Acta anaesthesiologica ScandinavicaJacob Hindborg Hovmann, Thomas Skjoldborg Sornn-Friese, Frederik Færgemann Lau, Niels Brandt, Isak Mazanti Cold, Janus C Jakobsen, Jasmin Dam Lukoschewitz, Ala…
BACKGROUND: Intermediate-high risk pulmonary embolism (PE) represents a clinically challenging subgroup of acute PE, characterized by right ventricular dysfunction and increased risk of hemodynamic deterioration despite treatment with anticoagulation therapy. Although systemic thrombolysis may provide more rapid reperfusion, its use is limited by an increased risk of major bleeding. Catheter-based treatment strategies have emerged as potential alternatives, but their comparative efficacy and safety remain uncertain. OBJECTIVE: To assess the benefits and harms of catheter-based treatment strategies compared with contemporary control regimens, including standard anticoagulation with or without systemic thrombolysis, in patients with intermediate-high risk PE. METHODS: This protocol outlines a systematic review with Bayesian pairwise meta-analysis and network meta-analysis of randomized clinical trials evaluating catheter-based therapies for hospitalized patients with intermediate-high risk PE. Eligible interventions include catheter-directed thrombolysis, ultrasound-assisted thrombolysis, and catheter-based embolectomy. Comparators may include standard anticoagulation alone or in combination with systemic thrombolysis or other active control regimens reflecting standard of care. Searches will be conducted in relevant databases, supplemented by trial registries. Two reviewers will independently screen studies, extract data, and assess risk of bias using the Cochrane Risk of Bias 2 tool. Bayesian pairwise meta-analyses and network meta-analysis will be performed using weakly informative priors to synthesize direct and indirect evidence across interventions. Results will be reported as posterior effect estimates with 95% credible intervals. The primary outcome will be all-cause mortality. Secondary and exploratory outcomes include major bleeding as defined according to the criteria of the International Society on Thrombosis and Haemostasis within 7 days, hospital length of stay, and change in RV/LV ratio within 48 h. GRADE assessments will be performed where applicable. DISCUSSION: This review will synthesize direct and indirect randomized evidence on catheter-based treatment strategies for intermediate-high risk PE. The findings may help clarify the role of these interventions in contemporary management, inform future guideline recommendations, and identify persistent evidence gaps requiring further large-scale randomized trials.
Magnetic resonance tissue phase mapping (TPM) has been used to encode voxel-wise myocardial motion velocity in various cardiac diseases. This study aimed to quantify alterations in myocardial motion velocity in the functional ventricle of Fontan patients using TPM and to investigate the relationship between myocardial motion and cardiac function. We prospectively enrolled 28 Fontan patients and 42 age- and sex-matched normal controls. Myocardial motion velocities were assessed using TPM in the longitudinal (Vz), radial (Vr), and circumferential (Vphi) directions. We evaluated the peak velocities, time-to-peak (TTPz, TTPr), and dyssynchrony index (DIz, DIr). Circumferential motion abnormalities were assessed using peak-to-peak (PTP) values, Vphi inconsistency, and twist. Compared to controls, Fontan patients demonstrated significantly reduced peak Vz and Vr during both systole and diastole (all p < 0.001), as well as prolonged systolic TTPz (p = 0.002) and TTPr (p < 0.001). Diastolic DIz was increased (p < 0.001), whereas systolic DIr was decreased (p = 0.04). In multivariable regression analysis, ejection fraction of Fontan patients positively correlated with peak systolic Vr and negatively correlated with mid Vphi PTP (R2 = 0.639). The cardiac output was positively associated with peak systolic Vr and diastolic DIz (R2 = 0.578). TPM may provide quantitative MR biomarkers for regional myocardial motion abnormalities, including impaired myocardial motion velocities, delayed contraction timing, and altered motion synchronization, in Fontan patients. These findings suggest global ventricular dysfunction and may provide insight into the mechanisms underlying reduced ejection fraction and cardiac output in the functional ventricle physiology in Fontan patients.
