at a district general hospital (DGH) with our usual practices, against 50 patients admitted with suspected/confirmed AA during a similar time period, one year prior to the pandemic.

Results

Demographics of patients in both groups were comparable with median age of 34 in the pandemic vs 32.5 in the pre-pandemic group. 74% of patients in the pandemic group (PG) underwent imaging to confirm appendicitis, compared to 58% of patients in the pre-pandemic group (PPG). 64% of PG patients were treated conservatively, compared to 8% in PPG patients. Outcomes demonstrated re-attendance events of 12% in the PG, as compared to 10% in the PPG, although the follow up period was longer in the PPG. Despite a significantly smaller number of patients managed surgically during the pandemic, 27% of patients undergoing appendicectomies had post-operative complications in the PG, as compared to 7% in the PPG.

Conclusions

During the pandemic, more patients at our DGH with AA were treated conservatively, more patients had re-attendance events and post-operative complications when compared to patients in the pre-pandemic group.

P–627 Optimal timing of day 6 blastocyst transfer in artificially prepared frozen-thawed embryo transfer cycles

Study question

When is the optimal timing of day 6 (D6) blastocyst transfer between the 6thday (P6)and the 7th(P7) day of progesterone administration in artificially prepared frozen-thawed embryo transfer(FET) cycle

Summary answer

When transferring D6 blastocysts in artificially prepared FET cycles, live birth rate tended to be higher in P6 group than in P7 group.

What is known already

Blastocyst transfer in FET cycles has increased due to several reasons including convenience for optimization of endometrial synchronization, improvement of laboratory techniques and preimplantation genetic testing. Meanwhile, D6 blastocyst which cryopreserved on day 6 after being developed to the full blastocyst stage, presented lower pregnancy outcomes in FET cycle than D5 blastocysts. However, there have been few studies on the optimal duration of progesterone administration when transferring D6 blastocysts.

Study design, size, duration

This was a retrospective cohort study including patients who underwent frozen-thawed blastocyst transfer in artificially prepared cycles from January 2000 to May 2020. Patients with D6 blastocyst transfer on the 6th day of progesterone administration were included in D6-P6 group, and patients with D6 blastocyst transfer on the 7th day of progesterone administration were included in D6-P7 group.

Participants/materials, setting, methods

Increasing dose of estradiol valerate was administered from the 3rd day of menstruation: 4 mg/day for the first four days, 6 mg/day for next four days, and then 8 mg/day until the confirmation of pregnancy. Progesterone was administered from the 14th day of menstruation if the endometrial thickness reached ≥7 mm. The independent t-test or Mann-Whitney test, chi-square test, and logistic regression analysis were performed.

Main results and the role of chance

A total of 50 patients were included, and 13 patients underwent FET on P6 and 37 patients underwent FET on P7. Live birth rate was comparable between the P6 group and the P7 group (18.9% vs. 15.4%, p = 0.775). Live birth rate was higher in the D6-P6 group than in the D6-P7 group after adjusting for age, AMH, endometrial thickness on the starting day of progesterone administration and good embryo rate transferred with statistical significance (OR: 6.716, p = 0.005).

Limitations, reasons for caution

Limitations of the present study is the retrospective design and the small sample size. Caution is needed in extrapolating results of this study because only intramural and vaginal progesterone supplementations were included in this study.

Wider implications of the findings: Even if the duration of blastocyst formation was delayed, frozen-thawed D6 blastocyst may need to be considered for on P6 rather than P7. The difference of live birth rate is not statistically significant. This study should be acknowledged for the underestimation of the difference because of the small sample size.

Trial registration number

Not applicable

Single center experience of inferior vena cava filter retrieval in trauma patients: contrast-enhanced CT-based retrieval within hospital stay

PURPOSE

To assess the safety and retrieval rate of a predischarge inferior vena cava (IVC) filter retrieval strategy based on contrast computed tomography (CT).

METHODS

IVC filter insertion for trauma patients from 2010 to 2018 were reviewed. An active filter retrieval strategy was established in March 2017. The strategy sought early evaluation of venous thromboembolism (VTE) status and filter retrieval before a patient's discharge. The possibility of early IVC filter retrieval was evaluated by a multidisciplinary team based on pre-filter retrieval VTE-CT findings. Overall VTE-CT findings, retrieval rate, indwelling time, and recurrence of venous thromboembolic events were compared before and after the filter retrieval strategy setup.

