ABSTRACT
Introduction: The 2018 GIRFT report and 2019 NICE renal and ureteric stone guidelines recommended regional, fixed-site lithotripsy units to provide elective and emergency extracorporeal shockwave lithotripsy (ESWL) for urinary tract calculus <20 mm. In our region, Trusts were serviced by a mobile lithotripter, which was unable to provide adequate emergency treatment, as such a new fixedsite regional service was developed. Methods: The ongoing pandemic resulted in many challenges in the service development, including a reduction in urological operating by 25% during the COVID-19 pandemic, with additional loss of capacity as only patients ASA 2 or below was able to be treated in peripheral centres. A new pathway was introduced aiming to reduce admissions to surgical wards, instead moving directly to treatment and pain relief at home, in line with the 2019 NHS long-term plan. After 6 weeks of treating local patients, the service was opened to Trusts across the region to enable equal access for all patients' for both emergency and elective ESWL. Results: In the first 6 months, 144 local stones were treated with ESWL (38 ureteric and 106 renal), of which 118 (81.9%) were successfully cleared, with the NICE guidelines quoting success rates between 72.4% and 83.8%. Across that period, this would have required 40 additional operating sessions (160 operative hours) to treat these stones ureteroscopically. With ureteroscopy £2347 more expensive than ESWL to get stone clearance (Constanti et al. BJUI 2020;125: 457-466), the treatment cost saving in the first 6 months is £281,666. In addition, 53 stones were treated as an emergency from the region, with a stone clearance rate of 81% and 53% treated within 48 hours. Conclusion: The new ESWL service has resulted in regional stone treatments with success rates in line with published data, in addition to providing economic and operative capacity benefits during a global pandemic.
ABSTRACT
Background: Moderate to severe coronary calcification results in suboptimal results with increased risk of procedural and future adverse events. Newer high-pressure balloons and atherectomy devices have not shown any superiority over the routine high pressure balloon dilatation. Intravascular lithotripsy (IVL) is the latest technique for treatment of moderate to severe calcific coronary artery disease. IVL converts the electrical energy into mechanical energy with cracking of calcium in both adventitia and intima. DISRUPT CAD III study has shown the short-term outcomes of Intravascular lithotripsy (IVL). However, the experience is limited with this new technique especially for mid-term and long-term outcomes. The Coronary IVL System is a proprietary balloon catheter system designed to enhance stent outcomes by enabling delivery of the calcium disrupting capability of lithotripsy prior to balloon dilatation at low pressures. The Coronary IVL System consists of an IVL Balloon Catheter with two integrated pairs of lithotripsy emitters, a Lithotripsy Generator, and Connector Cable. Methods: Our study is a single centre, observational study done at Apollo hospitals, Visakhapatnam, India, to evaluate the safety, mid-term and long-term effectiveness of Intravascular Lithotripsy (IVL). Subjects who are more than 18 years of age with moderate to severe calcification which require Percutaneous Coronary Intervention (PCI) and are willing to participate in the study are included. Baseline parameters were assessed. Procedural success was defined as no residual stenosis of <30% after stenting. Procedural and postprocedural complications were noted. Usage of adjuvant Atherectomy balloons or devices is noted. Both clinical and angiographic follow up was done. Clinical follow up parameters assessed were MACE which includes cardiac death, MI, target vessel revascularisation (TVR), Target lesion revascularisation (TVR). Any admissions for heart failure or change in functional class are also noted. On follow up, Angiographic assessment was done for In-stent restenosis (>50%) or In segment restenosis (>50%) or any fresh coronary lesions which mandates revascularisation. Results: Out of 35 subjects, only 2 were females. Mean age was 69.9 ± 2.8 years. 15 (42.8%) subjects were Diabetics and 17 (48.5%) were Hypertensives. 2 subjects underwent previous CABG surgery. 10 subjects had left ventricular dysfunction. 2 subjects had renal dysfunction. 29 (82.8%) subjects presented with Acute MI out of which 22 were presented with NSTEMI. 1 subject underwent the procedure during Primary PTCA successfully. Total number of stents implanted were4 1 with a mean stent implantation was 1.17. Rotablation system (Boston Scientific) was used in 2 subjects prior to IVL where the intimal calcium was extensive. OPN NC balloon (Translumina Therapeutics) was used in 6 subjects. Mean stent length was 35.9 ± 9.8 mm. Mean number of pulses delivered was 7.3 ± 1.4. All the subjects had good procedural outcomes with no residual stenosis. Only 1 subject had coronary dissection after IVL which could be stented successfully. 1 subject had an aneurysm in the proximal LAD which could be stented. Subjects were followed up clinically for a mean of 6.23 months. No MACEs were noted. None of them had any Heart failure admissions. 1 subject died of noncardiac cause (respiratory failure due to COVID-19 pneumonia). 7 patients followed up angiographically after a mean follow up of 9.4 months. No significant ISR was noted in any of them. 1 subject underwent repeat target vessel revascularisation (TVR). Another subject underwent revascularisation to another vessel which was planned earlier. Conclusion: Coronary Intravascular lithotripsy (IVL) is a safe and effective method in the treatment of moderate to severe coronary calcific coronary artery disease which is safe and effective with good short-term and mid-term outcomes. However, the data is limited on long-term outcomes.