Robot-assisted nephrectomy with renal vein or inferior vena cava (IVC) tumor thrombectomy is a technically demanding procedure used in selected patients with renal cell carcinoma (RCC) and venous tumor thrombus. The research map of this field has not been clearly described, and recent technical, comparative, and systemic-therapy developments make an updated focused analysis timely. We searched the Science Citation Index Expanded of the Web of Science Core Collection from database inception to 4 May 2026. English articles and reviews about robot-assisted nephrectomy or radical nephrectomy with renal vein or IVC tumor thrombectomy for RCC were included. Titles, abstracts, keywords, authors, affiliations, journals, citations, and cited references were extracted. Python 3.11 was used for descriptive analysis, keyword analysis, co-citation analysis, visualization, and clinical theme coding. We included 51 SCIE publications from 2011 to 2026, including 40 articles and 11 reviews. The papers received 1229 citations, with a mean of 24.10 citations per paper and a median of 12. Annual publications peaked in 2020 with 7 papers. The United States published 24 papers, China published 21, and Italy published 8 when all author affiliations were counted. The Chinese People's Liberation Army General Hospital published 14 papers, and the University of Southern California published 7. Ma X, Zhang X, and Wang BJ were the most productive authors. European Urology, Journal of Urology, and Journal of Endourology were the leading journals. After term cleaning, the most frequent keywords were renal cell carcinoma, tumor thrombus, robotic surgery, experience, inferior vena cava, and thrombectomy. This field has moved from early technical exploration to early evidence building. Future work should use multicenter prospective designs and should study high-level IVC thrombus, long-term oncologic outcomes, perioperative safety after neoadjuvant therapy, robotic training, and multidisciplinary care pathways.
Journal of robotic surgeryOzan Oğuz, Mehmet Akif Erdöl, Çağrı Yayla, Ahmet Göktuğ Ertem
This study aimed to analyze global research trends in robotic applications in cardiovascular medicine. Robotic technologies have been increasingly integrated into cardiovascular medicine, providing enhanced precision, improved visualization, and reduced operator-related risks. Despite growing interest in this field, comprehensive evaluations of global research trends remain limited. In this bibliometric study, publications indexed in the Web of Science Core Collection between 2019 and 2025 were systematically analyzed, and 261 original articles meeting predefined criteria were included. Bibliometric analyses were carried out using VOSviewer and Biblioshiny to evaluate publication trends, citation dynamics, leading sources, and collaboration patterns. Scientific output showed a steady upward trajectory over time, with a more pronounced increase after 2021 and reaching its peak in 2025. The highest average citation rate was observed in 2024. Journal of Robotic Surgery and Journal of Cardiac Surgery were identified as the most productive journals. The United States was the leading contributor in terms of both publication volume and citation impact and also played a central role in international collaborations. Keyword analysis showed that research activity was primarily focused on robotic surgery, minimally invasive surgery, coronary artery bypass grafting, and percutaneous coronary intervention. Overall, robotic applications in cardiovascular medicine represent a rapidly expanding research area characterized by increasing scientific output and growing international collaboration. The concentration of publications in specific journals and the prominence of leading countries suggest a developing and increasingly structured research landscape.
Journal of robotic surgeryAlessandro Dario Mazzotta, Giulia Gamberini, Giuseppe Giuliani, Selene Tognarelli, Niccolò Petrucciani, Andrea Pichetto, Giancarlo D'Ambrosio, Gianluca Mennini…
Robotic-assisted surgery (RAS) offers enhanced visualization, precision, and dexterity, but the absence of haptic feedback poses challenges during delicate dissection tasks such as vascular dissection. Simulation-based training has been proposed as a strategy to mitigate these limitations, yet evidence of translational effectiveness into in vivo surgical performance remains limited. We conducted a prospective, controlled feasibility study to evaluate the impact of a structured, simulator-based training program on robotic vascular dissection. Twelve novice surgeons were included in a prospective, controlled, non-randomized feasibility study. Six underwent structured dry-lab training with a sensorized high-fidelity vascular simulator, while six served as untrained controls, no baseline robotic performance assessment was performed before the intervention. Surgical performance was assessed during robotic vascular dissections in anesthetized porcine models using the da Vinci Xi platform. Performance was assessed by a single expert evaluator who was blinded to group allocation using the Global Evaluative Assessment of Robotic Skills (GEARS) and qualitative parameters including tissue handling, vessel exposure, and stapler placement. The trained group achieved significantly higher overall GEARS scores than the control group (25.7 ± 2.9 vs. 21.2 ± 2.4; p = 0.026). Depth perception was significantly improved in trained participants (4.33 ± 0.81 vs. 2.83 ± 0.75; p = 0.028). Trends toward enhanced bimanual dexterity and efficiency were observed but did not reach statistical significance. Qualitative analysis highlighted safer tissue handling, more consistent vessel exposure, and improved stapler positioning in the trained group compared with the controlgroup. Structured training with a sensorized high-fidelity vascular simulator was associated with better performance in selected components of robotic vascular dissection performance in an in vivo porcine model. These preliminary findings support the feasibility of this translational training pathway but require confirmation in larger randomized studies.