RESULTS

177 IVC filters were inserted in trauma patients. All patients underwent pre-filter retrieval VTE-CT. VTE-CT findings were as follows: completely resolved VTE, n = 108 (61%); partially improved, n = 58 (33%); no change, n = 8 (5%); aggravated, n = 3 (2%). The overall retrieval rate was 84% with a mean indwelling time of 32 days. In subgroup analyses, 95 (53%) had filter retrieval with the before strategy (BS) setup and 82 (47%) with the after strategy (AS) setup. The retrieval rate was significantly higher in the AS group [81/82 (99%) vs. 68/95 (72%), (p < 0.001)]. No patients had recurrent VTE during the follow-up period.

CONCLUSIONS

The active strategy of VTE-CT-based filter retrieval during the hospital stay markedly improved the filter retrieval rate from 72% to 99% without evidence of recurrence of VTE. Hazards of low retrieval rate versus CT-related radiation exposure should be studied in the future.

Long-Term Result of Tibioperoneal Trunk Bypass with an Autogenous Graft Using the Varicose Great Saphenous Vein for Acute Limb Ischemia

For the management of acute limb ischemia (ALI) and multilevel arterial occlusive disease, tibial bypass using the saphenous vein has been considered a mainstay due to the long-term durability in selected patients with acceptable saphenous veins and comorbid conditions. Traditionally, bypass using a varicose autogenous graft has been contraindicated due to the risk of late aneurysmal dilation and rupture. Here, we describe a patient who presented with ALI and received tibioperoneal trunk bypass using a varicose autogenous graft. The patient has been doing well during the 72-month follow-up without recurrent symptoms or revision. The follow-up images showed a favorably patent graft with mild aneurysmal changes at the valve cusp adjacent to the knee. If there are no other appropriate autologous veins for revascularization, a varicose autogenous vein graft may be a useful option for limb salvaging in selected patients with multilevel arterial occlusive diseases.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study

PURPOSE

To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR).

METHODS

This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement.

RESULTS

One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 μm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 μm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months.

CONCLUSION

Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Impact of Donor-Recipient Age Difference on Graft Function and Survival After Deceased Donor Kidney Transplantation

BACKGROUND

Donor-recipient age difference (DRAD) is one of the reasons why patients on kidney waiting lists refuse to receive the offered organ. However, its impact on deceased donor kidney transplantation (DDKT) outcomes is still controversial.

METHODS

One hundred fifty-three kidney transplant recipients (KTRs) who received their first-time DDKT were enrolled. The KTRs were divided into groups by DRAD: group 1 (n = 74) (DRAD < 0) and group 2 (n = 79) (DRAD ≥ 0). The KTRs in group 2 were divided into 3 subgroups: DRAD 0 to 10 (n = 35), 10 to 20 (n = 32), and ≥ 20 (n = 12). The outcome measures included estimated glomerular filtration rate (eGFR), delayed graft function (DGF), acute rejection (AR), and graft and patient survival.

RESULTS

There were no significant differences in clinical outcomes between group 1 and 2 except eGFR until 5 years after DDKT. Among the subgroups of group 2, DGF, AR, patient survival, and eGFR until 5 years showed no significant differences. However, graft survival was significantly different (P = .015); in addition, in the DRAD ≥ 20 subgroup, graft survival decreased compared with that in the DRAD 10 to 20 subgroup and DRAD 0 to 10 subgroup (P = .020, P = .012, respectively). In a multivariate Cox proportional hazards analysis, the DRAD ≥ 20 subgroup showed a higher risk for graft failure than the DRAD 0 to 10 subgroup.

CONCLUSIONS

Although donors were of the same age or older than recipients, DDKT showed acceptable graft outcomes. However, because donors over 20 years older than recipients showed a decreased graft survival, it might be important to consider this point in donor-recipient matching of DDKT.

Suitability of the Aortic Neck Anatomy for Endovascular Aneurysm Repair in Korean Patients with Abdominal Aortic Aneurysm

Purpose

To evaluate the aortic neck anatomy in Korean patients with abdominal aortic aneurysms (AAAs).