ABSTRACT
Introduction & Objectives: The Coronavirus pandemic has severely limited theatre capacity and at its peak in England theatre was reserved for lifesaving and emergency surgery. On-going elective theatre capacity remains problematic and so we adapted our service so that all patients presenting acutely with an obstructing ureteric calculus were initially listed for shockwave lithotripsy (SWL). This included patients traditionally expected to have poor outcomes. Furthermore, patients with no stone clearly visible on a plain radiograph would still be listed with an intention to treat should the stone be visible upon fluoroscopic screening at the lithotripter. We also adopted a more flexible approach to our normal protocol for delivery not to exceed two sessions before listing for ureteroscopic surgery (URS). Materials & Methods: Data was retrospectively collected for all patients listed with an intention to treat obstructing ureteric calculi with SWL from the 17th March to 20th October 2020. Patients would be treated using the onsite Storz Modulith SLX-F2 lithotripter where pre-treatment fluoroscopic screening was available. Patients would routinely be listed for 2 sessions of SWL and a Consultant Endourologist would decide whether to proceed with further SWL or URS. Patients with intolerable pain or sepsis would undergo prior insertion of a percutaneous nephrostomy. Results: The stone free rate for 110 patients treated with up to 2 sessions of SWL was 52.7%. If further sessions were delivered the stone free rate increased to 68.2%, following an average of 1.7 further sessions over an average of 21.5 days. Offering further SWL inferred an average cost saving of £888.40-1708.40 per patient by avoiding the additional cost of URS in 17 patients. Our very unselected cohort included 32% with 2 or more poor prognostic factors (upper ureteric, size >10mm, >1000 Hounsfield Units). These patients had a stone free rate of 62.9% following all sessions, compared to 70.7% of those with <2 poor prognostic factors. Only 3 patients listed for SWL with no stone visible on XR KUB were unable to be treated as no stone could be localised on fluoroscopic screening. However 20 patients thought to have non visible stones were able to be treated, and 75% of these patients were stone free after all sessions, avoiding theatre bookings in 15 patients. Conclusions: Offering our SWL service to all patients with obstructing ureteric stones has lightened the burden on theatre demand. Offering multiple sessions is effective, can be delivered in a timely manner and further reduces the need for URS at a lower cost. In addition fluoroscopic screening can be considered to identify stones not visible on XR KUB allowing more patients to be treated with SWL further avoiding theatre bookings.
ABSTRACT
Introduction & Objective: The COVID-19 pandemic brought significant challenges to all healthcare systems around the world. We studied its impact on our supra-regional ESWL service. Methods: Patients who received ESWL using our onsite lithotripter (Storz Modulith SLX-F2) during the initial National Lockdown (NL) period were compared with those treated over a similar time period in 2019. Patients with renal calculi were excluded for direct comparison as only a small number of patients with renal calculi were treated during NL. As the supraregional centre, we continued to provide acute treatment during NL albeit with restricted access due to staff redeployment, and within safety restrictions, and continued to receive patients from other network centres. Results: 25 patients with ureteric calculi treated in 2019 were compared with 23 patients treated during NL. The mean ages were 56.6 VS 50.0 (2019 VS NL). The mean time to treat were 20.9 VS 19.4 days (2019 VS NL). Two patients' 2nd treatment got delayed during NL. Treatment outcomes are outlined in table 1. The mean residual stone sizes were 4.9mm VS 5.7mm (2019 VS NL). In 2019, complication rate was 16.0% with the commonest being pain (75.0%) when compared to 21.7% during NL (80% pain). Steinstrasse were not seen in either group. One patient treated during NL sustained a moderate peri-renal haematoma managed conservatively. Treatment parameters such as number of shocks delivered and screening time were equivalent between groups. Conclusions: COVID-19 led to pressures on health services and also patients changed their patterns of presentation. Restricted access to the operating theatre made use of non-invasive treatments an essential part of patient management during the lockdown period. We show equivalent outcomes to normal practicedespite treating larger and potentially more challenging stones, with few complications and while minimising COVID- 19-related risks to the patient. (Table Presented).