Journal of robotic surgeryWagner Rios-Garcia, Sofia Fontana, Abigail D Via-Y-Rada-Torres, Mariel Andrea Portal Cordova, Carmen Del Rosario Rios Bermudo, MariaFe-Martinez-Acuna, Ekaterin…
Robot-assisted endovascular technologies have emerged as a promising innovation in neurointerventional surgery, particularly for mechanical thrombectomy in acute ischemic stroke. This scoping review aims to map and synthesize the current evidence on robot-assisted mechanical thrombectomy, focusing on technical feasibility, preliminary performance outcomes, and existing limitations.A scoping review was conducted following the Joanna Briggs Institute methodology and reported according to PRISMA-ScR guidelines. Searches were performed in PubMed, Embase, Scopus, and Web of Science without date or language restrictions. Studies evaluating robotic assistance in mechanical thrombectomy across preclinical and clinical settings were included.Fourteen studies met the inclusion criteria, including 13 preclinical studies and only 1 clinical study. Robotic systems demonstrated promising technical success and recanalization rates reported in controlled settings, although direct comparisons with conventional manual techniques remain limited. Additional benefits included reduced procedure times, improved navigation precision, decreased operator fatigue, and significant reductions in radiation exposure. However, most evidence remains experimental, with limited clinical validation.Robot-assisted mechanical thrombectomy appears technically feasible in preclinical and early clinical settings, with potential advantages for procedural safety and access to stroke care. However, the current evidence remains limited and predominantly preclinical, and robust clinical trials are required before widespread clinical adoption. These findings should therefore be interpreted as hypothesis-generating.
Robotic pancreaticoduodenectomy with venous resection and reconstruction (RPD-VR) is one of the most technically challenging procedures in hepatopancreaticobiliary surgery. While acceptance of robotic pancreaticoduodenectomy is growing, the safety, feasibility, and oncologic adequacy of combined portal vein (PV) and/or superior mesenteric vein (SMV) resection remain incompletely defined. A systematic review was conducted following PRISMA guidelines. PubMed/MEDLINE, Scopus and the Cochrane Library were searched from inception of the databases to June 2026. The Newcastle-Ottawa Scale was used to evaluate methodological quality. Twelve retrospective studies involving 202 patients undergoing RPD-VR were included. Indications were predominantly pancreatic ductal adenocarcinoma, but other periampullary and pancreatic malignancies were included. The venous reconstruction techniques were primary venorrhaphy, patch venoplasty, end-to-end anastomosis and interposition graft reconstruction. The conversion rates ranged from 0% to 36.4%. Major postoperative complications (Clavien-Dindo ≥ III) were 0% to 40%, postoperative pancreatic fistula 0% to 20% and mortality 0% to 14.3%. R0 resection rates ranged from 69.2 to 100% and lymph node harvest from 14.3 ± 6.7 to 60.0 ± 13.9 nodes. Limited long-term data suggested vascular patency rates exceeding 90% in the studies reporting follow-up imaging. Overall survival, disease-free survival and recurrence outcomes were, however, reported to a limited extent and heterogeneously across studies. Existing data suggest RPD-VR is technically feasible and may be associated with acceptable perioperative, vascular, and oncologic outcomes in carefully selected patients treated at experienced centers. However, the currently available evidence is limited by the retrospective study designs, small sample sizes, and lack of long-term oncologic follow-up. Standardised reporting and solid long-term outcome assessment in prospective multicenter studies are needed to better define the role of RPD-VR in contemporary pancreatic surgery. Prospero ID: CRD420261417822.