Materials and Methods

We examined computed tomography scans of 343 patients with AAAs (≥5.5 cm for men or ≥5 cm for women) between 2009 and 2018. Eligibility of neck anatomy for endovascular aneurysm repair (EVAR) was assessed with the standard instructions for use (IFU) (length ≥15 mm, suprarenal angulation (SRA) ≤45°, infrarenal angulation (IRA) ≤60°, and diameter 18-32 mm) and the extended IFU (length ≥10 mm, SRA ≤60°, IRA ≤75°, and diameter 17-32 mm).

Results

There were 71 women (20.7%), and 61 patients (17.8%) with rupture. Women had smaller neck diameters (21.3 vs. 23.4 mm, P<0.001 for proximal neck; 22.2 vs. 24.5 mm, P<0.001 for distal neck), and higher angulations (51.5° vs. 37.8°, P<0.001 for SRA; 77.7° vs. 57.0°, P<0.001 for IRA) than men. However, the neck length was not significantly different. Patients with ruptured AAAs had shorter neck lengths (21.0 vs. 26.8 mm, P=0.005) than those with intact AAAs. However, the neck diameters and angulations were not significantly different. EVAR eligibility for standard and extended IFUs was found in 37.5% and 55.1% of men, and 11.3% and 25.4% of women (P<0.001 for both IFUs); neck anatomy was eligible in 34.0% of intact AAAs and 23.0% of ruptured AAAs (P=0.098).

Conclusion

A significant proportion of the Korean patients did not meet the IFU for EVAR, mainly due to the angulated neck. Women, and patients with ruptured AAAs, were less likely to meet the IFU criteria.

P1274 Early surgery versus watchful waiting in patients with moderate aortic stenosis and left ventricular systolic dysfunction

Background

Aortic stenosis (AS) induces significant pressure overload to the left ventricle (LV) and its burden may increase if there is concomitant LV systolic dysfunction. Severe AS with LV systolic dysfunction is a class I indication for aortic valve replacement (AVR) irrespective of symptoms, however, this recommendation is not well established in those with moderate AS and LV systolic dysfunction. In this study, we sought to investigate the clinical impact of surgical AVR among patients with moderate AS and LV systolic dysfunction.

Methods

From 2001 to 2017, we retrospectively but consecutively identified patients with moderate AS and LV systolic dysfunction from a single tertiary hospital. Moderate AS was defined as aortic valve area between 1.0 and 1.5cm2 and LV systolic dysfunction as LV ejection fraction less than 50%. The primary outcome was all-cause death and we additionally analyzed cardiac death as a secondary endpoint. The outcomes were compared between those who underwent early surgical AVR at the stage of moderate AS versus those who were followed without AVR at the outpatient clinic.

Results

Among a total of 257 patients with moderate AS and concomitant LV systolic dysfunction (70.0 ± 11.3 years, 63.4% of male), 34 patients received early AVR. Patients in the AVR group was younger than the observation group (64.2 ± 8.1 vs. 70.9 ± 11.5, respectively), and had a lower prevalence of hypertension and chronic kidney disease. During a mean of 3-year follow up, 112 patients (47.5%) died and the overall death rate was 15.367 per 100 person-year (PY). The AVR group showed a significantly lower rate of all-cause death than the observation group (5.241PY vs. 18.160PY, p-value = 0.002). After multivariable Cox proportional hazard regression adjusting for age, sex, comorbidities and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of all-cause death (hazard ratio [HR] 0.340, 95% confidence interval [CI] 0.117 - 0.985, p-value = 0.047). However, there was no risk reduction of cardiac death (HR 0.578 95% CI 0.150 - 2.231, p-value = 0.426).

Conclusions

In patients with moderate AS and LV systolic dysfunction, AVR reduces the risk of all-cause death. A prospective design study is warranted to confirm our findings in the near future.

Abstract P1274 Figure. Kaplan-Meier curves for deaths

P1603 Changes of cardiac function in cirrhotic patients after liver transplantation

Funding Acknowledgements

This study was supported by the grant of CJ healthcare 2016 research fund.

Background

Liver cirrhosis (LC) has been known to affect cardiovascular performance. Limited study have evaluated the alteration of myocardial function in patients with LC after liver transplantation (LT).

