Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment

Endovascular methods have transformed treatment of lower extremity peripheral arterial disease but can still present technical challenges. We report the case of a 69-year-old man with rest pain who underwent superficial femoral artery recanalization with covered stents. During completion angiography, the distal stent was discovered to have been misdeployed into an anterior geniculate branch overlying the behind-the-knee popliteal artery. Subsequently, an endovascular reentry device was used to fenestrate the stent posteriorly to enter the lumen of the popliteal artery. Cutting balloons were used to enlarge the fenestration in the stent fabric, with placement of an additional 6 × 50-mm covered stent bridging from the popliteal artery into the fenestrated misdeployed covered stent. Completion angiography demonstrated no evidence of distal embolization and patent two-vessel runoff. The patient had an uncomplicated recovery and at 2 years of follow-up remained asymptomatic with documented popliteal stent patency

A summary of the 6th international conference on coagulation in liver disease : discussion, debate, deliberations

Editor’s Preface from Nahum Mendez Sanchez: Below, the Editors of Annals of Hepatology provide a summary report from the 2015 multidisciplinary Coagulation in Liver Disease group meeting. This group which originated in 2005 is dedicated to issues of Coagulation, Hemostasis and Thrombosis in Liver Disease patients and includes members from diverse Specialties including representation from the fields of Hepatology, Hematology, Surgery, Anesthesiology, Pathology, Interventional Radiology, Laboratory Medicine, Transfusion Sciences and Blood Banking with a combined approach of basic and clinical Sciences. The aim of the symposium was to raise points of convergence of interest and research and to provide a forum to facilitate collaboration in order to advance the field. [Introduction]peer-reviewe

Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment

Endovascular methods have transformed treatment of lower extremity peripheral arterial disease but can still present technical challenges. We report the case of a 69-year-old man with rest pain who underwent superficial femoral artery recanalization with covered stents. During completion angiography, the distal stent was discovered to have been misdeployed into an anterior geniculate branch overlying the behind-the-knee popliteal artery. Subsequently, an endovascular reentry device was used to fenestrate the stent posteriorly to enter the lumen of the popliteal artery. Cutting balloons were used to enlarge the fenestration in the stent fabric, with placement of an additional 6 × 50-mm covered stent bridging from the popliteal artery into the fenestrated misdeployed covered stent. Completion angiography demonstrated no evidence of distal embolization and patent two-vessel runoff. The patient had an uncomplicated recovery and at 2 years of follow-up remained asymptomatic with documented popliteal stent patency

Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure

Bacterial infections can trigger the development of organ failure/s and acute-on-chronic liver failure (ACLF). Different geographic variations in their bacteriology and clinical practices could lead to different epidemiology, phenotypes and outcomes of ACLF around the world. The aim of the study was to evaluate regional differences in bacterial infection-related ACLF in patients with cirrhosis admitted to hospital

Epidemiology and Effects of Bacterial Infections in Patients With Cirrhosis Worldwide

Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis

Determinants of clinical response to empirical antibiotic treatment in patients with cirrhosis and bacterial and fungal infections- Results from the ICA 'Global study' [EABCIR-Global Study]

BACKGROUND AND AIMSThe administration of an appropriate empirical antibiotic treatment is essential in cirrhosis and severe bacterial infections. We aimed to investigate the predictors of clinical response of empirical antibiotic treatment in a prospective cohort of patients with cirrhosis and bacterial and fungal infections included in the International Club of Ascites(ICA) "Global Study".METHODSHospitalized patients with cirrhosis and bacterial/fungal infection were prospectively enrolled at 46 centers. Clinical response to antibiotic treatment was defined according to changes in markers of infection/inflammation, vital signs, improvement of organ failure, and results of cultures.RESULTSFrom October 2015 to September 2016, 1302 patients were included at 46 centres. A clinical response was achieved only 61% of cases. Independent predictors of lack of clinical response to empirical treatment were C-reactive protein (OR=1.16;95%CI=1.02-1.31),blood leukocyte count (OR=1.39;95%CI=1.09-1.77), serum albumin (OR=0.70;95%CI=0.55-0.88), nosocomial infections (OR=1.96;95%CI=1.20-2.38), pneumonia (OR=1.75;95%CI=1.22-2.53),and ineffective treatment according to antibiotic susceptibility test (OR=5.32;95%CI=3.47-8.57). Patients with lack of clinical response to first-line antibiotic treatment had a significantly lower resolution rate of infections (55%vs. 96%;p<0.001), a higher incidence of second infections (29%vs. 15%;p<0.001),shock (35%vs. 7%;p<0.001) and new organ failures (52%vs. 19%;p<0.001) than responders. Clinical response to empirical treatment was an independent predictor of 28-day survival (sHR=0.20;95%CI=0.14-0.27).CONCLUSIONFour out of 10 patients with cirrhosis do not respond to the first-line antibiotic therapy, leading to lower resolution of infections and higher mortality. Broader-spectrum antibiotics and strategies targeting systemic inflammation may improve prognosis in patients with high degree of inflammation, low serum albumin levels and severe liver impairment.LAY SUMMARYIn a large, hospitalized cohort of patients with cirrhosis and infection at 46 multinational sites, lack of clinical response to empirical antibiotics was noted in four out of each ten patients. The non-response varied according to the geographic area and prevalence of multidrug/extensively drug resistant organisms with lowest response noted in the Asian countries particularly the Indian subcontinent. Severe systemic inflammation, as indicated by high white cell count, serum C-reactive protein levels low serum albumin concentration, presence of pneumonia, nosocomial infection and ineffective treatment were independent predictors of lack of clinical response to empirical antibiotic regimens. Patients with non-response to empirical regimen had worse clinical outcomes and this was identified as an independent predictor of higher in-hospital and 28-day mortality. Additional care and novel antibiotic protocols are an unmet need in cirrhosis patients, especially those with higher degree of inflammation, lower serum albumin levels and more severe liver impairment