NeurologyPhilip Heesen, Olga Ciobanu-Caraus, Karam Azem, Sharon Orbach-Zinger, Nicolin Hainc, Markus Möhlenbruch, Martin Bendszus
BACKGROUND AND OBJECTIVES: Endovascular thrombectomy (EVT) improves outcome in acute ischemic stroke (AIS) due to large vessel occlusion, yet the optimal anesthetic strategy remains controversial. Previous meta-analyses using frequentist methods reported no significant differences between general anesthesia (GA) and non-GA techniques; however, a recently published trial reported a high posterior probability of functional benefit with GA. We aimed to update the existing systematic review and to re-examine the cumulative randomized evidence using Bayesian statistical methods. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to January 3, 2026, for randomized controlled trials (RCTs) comparing GA with non-GA strategies during EVT in adults with AIS. Primary outcomes were functional independence (modified Rankin Scale [mRS] 0-2) at 90 days, successful reperfusion (thrombolysis in cerebral ischemia 2b-3), and 90-day mortality. Bayesian random-effects meta-analyses with weakly informative priors were performed. Results are reported as odds ratio (OR) or mean difference (MD) with 95% credible intervals (CrIs). A posterior probability of superiority exceeding 80% was considered substantial evidence of benefit. Meta-regression and sensitivity analyses were conducted. RESULTS: Ten RCTs (n = 1,601; mean age 70.0 years; 46.6% female) were included. For functional independence, GA was associated with a 94.2% posterior probability of superiority (OR 1.24, 95% CrI 0.94-1.66). GA was associated with higher successful reperfusion rates (OR 1.73, 95% CrI 1.23-2.43; P (superiority) > 99%). No substantial differences were observed for 90-day mortality (OR 0.92, 95% CrI 0.67-1.27; P [superiority] 69%), excellent functional outcome (mRS 0-1; OR 1.06, 95% CrI 0.80-1.41; P [superiority] 67%), or symptomatic intracranial hemorrhage (OR 0.93, 95% CrI 0.56-1.52; P [superiority] 62%). GA was associated with increased intraoperative hypotension (OR 4.28, 95% CrI 2.35-7.86; P [superiority] 0.01%) and increased pneumonia risk (OR 1.60, 95% CrI 0.95-2.81; P [superiority] 3%). DISCUSSION: This meta-analysis using a Bayesian approach provides evidence that GA during EVT for AIS is associated with improved functional outcomes, challenging previous conclusions of equivalence. These findings should be interpreted considering open-label designs and heterogeneous non-GA comparators. They suggest that GA may be preferred but confirmatory evidence is needed.
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) reduces thrombotic risk in acute coronary syndrome (ACS) but may increase bleeding, especially in chronic kidney disease (CKD). This study evaluated the impact of different DAPT durations on cardiovascular and bleeding outcomes in ACS patients with and without CKD. Using the Taiwan National Health Insurance Research Database (2001-2018), patients ≥20 years with ACS who underwent PCI and received clopidogrel plus aspirin for ≥1 month were analyzed. Primary outcomes were cardiovascular events and bleeding events. Subgroup analysis was conducted by CKD status, which was defined using claims-based International Classification of Diseases, Ninth and Tenth Revision (ICD-9/ICD-10) diagnostic codes. Among 4,800 patients with ACS identified (median age: 62 years; 77% male), there were no significant differences in cardiovascular events across DAPT duration groups. No associations between DAPT duration and cardiovascular outcomes were identified in patients with or without CKD. However, DAPT duration ≥7 months was associated with a higher incidence of other major bleeding in patients with CKD (adjusted odds ratio [aOR] = 29.7, 95% confidence interval [CI]: 1.80-491.05, p = 0.018). In patients undergoing PCI for ACS, no clear association was observed between longer DAPT duration and reduced cardiovascular events. In prespecified subgroup analyses, prolonged DAPT was associated with a higher incidence of bleeding events among patients with claims-defined CKD; however, this finding should be interpreted as exploratory given the observational design and low event rates. These results highlight the importance of individualized decision-making regarding DAPT duration, particularly in patients with increased bleeding susceptibility.
Renal failureRenzhong Ding, Yan Yang, Shiyi Xiang, Wenjun Wu, Ye Yuan, Tingting Li, Yi Song
BACKGROUND: Compartment syndrome (CS) is a severe complication after revascularisation for lower extremity arterial occlusive disease (LEAOD), but its association with systemic complications remains unclear. METHODS: This single-center retrospective cohort study included 153 patients with LEAOD who underwent revascularisation between January 2020 and December 2025. Postoperative CS was the primary exposure, and patients were classified into CS and non-CS groups. Clinical outcomes, including final amputation and acute kidney injury (AKI), were compared using multivariable logistic regression. RESULTS: CS occurred in 29 patients (19.0%). Patients with CS showed more severe ischemia and metabolic disturbance. The CS group had a higher crude final amputation rate than the non-CS group, but CS was not independently associated with final amputation after adjustment (OR 1.56; 95% CI 0.27-8.97; p = 0.618). AKI occurred more frequently in the CS group (69.0 vs. 12.1%, p < 0.001), and CS remained strongly associated with AKI after adjustment (OR 20.94; 95% CI 5.62-78.10; p < 0.001), with consistent findings in sensitivity analyses. Among patients with both CS and AKI, CS preceded AKI in all cases. CONCLUSIONS: Postoperative CS may represent a clinically recognizable marker of severe ischemia-reperfusion injury and systemic injury burden associated with AKI, rather than a definitive causal determinant of AKI or limb loss.