Purpose

The aim of study was to evaluate changes of cardiac function in patients with cirrhosis following LT using conventional and speckle-tracking echocardiography and late gadolinium enhancement (LGE) of cardiac magnetic resonance (MR).

Methods

Thirty-five patients with cirrhosis (mean age, 57.1 ± 9.0; male, 75%) who were listed for LT were prospectively enrolled. Patients underwent conventional, speckle-tracking echocardiography, and cardiac MR imaging with LGE. Echocardiography and cardiac MR were performed at pre and 1 year after LT. Cirrhotic patients were compared with normal control (n = 20, mean age, 65.0 ± 14.8; men, 11(55%)) and echocardiographic and cardiac MR data were compared pre and post LT.

Results

Conventional and speckle-tracking echocardiography and Cardiac MR imaging demonstrated hyperdynamic left ventricular (LV) function in patients with cirrhosis (LV ejection fraction (EF) with cardiac MR 67.8 ± 7.0% in LC vs. 63.4 ± 6.4% in control, P = 0.028; global longitudinal strain (GLS) -24.3 ± 2.6% in LC vs. -18.6 ± 2.2% in control, P &lt; 0.001). There were no LGE in patients with cirrhosis and no significant differences in LV size, LV wall thickness, LV mass index, and diastolic function between cirrhotic patients and control group (all P &gt; 0.1). Corrected QT interval (QTc) in electrocardiogram was prolonged in LC patients (P &lt; 0.001). One-year after LT, LV end-diastolic diameter and LV end-diastolic volume significantly decreased (P = 0.016 and 0.022, respectively). Although LVEF showed no significant changes 1 year post-LT (P = 0.362), LV-GLS (from -24.7 ± 1.8% to -20.8 ± 3.4%, P &lt; 0.001) significantly decreased. QTc interval also decreased 1 year after LT (from 470.4 ± 29.6msec to 428.2 ± 31.6msec, P = 0.001).

Conclusions

The present study demonstrated that cirrhotic patients showed hyperdynamic circulation and prolonged QTc interval compared with normal controls. After 1 year LT, LV size reduced and augmented LV function was normalized. Given that no LGE in cardiac MR and normalized GLS and QTc after LT, cardiac dysfunction in LC patients could be reversed by LT.

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

Mitochondrial DNA content and oxidation in bipolar disorder and its role across brain regions

The underlying pathology of bipolar disorder remains unknown, though evidence is accumulating to support a role of mitochondrial dysfunction. In this study, we aim to investigate electron transport chain complex I subunit NDUFS7 protein expression; mtDNA content; common deletion; and oxidation in the Broadmann area 24 (BA24), cerebellum, hippocampus, and prefrontal cortex from patients with bipolar disorder, schizophrenia, and non-psychiatric controls. Here, we demonstrate no changes in NDUFS7 in BA24, cerebellum or hippocampus, increases in mtDNA content in hippocampus of patients with bipolar disorder, and decreases in mtDNA oxidation in patients with bipolar disorder and schizophrenia, respectively. Paired analysis between BA24 and cerebellum reveal increases within NDUFS7 levels and mtDNA content in cerebellum of patients with bipolar disorder or schizophrenia. We found a positive correlation between NDUFS7 and mtDNA content (ND4 and ND5) when combining brain regions. Our study supports the involvement of mitochondrial dysfunction in bipolar disorder and schizophrenia.

Prevalence of fentanyl exposure and knowledge regarding the risk of its use among emergency department patients with active opioid use history at an urban medical center in Baltimore, Maryland