Expert opinion on bleeding risk from invasive procedures in cirrhosis

Background &amp; Aims: Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines. Methods: All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as ''high risk'' or ''low risk'' with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as “consensus” was ≥75% agreement. Results: Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as “high risk”, primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as “low risk”, primarily “diagnostic” procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures. Conclusions: This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis. Impact and implications: Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis

Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide

Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis156513681380This study was supported by a grant from the Italian Ministry of Education,University and Research (DOR1678487/16). PG is recipient of an ICREA Academia awar

Perioperative Pembrolizumab for Early-Stage Non-Small-Cell Lung Cancer

BACKGROUND Among patients with resectable early-stage non-small-cell lung cancer (NSCLC), a perioperative approach that includes both neoadjuvant and adjuvant immune checkpoint inhibition may provide benefit beyond either approach alone.METHODS We conducted a randomized, double-blind, phase 3 trial to evaluate perioperative pembrolizumab in patients with early-stage NSCLC. Participants with resectable stage II, IIIA, or IIIB (N2 stage) NSCLC were assigned in a 1:1 ratio to receive neoadjuvant pembrolizumab (200 mg) or placebo once every 3 weeks, each of which was given with cisplatin-based chemotherapy for 4 cycles, followed by surgery and adjuvant pembrolizumab (200 mg) or placebo once every 3 weeks for up to 13 cycles. The dual primary end points were event-free survival (the time from randomization to the first occurrence of local progression that precluded the planned surgery, unresectable tumor, progression or recurrence, or death) and overall survival. Secondary end points included major pathological response, pathological complete response, and safety.RESULTS A total of 397 participants were assigned to the pembrolizumab group, and 400 to the placebo group. At the prespecified first interim analysis, the median follow-up was 25.2 months. Event-free survival at 24 months was 62.4% in the pembrolizumab group and 40.6% in the placebo group (hazard ratio for progression, recurrence, or death, 0.58; 95% confidence interval [CI], 0.46 to 0.72; P<0.001). The estimated 24-month overall survival was 80.9% in the pembrolizumab group and 77.6% in the placebo group (P = 0.02, which did not meet the significance criterion). A major pathological response occurred in 30.2% of the participants in the pembrolizumab group and in 11.0% of those in the placebo group (difference, 19.2 percentage points; 95% CI, 13.9 to 24.7; P<0.0001; threshold, P = 0.0001), and a pathological complete response occurred in 18.1% and 4.0%, respectively (difference, 14.2 percentage points; 95% CI, 10.1 to 18.7; P<0.0001; threshold, P = 0.0001). Across all treatment phases, 44.9% of the participants in the pembrolizumab group and 37.3% of those in the placebo group had treatment-related adverse events of grade 3 or higher, including 1.0% and 0.8%, respectively, who had grade 5 events.CONCLUSIONS Among patients with resectable, early-stage NSCLC, neoadjuvant pembrolizumab plus chemotherapy followed by resection and adjuvant pembrolizumab significantly improved event-free survival, major pathological response, and pathological complete response as compared with neoadjuvant chemotherapy alone followed by surgery. Overall survival did not differ significantly between the groups in this analysis