Annals of medicineYu-Hern Tan, Huai-Hsuan Tung, Shih-Chieh Chien, Chen-Yen Chien
OBJECTIVE: The optimal surgical strategy for coronary artery bypass grafting (CABG) in patients with heart failure with reduced ejection fraction (HFrEF) is uncertain. This study aimed to compare postoperative outcomes between off-pump/on-pump CABG (OPCAB vs ONCAB) in patients with HFrEF. METHODS: This retrospective cohort study included adults with HFrEF undergoing CABG from the National Health Insurance Research Database, 2001-2021. Primary outcome was all-cause mortality. Secondary outcomes were postoperative complications. Logistic regression was used to determine associations by estimating odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Data of 855 patients were analyzed (OPCAB n = 252; ONCAB n = 603). After multivariable adjustment, OPCAB was not significantly associated with all-cause mortality within 30 days compared with ONCAB. OPCAB was also not significantly associated with 31-day to one-year all-cause mortality, overall cardiovascular events, IS/TIA, AKI, infection other than pneumonia, sepsis, or pneumonia compared with ONCAB. In stratified analyses, OPCAB was associated with higher odds of sepsis among patients with less extent of coronary artery disease (<3-vessel disease) (aOR = 3.16, 95% CI: 1.24-8.07) and among those with cerebrovascular disease (aOR = 3.40, 95% CI: 1.13-10.21). CONCLUSIONS: In patients with HFrEF undergoing CABG, surgical approach (OPCAB vs ONCAB) was not independently associated with 30-day mortality, 1-year mortality, or major postoperative complications after adjustment. Further prospective studies with detailed operative and patient-level data are still warranted.
NeurologyNefeli Eirini Valyraki, Richard Leigh, Adrien Ter Schiphorst, Adrián Valls-Carbó, Frédérique Charbonneau, Caroline Arquizan, Denis Sablot, Anne Wacongne, Vince…
BACKGROUND AND OBJECTIVES: In acute ischemic stroke with large vessel occlusion (AIS-LVO), interhospital transfer for endovascular therapy (EVT) provides an ideal therapeutic window during which neuroprotective strategies could be evaluated, allowing sufficient exposure before reperfusion. We aimed to determine whether blood-brain barrier (BBB) disruption assessed before interhospital transfer for EVT is associated with 24-hour hemorrhagic transformation (HT) and 3-month functional outcome. METHODS: In this multicenter retrospective study, we included patients with anterior circulation AIS-LVO transferred from 4 French primary stroke centers (PSCs) to comprehensive stroke centers for EVT assessment, with baseline MR perfusion imaging performed at the PSC before transfer. BBB disruption was quantified as the percentage signal change due to gadolinium leakage on perfusion source images. Mean permeability derangement (MPD) was defined as the average of all voxels within the ischemic core exhibiting permeability values greater than a prespecified threshold. The primary outcome was any intraparenchymal HT on 24-hour follow-up imaging. The association between MPD and HT was studied in multivariable mixed binary logistic regression analyses. RESULTS: A total of 289 patients were included: the median age was 74 years (interquartile range 63-81), 49% were female, the median NIHSS score was 13 (7-19), the median last-seen-well-to-PSC imaging time was 2.5 hours (1.7-4.7), and the median core volume was 17 mL (0-40). Intravenous thrombolysis was administered before transfer in 71% of patients, and EVT was eventually performed in 71%. The median time from PSC imaging to comprehensive stroke center arrival was 3.3 hours (2.6-3.8). Any HT at 24 hours occurred in 129 patients (45%). In multivariable analysis, MPD ≥3% was independently associated with any HT (OR 6.58; 95% CI 2.84-15.22; p < 0.001) after adjustment for core volume, glucose level, occlusion site, onset-to-imaging time, and whether EVT was performed. Similar associations were observed for parenchymal hematoma (adjusted OR 3.31; 95% CI 1.48-7.41; p = 0.004) and poor 3-month functional outcome (modified Rankin Scale score 3-6, adjusted OR 3.13; 95% CI 1.38-7.09; p = 0.006). DISCUSSION: BBB disruption on pretransfer perfusion MRI is associated with 24-hour HT and poor 3-month functional outcome in patients with AIS-LVO. These findings highlight its potential value for early risk stratification and justify prospective evaluation of BBB-targeted strategies during interhospital transfer for EVT.