Background: Overdose deaths from fentanyl and its analogs have increased significantly since 2013. There are limited data regarding the prevalence of fentanyl exposure among emergency department (ED) patients with active opioid use.Methods: We conducted a cross-sectional study at an urban hospital from May 20 to July 30, 2018. A convenience sample of adult ED patients with active opioid use, defined as opioid use within seven days prior to ED visit, were enrolled. Rapid Response^® Single Drug Test Strip (BTNX Inc., Markham, Canada) was used to detect fentanyl in urine samples. Information on demographic, substance use history, and knowledge of fentanyl was obtained using a brief survey tool. Our primary outcome was the prevalence of fentanyl exposure; secondary outcomes included patients' knowledge regarding potency, risk of overdose death from fentanyl and intentional purchase of fentanyl.Results: During our study period, 451 patients reported active substance use. Of these, 208 reported active opioid use and 165 consented for the study. The median age was 49 years [interquartile range: 38, 57] and 77.0% (n = 127) were male; 42 participants (25.5%) presented to ED after an acute overdose event. Heroin was the preferred opioid of use in 90.8% of the participants, primarily via intranasal route (64.6%). Polysubstance use was reported in 98.8%, most commonly with cocaine (57.6%; n = 95). Fentanyl was detected in 104 out of 129 urine samples tested (80.6%). 84.2% (n = 139) identified fentanyl as highly potent and 85.5% (n = 141) recognized highest risk of death in fentanyl overdose. A larger proportion of non-overdose participants intentionally purchased fentanyl (34.1%; n = 42) compared to the overdose group (16.7%, n = 7; p = .04).Conclusions: The majority of ED patient with active opiate use were exposed to fentanyl while one in three participants intentionally purchased fentanyl despite their awareness of its potency and the high-risk of death from overdose.

Impact of Conversion From Cyclosporine to Tacrolimus on Glucose Metabolism and Cardiovascular Risk Profiles in Long-Term Stable Kidney Transplant Recipients

BACKGROUND

Compared to tacrolimus, cyclosporine increases cardiovascular risk. Furthermore, tacrolimus has a negative effect on glucose metabolism compared to cyclosporine. This study investigated the effect of the conversion from cyclosporine to tacrolimus for immunosuppressive therapy on glucose metabolism and cardiovascular risk profiles in long-term stable kidney transplant recipients (KTRs).

METHODS

In this prospective, open-label, single-arm study, 36 KTRs were enrolled; 3 were excluded. Patients were evaluated for glucose metabolism and cardiovascular risk factors at baseline, 3, and 6 months after conversion of medication. Serial changes were analyzed by repeated analysis of variance.

RESULTS

The mean duration from transplantation was 12.6 ± 4.0 years and baseline serum creatinine levels were 1.10 ± .23 mg/dL. After conversion, fasting plasma glucose levels increased sequentially from 101.7 ± 18.5 to 107.4 ± 21.3 mg/dL (P = .007), and glycated hemoglobin levels increased from 5.7 ± .8 to 6.0 ± 1.2% (P = .016). Among cardiovascular risk factors, fibrinogen levels were decreased (P = .015), but other factors, including blood pressure and lipid profile, did not change (all P > .05). There was no change in renal function, including serum creatinine (P = .611) and urine protein-to-creatinine ratio (P = .092). Body mass index levels were decreased (P = .037) and body weight tended to decrease (P = .063).

CONCLUSIONS

Switching immunosuppressant therapy to tacrolimus has an apparent negative effect on glucose metabolism and imparts an unclear advantage on cardiovascular risk profiles for long-term stable KTRs.

Comparison of Transplant Outcomes for Low-level and Standard-level Tacrolimus at Different Time Points after Kidney Transplantation

BACKGROUND

Optimal tacrolimus (TAC) trough levels for different periods after kidney transplantation (KT) has not been definitely established. This study aimed to investigate transplant outcomes of low-level (LL) and standard-level (SL) TAC according to post-transplant period.

METHODS

A total of 278 consecutive kidney transplant recipients (KTRs) receiving TAC-based immunosuppression were divided into LL and SL-TAC groups (4-7 and 7-12 ng/mL for 0-2 months, 3-6 and 6-10 ng/mL for 3-6 months, 2-5 and 5-8 ng/mL for 7-12 months, respectively) according to TAC trough level at each period. We compared estimated glomerular filtration rate (eGFR), biopsy-proven acute rejection (BPAR), de novo donor-specific antibody (dnDSA), calcineurin inhibitor (CNI) toxicity, opportunistic infection, and allograft survival.

RESULTS

SL-TAC group showed significantly higher mean eGFR at 0-2 months than LL-TAC group (72.1 ± 20.3 vs. 64.2 ± 22.7 mL/min/1.73m²; P = 0.003). Incidence of BPAR at 7-12 months was significantly lower in SL-TAC group than in LL-TAC group (0.0% vs. 3.9%; P = 0.039). Patients with persistent SL-TAC lasting 12 months showed higher eGFR at 7-12 months than those with persistent LL-TAC (65.5 ± 13.0 vs. 57.9 ± 13.9 mL/min/1.73m²; P = 0.007). No significant differences in dnDSA, CNI toxicity, serious infections, or allograft survival were observed.

