Assessment of Central Arterial Hemodynamics in Children: Comparison of Noninvasive and Invasive Measurements.

BACKGROUND: In adults, central systolic blood pressure (cSBP) and augmentation index (cAIx) are independently associated with cardiovascular events and mortality. There is increasing interest in central hemodynamic indices in children. We aimed to assess the accuracy of current techniques against invasive intra-aortic measurements in children. METHODS: Intra-aortic pressure waveforms were recorded with simultaneous brachial, radial, and carotid waveforms in 29 children (6.7 ± 3.9 years old) undergoing cardiac catheterization. Adult and age-appropriate transfer functions (TFs) (brachial adult: b-aTF; radial adult: r-aTF; radial for 8-year-old children: TF8; and radial for 14-year-old children: TF14) were used to synthesize central aortic waveforms from peripheral waveforms calibrated either to invasively or noninvasively recorded BP. Central hemodynamic indices were measured by pulse wave analysis. RESULTS: cSBP measured from invasively calibrated r-aTF (ß = 0.84; intraclass correlation coefficient = 0.91; mean error ± SDD = -1.0 ± 5.0 mm Hg), TF8 (ß = 0.78; intraclass correlation coefficient = 0.84; mean error ± SDD = 4.4 ± 5.6 mm Hg), and TF14 (ß = 0.82; intraclass correlation coefficient = 0.90; mean error ± SDD = 2.0 ± 4.7 mm Hg)-synthesized central waveforms correlated with and accurately estimated intra-aortic cSBP measurements, while noninvasively calibrated waveforms did not. cAIx derived from TF-synthesized central waveforms did not correlate with intra-aortic cAIx values, and degree of error was TF-dependent. CONCLUSIONS: The currently available r-aTF accurately estimates cSBP with invasive pulse pressure calibration, while. Age-appropriate TFs do not appear to provide additional benefit. Accuracy of cAIx estimation appears to be TF dependent.

Paget-Schroetter syndrome: A contemporary review of the controversies in management.

AIM: To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. MATERIALS AND METHODS: We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. RESULTS: There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. CONCLUSIONS: Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

Validation of a cuff-based device for measuring carotid-femoral pulse wave velocity in children and adolescents.

Carotid-femoral pulse wave velocity is associated with arterial stiffness in major elastic arteries, and predicts future cardiovascular events. However, little is known about carotid-femoral pulse wave velocity as a marker of vascular health in children. Semi-automated cuff-based devices for assessing pulse wave velocity are increasingly popular, although these utilize an algorithm developed and validated in adults. Physiological differences between adults and children may, however, reduce the accuracy of cuff-based methods. We sought to determine the accuracy of a cuff-based pulse wave velocity device in healthy children, and determine whether a novel age-appropriate algorithm increases accuracy. We recruited 29 healthy children between the ages of 2 and 20 years. Pulse wave velocity was measured both by using a tonometer on the carotid artery and an inflated cuff on the thigh, and using a tonometer on both the carotid artery and femoral artery as a reference standard. Accuracy of the cuff-based device with its standard algorithm developed in adults, and a novel age-appropriate algorithm corrected for physiological differences in leg pulse wave velocity was assessed with Regression analysis and Bland-Altman plots. Cuff-based device estimates of pulse wave velocity had excellent agreement to the reference standard (Δ = -0.26 ms-1 [SD 0.44]). The novel age-appropriate algorithm improved the accuracy of the cuff-based method (Δ = 0.02 ms-1 [SD 0.44]). The cuff-based semi-automatic approach estimates carotid-femoral pulse wave velocity with excellent agreement to the reference standard. However, adjusting the algorithm for known differences in leg pulse wave velocity further improves the accuracy of cuff-based measurement in children and adolescents.

Predicting non-sentinel lymph node metastasis in Australian breast cancer patients: are the nomograms still useful in the post-Z0011 era?

BACKGROUND: Axillary lymph node dissection (ALND) can be avoided in breast cancer patients with low-volume disease in the sentinel lymph nodes (SLNs) according to Z0011 trial. We believe that nomograms developed for predicting non-sentinel lymph node (NSLN) metastases can guide the axillary treatment in patients who do not fully match the criteria of Z0011 study. We identified risk factors and evaluated the performance of three nomograms to predict NSLN status in patients with positive SLNs. METHODS: Data from 526 breast cancer patients with positive SLNs who underwent ALND at two Australian hospitals from 2002 to 2015 were studied. Univariate and multivariate associations for NSLN metastasis were analysed. Predictive models evaluated were MD Anderson Cancer Centre (MDA), Helsinki University Hospital and Memorial Sloan Kettering Cancer Centre. RESULTS: Thirty-nine per cent of patients demonstrated NSLN metastasis. The multivariate analysis identified extranodal extension (OR 3.2, 95% CI 2.07-4.80), tumour size >2 cm (OR 2.5, 95% CI 1.66-3.89), macrometastasis (OR 1.9, 95% CI 1.09-3.47), positive SLN ratio >0.5 (OR 1.7, 95% CI 1.16-2.60) and lymphovascular invasion (OR 1.6, 95% CI 1.09-2.44) as independent predictors for NSLN metastasis. MDA nomogram showed the best discrimination (area under the curve of 0.74) and a 9% false negative rate for predicted probability of NSLN metastasis ≤10%. CONCLUSION: Our results suggest that presence of extranodal extension and tumour size >2 cm may influence the need of further axillary treatment. Conversely, ALND can be safety spared in low risk patients identified by MDA nomogram.

