Esophageal Achalasia: An Uncommon Complication during Pregnancy Treated Conservatively

A 38-year-old Caucasian woman, gravida 3 para 2, was admitted at 29 weeks of gestation because of vomiting, dysphagia for solids and liquids, and loss of weight. An enlargement of the anterior left neck region was noted on the palpation of the thyroid gland. An MRI of the neck showed a marked esophageal dilatation with the presence of food remnants along its length and the displacement of the trachea to the right. The findings of the upper gastrointestinal endoscopy and manometry were suggestive of esophageal achalasia. Conservative management with total parenteral nutrition (TPN) through a peripheral line proved to be successful. A healthy male baby was born by a cesarean section at 37 weeks. The patient underwent laparoscopic esophageal myotomy and fundoplication seven days postpartum

Emerging Stent and Balloon Technologies in the Femoropopliteal Arteries

Endovascular procedures for the management of the superficial femoral (SFA) and popliteal artery disease are increasingly common. Over the past decade, several stent technologies have been established which may offer new options for improved clinical outcomes. This paper reviews the current evidence for SFA and popliteal artery angioplasty and stenting, with a focus on randomized trials and registries of nitinol self-expanding stents, drug-eluting stents, dug-coated balloons, and covered stent-grafts. We also highlight the limitations of the currently available data and the future routes in peripheral arterial disease (PAD) stent and balloon technology

Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis

Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14–0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04–0.07; kidney injury incidence 16%; 95% CI, 0.11–0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required

Risk of Major Amputation Following Application of Paclitaxel Coated Balloons in the Lower Limb Arteries : A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective: There have been concerns about the long term safety of paclitaxel coated devices in the lower limbs. A formal systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to examine the long term risk of major amputation using paclitaxel coated balloons in peripheral arterial disease (PAD). Method: This systematic review was registered with PROSPERO (ID 227761). A broad bibliographic search was performed for RCTs investigating paclitaxel coated balloons in the peripheral arteries (femoropopliteal and infrapopliteal) for treatment of intermittent claudication or critical limb ischaemia (CLI). The literature search was last updated on 20 February 2021 without any restrictions on publication language, date, or status. Major amputations were analysed with time to event methods employing one and two stage models. Sensitivity and subgroup analyses, combinatorial meta-analysis, and a multivariable dose response meta-analysis to examine presence of a biological gradient were also performed. Results: In all, 21 RCTs with 3 760 lower limbs were analysed (52% intermittent claudication and 48% CLI; median follow up two years). There were 87 major amputations of 2 216 limbs in the paclitaxel arms (4.0% crude risk) compared with 41 major amputations in 1 544 limbs in the control arms (2.7% crude risk). The risk of major amputation was significantly higher for paclitaxel coated balloons with a hazard ratio (HR) of 1.66 (95% CI 1.14 - 2.42; p = .008, one stage stratified Cox model). The prediction interval was 95% CI 1.10 - 2.46 (two stage model). The observed amputation risk was consistent for both femoropopliteal (p = .055) and infrapopliteal (p = .055) vessels. Number needed to harm was 35 for CLI. There was good evidence of a significant non-linear dose response relationship with accelerated risk per cumulative paclitaxel dose (chi square model p = .007). There was no evidence of publication bias (p = .80) and no significant statistical heterogeneity between studies (I-2 = 0%, p = .77). Results were stable across sensitivity analyses (different models and subgroups based on anatomy and clinical indication and excluding unpublished trials). There were no influential single trials. Level of certainty in evidence was downrated from high to moderate because of sparse events in some studies. Conclusion: There appears to be heightened risk of major amputation after use of paclitaxel coated balloons in the peripheral arteries. Further investigations are warranted urgently.Peer reviewe

The Role of BNP and CRP in Predicting the Development of Atrial Fibrillation in Patients Undergoing Isolated Coronary Artery Bypass Surgery

Objective. To evaluate the association of BNP and CRP with the development of postoperative atrial fibrillation following coronary artery bypass grafting surgery. Methods. The series consists of 125 patients (aged 65 ± 9 years), who underwent isolated CABG-surgery. BNP and CRP levels were measured pre- and 24 hours postoperatively and their correlation to the development of postoperative AF was analyzed. Results. Forty-four patients (35%) developed AF postoperatively. They were significantly older (68 ± 8 versus 63 ± 9, P = 0.01) and predominantly nonsmokers (18% versus 46%, P = 0.004), compared to the non-AF cases. In addition they showed significant higher preoperative mean BNP levels of 629 versus 373 pg/mL (P = 0.019). Postoperative BNP levels were significantly higher in both groups (AF-group: 1032 pg/mL versus non-AF group: 705 pg/mL; P&lt;0.001), while there was a trend of more increased postoperative levels in AF-cases (P = 0.065). AF-episodes appeared significantly more frequent in the two highest quartiles of BNP levels with 44% (P = 0.035). On the contrary pre- and postoperative CRP levels were not associated with AF. Multivariable analysis revealed only increased preoperative BNP levels as independent predictor for postoperative AF (P = 0.036). Conclusion. Elevated preoperative BNP serum levels are associated with the development of post-CABG AF, while CRP does not seem to be influential.</jats:p

Esophageal Achalasia: An Uncommon Complication during Pregnancy Treated Conservatively

A 38-year-old Caucasian woman, gravida 3 para 2, was admitted at 29 weeks of gestation because of vomiting, dysphagia for solids and liquids, and loss of weight. An enlargement of the anterior left neck region was noted on the palpation of the thyroid gland. An MRI of the neck showed a marked esophageal dilatation with the presence of food remnants along its length and the displacement of the trachea to the right. The findings of the upper gastrointestinal endoscopy and manometry were suggestive of esophageal achalasia. Conservative management with total parenteral nutrition (TPN) through a peripheral line proved to be successful. A healthy male baby was born by a cesarean section at 37 weeks. The patient underwent laparoscopic esophageal myotomy and fundoplication seven days postpartum

Below the knee angioplasty: bare versus drug-eluting stents

Abstract A 74-year-old patient suffering from critical limb ischaemia underwent percutaneous endovascular revascularization in the interventional radiology department. Baseline symptomatology included severe rest pain not responding to common analgesics, and dry gangrene of the left toe (Rutherford–Becker stage 5). The ankle-brachial index at presentation was 0.60. Selective digital subtraction angiography revealed significant 50–60% tortuous multiple stenoses and one near occlusion, all detected at the proximal segment of the peroneal artery which was the only patent infrapopliteal vessel. The arterial supply of the distal foot was preserved by the distal peroneal collateral network. Direct stenting of the diseased proximal peroneal segment using three sirolimus-eluting stents in an overlapping manner was performed. The total stented length was 94mm. Dual antiplatelet therapy was prescribed for 6 months, followed by monotherapy with clopidogrel 75mg 1 × 1. Complete wound healing and clinical improvement by three stages (Rutherford-Becker stage 2 from stage 5) was detected at one-year follow-up and was sustained throughout a three-year follow-up period. The lesion was patent without any in-stent restenosis at two years angiographic follow-up.</jats:p