CONCLUSIONS

Maintenance of proper TAC trough level after 6 months could reduce BPAR without adverse drug toxicities in KTRs. Moreover, persistent SL-TAC during the first year after KT might have a beneficial effect on a trend for a lower incidence of dnDSA and better renal allograft function.

Characteristics and Clinical Significance of De Novo Donor-Specific Anti-HLA Antibodies after Kidney Transplantation

BACKGROUND

The association of de novo donor-specific anti-human leukocyte antigens (HLA) antibodies (DSA) and development of antibody-mediated rejection (AMR) in kidney transplant recipients (KTRs) is still undetermined.

METHODS

We prospectively screened de novo DSA in 167 KTRs during 32 months after kidney transplantation (KT). Timing of DSA detection was at 3, 6, and 12 months post-transplant and annually thereafter and when clinically indicated. DSA levels were determined by Luminex assays and expressed as mean fluorescence intensity (MFI). We evaluated the incidence, characteristics of DSA, and association between DSA and tacrolimus trough levels or AMR.

RESULTS

De novo DSA developed in 16 KTRs (9.6%) and acute AMR occurred more commonly in KTRs with de novo DSA compared to KTRs without de novo DSA (18.8% vs. 0%, P < 0.001). All de novo DSA were against class II antigens. The mean number of DSA was 1.8 ± 1.2 and the average MFI of DSA was 7,399 ± 5,470. Tacrolimus trough level during the first 0-2 months after KT was an independent predictor of DSA development (hazard ratio, 0.70; 95% confidence interval, 0.50-0.99; P = 0.043). No differences were found in the number of DSA, average MFI of DSA, and tacrolimus levels during the first year between de novo DSA-positive KTRs with AMR and those without AMR.

CONCLUSION

The results of our study suggest that monitoring of DSA and maintaining proper tacrolimus levels are essential to prevent AMR during the initial period after KT.

Treatment Outcomes and Risk Factors for In-Hospital Mortality in Patients with Acute Aortic Occlusion

Purpose

The aims of the present study are to determine the outcomes after acute aortic occlusion (AAO) and analyze the risk factors for in-hospital mortality.

Materials and Methods

We retrospectively analyzed 24 patients who were diagnosed with AAO from 2002 to 2017 in our registered data. Demographic and radiologic characteristics of AAOs were retrospectively collected. Perioperative treatment outcomes including in-hospital mortality were also assessed and the risk factors of in-hospital mortality were analyzed.

Results

The median symptom duration was 21 hours. Five patients had complete paraplegia and 10 patients (41.7%) were initially evaluated for central nervous system disorders instead of acute arterial occlusion. The etiology was determined to be aortoiliac thrombosis in 17 patients (70.8%) and embolic occlusion in 7. Surgical revascularization was performed in 23 patients, and one patient did not receive any treatment. The overall in-hospital mortality was 34.8% (8/23) and 30-day mortality was 26.1%. In the univariate analysis, age (P=0.040), preoperative renal insufficiency (serum creatinine over 1.5 mg/dL at the time of presentation) (P=0.008), postoperative acute kidney injury (need for dialysis or an increase in serum creatinine of >50.0% within 48 hours) (P=0.006), combined external iliac artery occlusion (P=0.019) and combined bilateral internal iliac artery occlusion (P=0.039) were associated with in-hospital mortality.

Conclusion

A substantial number of AAO patients were initially evaluated for a central nervous system lesion, which led to a delay in diagnosis. Thus, vascular examinations should always be performed in every patient presenting with lower limb neurologic deficits. Age, perioperative renal function, and combined iliac artery occlusion were associated with the prognosis of AAOs.

