Side-hole catheters have higher thrombus aspiration efficiency than regular end-hole catheters in an in vitro model

PURPOSEWe aimed to evaluate and compare thrombus aspiration efficiency between side-hole and end-hole thrombus-aspirating catheters.METHODSUsing an in vitro model of acute thrombus occlusion, we performed thrombus aspiration with two catheter designs. Two end-hole and two side-hole catheters, 8 F and 10 F in diameter, were examined. Thrombus aspiration was performed with each catheter 30 times, and the amount of thrombotic material aspirated in each attempt was determined. The mean weight of the thrombotic material and the mean weight of the non-fluid thrombotic material extracted in all 30 attempts by each catheter were also determined.RESULTSThe 10 F side-hole catheter aspirated more thrombotic material than did the 10 F end-hole catheter (44.76 g vs. 28.35 g). The 8 F side-hole catheter had higher thrombus aspiration capacity than did the 8 F end-hole catheter in terms of the mean weight of the aspirated thrombus at each aspiration attempt (1.41 g vs. 0.58 g; P < 0.001) and the mean volume of the aspirated thrombotic material at each aspiration attempt (1.79 mL vs. 1.01 mL; P < 0.001). The mean weight of the non-fluid thrombotic material aspirated with the side-hole catheters was higher than that aspirated by the end-hole catheters with the same diameter size (31.06 g vs. 22.41 g for the 10 F catheters; P < 0.001; and 4.54 g vs. 2.99 g for the 8 F catheters; P < 0.001).CONCLUSIONSide-hole catheters are more effective in aspirating acute thrombi. The added benefit of the side-hole design is more remarkable in smaller-sized catheters. Animal models are needed to examine their aspiration capacity in a real elastic vascular conduit and in the presence of wall-adherent thrombi

Importance of Follow-up Imaging in the Detection of Delayed Type 2 Endoleaks Despite Complete Aneurysmal Sac Shrinkage

Type 2 endoleaks usually constitute a benign and self-limited phenomenon, which rarely leads to aneurysmal sac expansion. However, in a small subset of patients, a persistent type 2 endoleak might pressurise the aneurysmal sac causing expansion. The authors present two cases with delayed new-onset type 2 endoleak. One occurred after standard endovascular aortic repair and the other after chimney endovascular aortic repair, causing expansion of the aneurysmal sac after a period of complete aneurysmal sac shrinkage. Accordingly, there is a risk of sac re-expansion due to delayed onset endoleaks, independent of the technique, justifying the need for a continuous follow-up despite long-term aneurysmal sac shrinkage

Machine learning to predict major bleeding during anticoagulation for venous thromboembolism: possibilities and limitations

Predictive tools for major bleeding (MB) using machine learning (ML) might be advantageous over traditional methods. We used data from the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) to develop ML algorithms to identify patients with venous thromboembolism (VTE) at increased risk of MB during the first 3 months of anticoagulation. A total of 55 baseline variables were used as predictors. New data prospectively collected from the RIETE were used for further validation. The RIETE and VTE-BLEED scores were used for comparisons. External validation was performed with the COMMAND-VTE database. Learning was carried out with data from 49 587 patients, of whom 873 (1.8%) had MB. The best performing ML method was XGBoost. In the prospective validation cohort the sensitivity, specificity, positive predictive value and F1 score were: 33.2%, 93%, 10%, and 15.4% respectively. F1 value for the RIETE and VTE-BLEED scores were 8.6% and 6.4% respectively. In the external validation cohort the metrics were 10.3%, 87.6%, 3.5% and 5.2% respectively. In that cohort, the F1 value for the RIETE score was 17.3% and for the VTE-BLEED score 9.75%. The performance of the XGBoost algorithm was better than that from the RIETE and VTE-BLEED scores only in the prospective validation cohort, but not in the external validation cohort

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality among Patients with COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial

Importance: Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis. Objective: To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU). Design, Setting, and Participants: Multicenter randomized trial with a 2 � 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020. Interventions: Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up. Main Outcomes and Measures: The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count &lt;20 �103/µL). All outcomes were blindly adjudicated. Results: Among 600 randomized patients, 562 (93.7) were included in the primary analysis (median interquartile range age, 62 50-71 years; 237 42.2% women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% 95% CI,-6.6% to 9.8%; odds ratio, 1.06 95% CI, 0.76-1.48; P =.70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% 1-sided 97.5% CI,-� to 3.4%; odds ratio, 1.83 1-sided 97.5% CI, 0.00-5.93), not meeting the noninferiority criteria (P for noninferiority &gt;.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% 95% CI, 0.4%-3.8%; P =.01). Conclusions and Relevance: Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04486508. © 2021 American Medical Association. All rights reserved

An anomalous Origin of Left Anterior Descending Coronary Artery from Right Coronary Artery in a Patient with Acute Coronary Syndrome

A double left anterior descending (LAD) coronary artery emerging from the left and right coronary arteries is classified among rare coronary anomalies. We herein report a 73-year-old man presenting with acute coronary syndrome (posterolateral myocardial infarction). He was admitted with typical chest pain, and due to his progressive ischemic changes on electrocardiography (ECG) and elevated cardiac enzyme, he was candidated for cardiac catheterization. The coronary angiography revealed an anomalous LAD from the right sinus of Valsalva. The unusual coronary anatomy was perfectly matched with the distribution of ischemia and its clinical evidence on echocardiography and ECG. The culprit lesion was stented, and the patient was discharged in good physical condition from the hospital

Cost-utility analysis of Cryoballoon ablation versus Radiofrequency ablation in the treatment of paroxysmal atrial fibrillation in Iran.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia (Calkins H, et al. 2012). There are various methods to treat AF of which Ablation is one of the most effective. We aimed to assess the cost-utility of Cryoballoon ablation (CBA) compared to Radiofrequency ablation (RFA) to treat patients with paroxysmal AF in Iran. A cost-utility analysis was done using a decision-analytic model based on a lifetime Markov structure which was drawn considering the nature of interventions and the natural progress of the disease. Costs data were extracted from medical records of 47 patients of Shahid Rajaie Cardiovascular Medical Center in Tehran in 2019. Parameters and variables such as transition probabilities, risks related to side effects, mortality rates, and utility values were extracted from the available evidence. Deterministic and probabilistic sensitivity analysis was also done. TreeAge pro-2020 software was used in all stages of analysis. In the base case analysis, the CBA strategy was associated with higher cost and effectiveness than RFA, and the incremental cost-effectiveness ratio was $11,223 per Quality-adjusted life year (QALY), which compared to Iran's GDP per capita as Willingness to pay threshold, CBA was not cost-effective. On the other hand, considering twice the GDP per capita as a threshold, CBA was cost-effective. Probabilistic sensitivity analysis confirmed the findings of base case analysis, showed that RFA was cost-effective and the probability of cost-effectiveness was 59%. One-way sensitivity analysis showed that the results of the study have the highest sensitivity to changes in the RFA cost variable. Results of sensitivity analysis showed that the cost-effectiveness results were not robust and are sensitive to changes in variables changes. Primary results showed that CBA compared to RFA is not cost-effective in the treatment of AF considering one GDP per capita. But the sensitivity analysis results showed considerable sensitivity to changes of the ablation costs variable