Journal of infection and chemotherapy : official journal of the Japan Society of ChemotherapyMisato Kai, Kodai Kawamura, Misako Murakami, Yukie Kumanda, Kenta Yoshida, Hiroyuki Muranaka
INTRODUCTION: Peripheral line-associated bloodstream infection (PLABSI) is a critical healthcare-associated infection. This study aimed to comprehensively clarify PLABSI risk factors and evaluate the independent impact of amino acid preparations. METHODS: A retrospective observational study (April 2015-December 2022) included 5553 patients with peripheral intravenous catheters. To adjust for confounding, propensity score matching was performed based on amino acid administration. A doubly robust multivariate logistic regression analysis was conducted on 4664 matched cases (88 with PLABSI). RESULTS: Pre-matching, Staphylococcus aureus (25.0%) was the most frequent pathogen among 108 PLABSI cases. In the matched cohort, amino acid administration (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.35-3.65), hospital transfer (OR, 1.44; 95% CI, 1.11-1.87), older age (OR, 1.02; 95% CI, 1.00-1.04), and intravenous injection frequency (per 10-time increase: OR, 1.03; 95% CI, 1.02-1.05) were identified as independent risk factors. DISCUSSION: Frequent catheter manipulation and the nutrient-rich, endothelial-damaging environment caused by amino acid preparations strongly elevate the risk of PLABSI. CONCLUSIONS: Strict aseptic handling of catheter hubs and continuous daily site monitoring are essential.
International emergency nursingBo Chen, Yanyan Song, Jianhua Jia
BACKGROUND: Difficult intravenous access (DIVA) affects an estimated 8%-39% of hospitalized adults and is associated with treatment delays, increased pain, and elevated healthcare costs. Multiple interventions have been developed to address this challenge, yet, to our knowledge, no network meta-analysis (NMA) has simultaneously compared the full range of available interventions in adult patients. METHODS: A systematic search of PubMed, Embase, the Cochrane Library, and Web of Science was conducted from inception through February 1, 2026, for randomized controlled trials comparing any DIVA intervention with standard practice or another active intervention in adults. Primary outcomes were first-attempt and overall success rates. Secondary outcomes included number of attempts, procedure time, pain score, and patient satisfaction. Random-effects NMA was performed using the netmeta package in R. Treatment rankings were summarized using P-scores. Subgroup analyses, meta-regression, sensitivity analyses, and publication bias assessments were conducted. RESULTS: Twenty-four RCTs (8014 participants) evaluating 11 active interventions were included. For first-attempt success, ultrasound guidance (OR = 5.58; 95% CI: 2.74-11.36) and local warming (OR = 5.72; 95% CI: 1.71-19.19) were significantly superior to standard practice. For overall success, only ultrasound guidance achieved significance (OR = 4.12; 95% CI: 2.07-8.19). Local warming uniquely reduced procedure time and pain, while near-infrared devices reduced cannulation attempts and improved patient satisfaction. Long catheters were associated with increased pain and longer procedure times. Meta-regression identified publication year and DIVA status as significant effect modifiers. No publication bias was detected. CONCLUSIONS: Ultrasound-guided cannulation showed the most consistent benefit for first-attempt and overall success and rested on the strongest evidence base; local warming showed a comparable but less certain effect from limited data. A stratified, context-sensitive approach integrating patient acuity, resource availability, and intervention-specific profiles appears reasonable, although the sparse network and the transitivity assumption temper the certainty of these conclusions.
The International journal of artificial organsMilad Rostami, Majid Abdolalinezhad, Mohsen Hashemi, Mohammad Amin Rahimi
Arteriovenous fistula (AVF) failure in hemodialysis patients is strongly influenced by local hemodynamic factors such as elevated wall shear stress, flow separation, and vortex formation. In this study, computational fluid dynamics (CFD) simulations are performed to investigate the influence of anastomosis angle and blood rheology on AVF hemodynamics. Three non-Newtonian blood models (Carreau, power-law, and Casson) are first evaluated at 45°, 90°, and 135° anastomosis angles and validated against available experimental data. Based on shear stress prediction accuracy, the Carreau model is demonstrated as the best agreement and is selected for further simulations. Subsequently, AVFs with 45°, 90°, 110°, 120°, 135°, 145°, and 160° anastomosis angles are analyzed under maximum, medium, and minimum pulsatile flow conditions. Hemodynamic parameters including velocity patterns, wall shear stress distribution, vortex formation, and pressure drop between the proximal artery and vein are evaluated. Results indicate that increasing the anastomosis angle significantly reduces maximum wall shear stress, high-shear regions, vortex intensity, and pressure drop. Compared with the 45° configuration, the 160° angle reduced maximum shear stress by ~78% under peak flow conditions. Overall, obtuse anastomosis angles demonstrated improved hemodynamic performance, suggesting that larger angles may reduce thrombosis risk and cardiovascular burden in hemodialysis patients. Considering both hemodynamic performance and surgical feasibility, the 120° configuration is proposed as a clinically practical and effective option.