Hybrid treatment of multilevel revascularization in patients with peripheral arterial disease – a multi-centre study in Korea

Abstract. Background: Endovascular treatment is an alternative first-line management for peripheral artery disease (PAD). Hybrid treatment (HT) is defined as a combined treatment for patients with PAD using endovascular and open surgery, simultaneously performed in an operating room. The results of HT are reportedly good for multilevel revascularization (MR) in patients with chronic limb ischaemia, and even in older high-risk patients. The goal of this study was to examine the clinical and haemodynamic outcomes of HT in patients who need MR. Patients and methods: Nine university hospitals in Korea participated in this multicentre study. A total of 134 patients with multilevel PAD underwent HT and MR. Patients were enrolled from July 2014 to June 2015 and were followed for 18 months. Results: The mean age of the patients was 68.8 ± 9.93 years and 88.1 % were men. Patients with Rutherford category 2 to 3 and 4 to 6 comprised 59.0 % and 42.0 % of the group, respectively. The technical success rate was 100 %. The primary patency rates at 12 and 18 months were 77.6 % and 63.9 %, respectively. The primary-assisted patency rates at 12 and 18 months were both 90.0 %. The pre-operative mean ankle brachial index (0.43 ± 0.23) increased to 0.87 ± 0.23 at six months post-operatively (t-test, p < 0.05). The amputation free survival rate was 97.1 %. Conclusions: Although outcomes of multilevel PAD are reportedly poor when endovascular treatment alone is used, we have shown that HT is a feasible alternative modality for patients with multilevel PAD, with satisfactory amputation-free survival and freedom from re-intervention rates.

Adventitial Cystic Disease of the Iliac Artery with a Connection to the Hip Joint

More than 700 adventitial cystic diseases (ACDs) have been reported in the literature, with most cases affecting the popliteal artery in young men. Here, we describe our treatment and etiologic consideration of a patient who presented with an ACD of the external iliac artery, known to be an extremely rare location. On preoperative imaging, the ACD had a connection to the nearby hip joint and was treated with resection of the affected segment, including ligation of the joint connection and interposition with a prosthetic graft. The pathogenesis of ACDs is not fully understood; however, we believe that joint connections are important in their development and treatment.

Detection of bovine coronavirus in nasal swab of non-captive wild water deer, Korea

Bovine coronavirus (BCoV) is a causative agent of respiratory and enteric diseases in cattle and calves. BCoV infection was also evident in captive wild ruminants. Recently, water deer are recognized as the most common wildlife to approach farmhouses and livestock barns in Korea. Therefore, we investigated 77 nasal swab samples from non‐captive wild water deer (Hydropotes inermis) between November 2016 and September 2017 and identified three samples positive for coronavirus, indicating potential for respiratory shedding. The full genomic sequences of the water deer coronavirus were closely related to BCoV (>98%). Therefore, effective biosecurity system in bovine farms would be necessary to prevent contact between farm ruminants and free‐ranging wild water deer.

Solid pseudopapillary neoplasm of the pancreas with liver metastasis initially misinterpreted as benign haemorrhagic cyst

Solid pseudopapillary neoplasm (SPN) of the pancreas is considered a low-malignant neoplasm with a good prognosis. However, 5% to 15% of patients with SPNs develop metastatic disease, most commonly in the liver. Metastatic hepatic malignancies that show pseudocystic features are rare. Here we describe the case of a middle-aged female with a cystic liver metastasis from SPN. To the best of our knowledge, SPN with a single cystic liver metastasis has not been described, although these tumours frequently undergo haemorrhagic-cystic degeneration. Thus, in these patients the marked cystic change could be misinterpreted as a benign lesion.

Interregional correlations of glucose metabolism between the basal ganglia and different cortical areas: an ultra-high resolution PET/MRI fusion study using 18F-FDG