Early outcomes using dedicated venous stents in the upper limb of patients with venous thoracic outlet syndrome: A single centre experience.

INTRODUCTION: Surgical management of Venous Thoracic Outlet Syndrome (vTOS) is based upon resection of the first rib. The optimal method to treat any residual venous scarring however remains unclear. The purpose of this study was to evaluate a single quaternary centre's early and mid-term outcomes following endovascular reconstruction of the axillo-subclavian vein using dedicated venous stents in patients with VTOS. METHODOLOGY: A retrospective analysis of patients at Royal Prince Alfred Hospital, who underwent upper limb deep venous stenting as an adjunct in the treatment of vTOS was performed. All patients between 2012 and 2017 were included. Stent patency was assessed with duplex ultrasonography. All re-interventions and their indications were recorded. RESULTS: A total of 24 limbs in 21 patients (13 female, median age 44 yrs) were treated with dedicated venous stents between 2012 and 2017. All patients had resection of their first rib using a transaxillary approach. Nine patients initially presented with an acute DVT and underwent thrombolysis. In three of these patients a venous stent was placed before rib resection following completion of lysis. In the remainder, the median time for stent placement following surgery was 64 days. Median follow-up from stent insertion was 50 months. Primary, primary-assisted and secondary patency at 24 months was 55%, 95% and 100% respectively with one patient lost during follow-up. There were no major complications. A total of 14 re-interventions were performed on these patients. Three patients reported residual symptoms following stenting including heaviness (n = 1), bluish discolouration (n = 1) and prominent veins on the chest (n = 1) with the remainder asymptomatic. CONCLUSION: In this single centre study, endovascular reconstruction using dedicated venous stents appears to be an effective and safe method to reconstruct a damaged subclavian vein following rib resection in patients with vTOS.

Carotid extramedial thickness is associated with local arterial stiffness in children.

OBJECTIVES: Experimental evidence suggests that structural changes to the arterial adventitia may be a key vascular determinant of early arterial stiffening, although this has not been directly studied. Accordingly, we hypothesized that in young children, in whom this relationship would not be altered by atheroma, carotid extramedial thickness (EMT), a measure that incorporates the thickness of the arterial adventitia, perivascular tissues and the internal jugular venous wall, would be associated with localized arterial stiffness of the same arterial region. METHODS: We studied 248 healthy prepubescent children (aged 8 years). Carotid diameter and carotid EMT were measured by high-resolution ultrasound. Carotid blood pressure was derived from brachial blood pressure and carotid tonometry. Three measures of localized arterial stiffness (ß stiffness index, distensibility coefficient and incremental modulus of elasticity) were calculated for the common carotid artery. Results were adjusted for heart rate and DBP, two important hemodynamic determinants of arterial stiffness. RESULTS: Carotid EMT was associated with all three measures of arterial stiffness (ß stiffness index: standardized ß = 0.121, P = 0.03; distensibility coefficient: standardized ß = -0.121, P = 0.05; incremental modulus of elasticity: standardized ß = 0.140, P = 0.02). These associations remained significant after adjustment for potential confounders such as sex, height, waist circumference, BMI and body surface area. CONCLUSION: Carotid EMT is associated with the stiffness of the same arterial segment in children, suggesting that the arterial adventitia may be involved in early changes in arterial stiffness during childhood.

Effect of periodontal therapy on arterial structure and function among aboriginal australians: a randomized, controlled trial.

Observational studies and nonrandomized trials support an association between periodontal disease and atherosclerotic vascular disease. Both diseases occur frequently in Aboriginal Australians. We hypothesized that nonsurgical periodontal therapy would improve measures of arterial function and structure that are subclinical indicators of atherosclerotic vascular disease. This parallel-group, randomized, open label clinical trial enrolled 273 Aboriginal Australians aged ≥18 years with periodontitis. Intervention participants received full-mouth periodontal scaling during a single visit, whereas controls received no treatment. Prespecified primary end points measured 12-month change in carotid intima-media thickness, an indicator of arterial structure, and 3- and 12-month change in pulse wave velocity, an indicator of arterial function. ANCOVA used complete case data to evaluate treatment group differences. End points could be calculated for 169 participants with follow-up data at 3 months and 168 participants at 12 months. Intima-media thickness decreased significantly after 12 months in the intervention group (mean reduction=-0.023 [95% confidence interval {CI}, -0.038 to -0.008] mm) but not in the control group (mean increase=0.002 [95% CI, -0.017 to 0.022] mm). The difference in intima-media thickness change between treatment groups was statistically significant (-0.026 [95% CI, -0.048 to -0.003] mm; P=0.03). In contrast, there were no significant differences between treatment groups in pulse wave velocity at 3 months (mean difference, 0.06 [95% CI, -0.17 to 0.29] m/s; P=0.594) or 12 months (mean difference, 0.21 [95% CI, -0.01 to 0.43] m/s; P=0.062). Periodontal therapy reduced subclinical arterial thickness but not function in Aboriginal Australians with periodontal disease, suggesting periodontal disease and atherosclerosis are significantly associated.