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke AssociationYuxia Gao, Gege Yu, Yongshi Teng, Hongli Pang, Peng Yan, Yuanhui Li, Chunyun Ruan
OBJECTIVE: To investigate whether fluid-attenuated inversion recovery vascular hyperintensity/diffusion-weighted imaging (FVH/DWI) mismatch is associated with post-procedural recanalization in patients with acute anterior-circulation large-vessel occlusion (LVO) treated with mechanical thrombectomy. METHODS: This retrospective cohort study enrolled 120 consecutive patients with acute anterior-circulation LVO who underwent mechanical thrombectomy at our hospital from March 2021 to June 2024. Clinical characteristics, imaging variables, and treatment-workflow data were collected. Based on angiographic reperfusion, patients were divided into a good recanalization group (modified Thrombolysis in Cerebral Infarction [mTICI] grade 2b-3; n = 82) and a poor recanalization group (mTICI grade 0-2a; n = 38). According to 90-day functional outcome assessed by the modified Rankin Scale (mRS), patients were further classified as having a favorable outcome (mRS 0-2; n = 74) or an unfavorable outcome (mRS 3-6; n = 46). Between-group differences were examined, and multivariable logistic regression was used to identify independent predictors of poor recanalization and unfavorable outcome. RESULTS: The mean age in the good recanalization group was 66.81±9.10 years, which was significantly lower than that in the poor recanalization group (P < 0.05). FVH/DWI mismatch was more common in the good recanalization group (76.83%) than in the poor recanalization group (P < 0.05). Compared with patients with favorable outcomes, those with unfavorable outcomes were older (76.61±7.98 years), had higher admission National Institutes of Health Stroke Scale (NIHSS) scores (17.20±3.12), and exhibited a higher rate of poor recanalization (52.17%) (all P < 0.05), while the FVH/DWI mismatch rate was lower (28.26%, P < 0.05). Multivariable analysis showed that age (per 1-year increase: OR=1.089, 95%CI 1.032-1.149) and FVH/DWI mismatch (OR=0.523, 95%CI 0.312-0.876) were independent factors associated with poor recanalization (both P < 0.05). Age (per 1-year increase: OR=1.102, 95%CI 1.045-1.162), admission NIHSS score (per 1-point increase: OR=1.212, 95%CI 1.089-1.348), successful recanalization (OR=0.467, 95%CI 0.267-0.817), and FVH/DWI mismatch (OR=0.432, 95%CI 0.245-0.761) were independently associated with an unfavorable 90-day outcome (all P < 0.05). CONCLUSION: FVH/DWI mismatch is independently associated with both angiographic recanalization after mechanical thrombectomy and 90-day neurological outcomes in acute anterior-circulation LVO, and may serve as an imaging biomarker for predicting reperfusion success and clinical prognosis.
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke AssociationMostafa Hossam El Din Moawad, Dina Essam Abo-Elnour, Yasmine M Osman, Mohamed Hendawy, Muhammad Daoud Tariq, Ahmed Hassan A Rady, Anfel Rahai, Ahmed Abdullah A…
Background We conducted a comprehensive systematic review and meta-analysis of RCTs and observational studies comparing the effectiveness and safety of tirofiban as an adjunct to endovascular thrombectomy (EVT) in patients with large vessel occlusion (LVO) ischemic stroke. Methods We performed electronic searches across Medline through PubMed, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from inception to October 2024. Statistical analysis was conducted using RevMan software (version 5.4.1). Odds ratios (OR) were used for dichotomous outcomes and mean differences (MD) for continuous outcomes under 95% confidence intervals (CI). Results A total of 30 studies (28 cohort studies and 2 RCTs) were included in the systematic review. Of these, 28 studies comprising 7,427 cases contributed data for the analysis of symptomatic intracranial hemorrhage (sICH). There was no significant difference between tirofiban and control groups even after doing subgroup analysis based on the route of tirofiban administration (OR 0.93, 95%CI = 0.78 to 1.11). The pooled data revealed no significant difference between both groups (OR 0.92, 95%CI = 0.62 to 1.35) regarding asymptomatic intracranial hemorrhage (AsICH). On doing subgroup analysis based on the route of tirofiban administration, only the tirofiban intravenous (IV)+ intraarterial (IA) group demonstrated a lower probability of having AsICH compared to the control group (OR 0.68, 95%CI= 0.49 to 0.94). Conclusion Using tirofiban as an adjunct to EVT in patients with LVO stroke is demonstrated to be safe and effective, especially when using IV+IA dosing of tirofiban, which reduced the risk of AsICH, 3-month mortality and increased the incidence of good functional outcomes presented by modified Rankin score.
