S. Pasupathy

Randomized clinical trial of cutting balloon angioplasty versus high-pressure balloon angioplasty in hemodialysis arteriovenous fistula stenoses resistant to conventional balloon angioplasty.

PURPOSE To compare the efficacy and safety of cutting balloon angioplasty (CBA) versus high-pressure balloon angioplasty (HPBA) for the treatment of hemodialysis autogenous fistula stenoses resistant to conventional percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS In a prospective, randomized clinical trial involving patients with dysfunctional, stenotic hemodialysis arteriovenous fistulas (AVFs), patients were randomized to receive CBA or HPBA if conventional PTA had suboptimal results (ie, residual stenosis > 30%). A total of 516 patients consented to participate in the study from October 2008 to September 2011, 85% of whom (n = 439) had technically successful conventional PTA. The remaining 71 patients (mean age, 60 y; 49 men) with suboptimal PTA results were eventually randomized: 36 to the CBA arm and 35 to the HPBA arm. Primary and secondary target lesion patencies were determined by Kaplan-Meier analysis. RESULTS Clinical success rates were 100% in both arms. Primary target lesion patency rates at 6 months were 66.4% and 39.9% for CBA and HPBA, respectively (P = .01). Secondary target lesion patency rates at 6 months were 96.5% for CBA and 80.0% for HPBA (P = .03). There was a single major complication of venous perforation following CBA. The 30-day mortality rate was 1.4%, with one non-procedure-related death in the HPBA group. CONCLUSIONS Primary and secondary target lesion patency rates of CBA were statistically superior to those of HPBA following suboptimal conventional PTA. For AVF stenoses resistant to conventional PTA, CBA may be a better second-line treatment given its superior patency rates.

Bare nitinol stent enabled recanalization of long-segment, chronic total occlusion of superficial femoral and adjacent proximal popliteal artery in diabetic patients presenting with critical limb ischemia

PURPOSE To evaluate our experience of limb salvage with bare nitinol stent enabled recanalization of long length occlusions of superficial femoral artery (SFA) and adjacent proximal popliteal artery (PPA) in diabetic patients. METHODS A total of 573 patients underwent 842 lower limb interventions from August 2006 to September 2008 at our institute. A retrospective review was done of diabetic patients undergoing recanalization of long length SFA/adjacent PPA (>10 cm) occlusions with self expanding bare nitinol stents evaluating their impact on limb salvage. RESULTS Forty-four patients (mean age 65.2 years, M:F 25:19) underwent 49 long-length (>10 cm) SFA/PPA stenting procedures over a period of 26 months. Diabetics comprised 66% of patients (n=29, mean age: 63.7 years, M: F 19:10). The infrapopliteal distal run-off in this diabetic subgroup comprised one vessel (n=14/29, 48%), two vessels (n=12/29, 41%), and three vessels (n=3/29, 10%). The spectrum of critical limb ischemia included rest pain (n=8), ulcer (n=7) and gangrene (n=14). The lengths of occlusions recanalized were 10-39 cm. A total of 58 stents (individual length 10-17 cm, average diameter 6 mm, mean 2 stents per patient) were placed with average length of stented segment being 23.8 cm. Four patients had stents placed through ipsilateral popliteal artery approach with rest placed through femoral artery approach. Significant complications of the procedure included distal embolization (n=3) successfully managed with thrombolysis and popliteal arteriovenous fistula in one patient undergoing recanalization through popliteal approach, managed with covered stent placement. No procedure related mortality occurred during thirty-day follow-up period. All were followed up over an average duration of twelve months post-procedure. Three patients died due to associated medical conditions during this period. The following amputations were done on follow-up (three toe amputations, five forefoot amputations, three below-knee amputations, two above-knee amputations). The overall limb salvage rate was 80%. CONCLUSION Our study shows beneficial result of SFA/PPA stent placement in diabetic occlusions with significant concomitant infrapopliteal disease.

Methylene blue injection to localize the site of small intestinal haemorrhage

A 50-year-old patient who was on aspirin following an acute myocardial infarction 1 year earlier, presented with hypotension secondary to massive bleeding per rectum. Haemoglobin level on admission was 8 g/dL. He was resuscitated with blood products and managed in the high dependency unit (HDU) until he was stable for endoscopic evaluation of his gastrointestinal (GI) tract 6 h later. Both upper and lower GI endoscopy were negative. Because the patient was clinically stable he was returned to the HDU, and it was planned to carry out mesenteric angiography if he bled again. The patient became hypotensive 12 h later and passed large amounts of altered blood per rectum. Superselective superior mesenteric artery cannulation localized the bleeding source to be in the mid-jejunum (Fig. 1). The capillary microcatheter was left in situ to identify the site and the patient was transferred directly to the emergency operating theatre. A midline laparotomy incision was made for access and the small bowel run through. Methylene blue injection through the capillary microcatheter (which was taped to the patient’s right groin) by an unscrubbed assistant immediately demonstrated the bleeding segment of bowel by staining the mesenteric arcades blue. The stained segment (20 cm) was promptly resected and a primary anastomosis carried out. The laparotomy was completed in 45 min. The patient recovered in the intensive care unit and was well enough for discharge 1 week later. He remains well on follow up at 6 months with no further episodes of bleeding. Histology of the segment of bowel resected (Fig. 2) revealed multiple small ulcers, which were believed to be related to aspirin use. 1 DISCUSSION

Can bariatric surgery be performed safely in patients with severe treatment-resistant asthma?

Obesity-associated severe asthma is a distinct phenotype characterised by resistance to standard asthma therapies. Bariatric surgery appears to be a viable alternative for those who have failed trials of traditional weight loss methods. However, anaesthetic and surgical risks are potential barriers. We describe three patients with treatment-resistant obesity-associated severe asthma who underwent bariatric surgery without complications due to the multidisciplinary perioperative planning and care involved in these complex cases. All three patients showed improvements in asthma control and reduction in maintenance medication use post-surgery.