Basal ganglia have complex functional connections with the cerebral cortex and are involved in motor control, executive functions of the forebrain, such as the planning of movement, and cognitive behaviors based on their connections. The aim of this study was to provide detailed functional correlation patterns between the basal ganglia and cerebral cortex by conducting an interregional correlation analysis of the ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) data based on precise structural information. Fifteen participants were scanned with 7-Tesla magnetic resonance imaging (MRI) and high resolution research tomography (HRRT)-PET fusion system using ¹⁸F-FDG. For detailed interregional correlation analysis, 24 subregions of the basal ganglia including pre-commissural dorsal caudate, post-commissural caudate, pre-commissural dorsal putamen, post-commissural putamen, internal globus pallidus, and external globus pallidus and 80 cerebral regions were selected as regions of interest on the MRI image and their glucose metabolism were calculated from the PET images. Pearson's product-moment correlation analysis was conducted for the interregional correlation analysis of the basal ganglia. Functional correlation patterns between the basal ganglia and cerebral cortex were not only consistent with the findings of previous studies, but also showed new functional correlation between the dorsal striatum (i.e., caudate nucleus and putamen) and insula. In this study, we established the detailed basal ganglia subregional functional correlation patterns using ¹⁸F-FDG PET/MRI fusion imaging. Our methods and results could potentially be an important resource for investigating basal ganglia dysfunction as well as for conducting functional studies in the context of movement and psychiatric disorders.

The efficacy and stability of an information and communication technology-based centralized monitoring system of adherence to immunosuppressive medication in kidney transplant recipients: study protocol for a randomized controlled trial

Background

Immunosuppression non-adherence in kidney transplant recipients (KTRs) not only increases the risk of medical intervention due to acute rejection and graft loss but burdens the socioeconomic system in the form of increased healthcare costs. An aggressive preemptive effort by healthcare professionals, geared to ensure adherence to immunosuppressants in KTRs, is significant and imperative.

Methods/design

This study was designed as a prospective, open-label, multicenter, randomized controlled study aimed at evaluating the efficacy and stability of an information and communication technology (ICT)-based centralized monitoring system in boosting medication adherence in KTRs. One hundred fourteen KTRs registered throughout the year 2017 to 2018 are randomized into either the ICT-based centralized home monitoring system or to ambulatory follow-up. The planned follow-up duration is 6 months. The ICT-based centralized home monitoring system described consists of a smart pill box equipped with personal identification system, a home monitoring system, an electronic Case Report Form (eCRF) system, and a comprehensive clinical trial management system (CTMS). It alerts both patients and medical staff with texts and pill box alarms if there is a dosage/dosing time error or a missed dose. Medication adherence and transplant outcomes for the follow-up period are compared between the two groups, while patient satisfaction as well as the stability and cost-effectiveness of the ICT-based monitoring system are to be evaluated.

Discussion

This on-going study is expected to determine if consistent use of the ICT-based centralized monitoring system described could maximize mediation adherence and subsequently enhance transplant outcomes in KTRs. Further, it would lay the foundation for successful implementation of this ICT-based monitoring system for effective management of medication adherence in KTRs.

Trials registration

ClinicalTrials.gov, Identifier: NCT03136588. Registered on 20 April 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2221-z) contains supplementary material, which is available to authorized users.

Effect of Clinical Suspicion by Referral Physician and Early Outcomes in Patients with Acute Superior Mesenteric Artery Embolism

PURPOSE

To investigate the pattern of referral of patients with superior mesenteric artery embolism (SMAE) and its effect on outcomes, and to evaluate the risk factors for bowel infarction.

MATERIALS AND METHODS

This retrospective study included 66 consecutive patients diagnosed with acute SMAE between January 2001 and June 2016. Appropriate diagnosis by the referring physician was defined if the referral letter indicated that acute mesenteric ischemia was suspected or had been diagnosed at the referral center. Surgical delay was defined as the interval between symptom onset and surgery for definitive treatment.

RESULTS

Among 54 patients transferred from other centers, 26 patients (48.1%) were diagnosed appropriately by the referring physician. The rate of appropriate diagnosis was differed significantly by the use of computed tomography (CT) scan at referral center (25/35 with CT and 1/19 without CT, P=0.00). The surgical delay was significantly longer in patients without appropriate diagnosis compared with the patients with appropriate diagnosis (53.5±52.3 hours vs. 28.8±23.6 hours, P=0.04). Initially, 56 patients received surgical treatment with 31 underwent bowel resection due to infarction, 6 received conservative treatment, and the remaining 4 patients refused any treatment. The surgical delay, abdominal distension, tenderness, rebound tenderness, and level of C-reactive protein were associated with bowel infarction at initial operation. Overall in-hospital mortality was 32%.

CONCLUSION

A high index of suspicion with appropriate diagnostic modality, such as CT scan is crucial in patients with SMAE for reducing surgical delay as a risk factor of bowel infarction.