Journal of the neurological sciencesSatoru Fujiwara, Joachim Fladt, Faysal Benali, Fouzi Bala, Nishita Singh, Raul Nogueira, Ryan A McTaggart, Andrew M Demchuk, Alexandre Y Poppe, Jeremy L Rempel…
BACKGROUND: Brain frailty, characterized by atrophy and/or chronic vascular lesions, is associated with worse outcomes after endovascular thrombectomy (EVT), but whether its impact differs by sex remains unclear. Therefore, we investigated sex differences in the association between imaging brain frailty markers and 90-day outcome after EVT. METHODS: We conducted a post-hoc analysis of the ESCAPE-NA1 randomized trial, which evaluated intravenous nerinetide in patients undergoing EVT for acute ischemic stroke due to large vessel occlusion. Brain frailty markers-including global cortical atrophy (GCA) scale, subcortical atrophy, Fazekas score, lacunes, and old infarctions-were assessed on baseline non-contrast CT (NCCT), and among those with follow-up MRI, perivascular spaces and microbleeds were also evaluated. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. Multivariable logistic regression was performed, stratified by sex. RESULTS: Among 1102 patients with NCCT (568 with MRI), no significant sex interactions were identified between brain frailty markers and 90-day outcomes. However, exploratory sex-stratified analyses showed that several brain frailty markers were associated with a lower likelihood of achieving functional independence (mRS 0-2) at 90 days in women, whereas no clear associations were observed in men. For example, cortical atrophy was associated with a lower likelihood of achieving an mRS score of 0-2 in women but not in men (adjusted OR for GCA 1 vs. 0: 0.54, 95% CI 0.32-0.91 in women; 0.76, 95% CI 0.45-1.28 in men). Similar patterns were observed for subcortical atrophy. CONCLUSIONS: Although sex-stratified analyses suggested nominal differences, no statistically significant sex-by-brain frailty interactions were observed. Brain frailty should be considered a prognostic marker irrespective of sex, and these exploratory findings warrant further investigation in adequately powered studies.
The Journal of emergency medicineEduardo Saadi Neto, Kavita John-Pierce, Ivan Khapov, Graciela Maldonado, Larissa T Shiue, Tobias Kummer
BACKGROUND: Peripheral intravenous (PIV) cannulation is the most common in-hospital procedure. In patients with difficult access, standard upper-extremity veins may be unsuitable, and alternative access sites need to be sought. The great saphenous vein (GSV) at the level of the distal medial thigh has been proposed as a potential alternative site for rescue access. Yet, the feasibility and reliability of targeting this site remain underexplored. OBJECTIVE: To assess the feasibility of ultrasound visualization and measurement of the GSV in the distal medial thigh as a reliable target for rescue PIV access. METHODS: This prospective, cross-sectional study enrolled 166 pediatric and adult emergency department participants at a tertiary academic medical center. The GSV was evaluated bilaterally using high-frequency linear ultrasound. Depth and diameter measurements were recorded at proximal, medial, and distal sites. Detection rates and vessel characteristics were compared across age, sex, comorbidity status, and history of difficult IV access. RESULTS: The GSV was visualized in ≥95% of participants across all thigh regions. Median depth was greatest proximally (11.7 mm) and shortest distally (9.9 mm), while median diameter was largest proximally (3.0 mm) and smallest distally (2.8 mm). Visualization was consistent across age groups, sex, and history of difficult IV access. CONCLUSION: The distal medial thigh GSV can be reliably visualized using ultrasound across pediatric and adult populations, including those with prior difficult intravenous access. Its consistent visualization and favorable anatomical characteristics support its potential as a rescue site for ultrasound-guided peripheral venous access in the emergency department.
Replantation is generally recommended for thumb amputations, multiple-digit amputations, and single-digit amputations distal to the flexor digitorum superficialis insertion, because it offers superior functional outcomes compared with revision amputation. Replantation of distal forearm amputations is also considered beneficial, as it results in better postoperative function than prostheses and offers a high likelihood of successful return to work. Elective amputation with bionic reconstruction may be a viable alternative when hand function remains poor, particularly when combined with diminished sensibility following replantation of major upper limb amputations.