Effectiveness of Intra-operative Contrast-Enhanced Ultrasound Assessment to Optimize Type II Endoleak Embolization.

PURPOSE: To analyze the effectiveness of type II endoleaks (T2E) embolization using intra-operative contrast-enhanced ultrasound (CEUS). METHODS: Consecutive patients treated for T2E underwent a standardized protocol with trans-arterial or trans-lumbar access, large volume embolization, onlay fusion, and intra-operative CEUS. Technical success was defined by exclusion of endoleak by CEUS. RESULTS: Twenty-six patients (mean age 81 ± 11 years old; 89% male) were treated. The mean aneurysm sac enlargement was 11 ± 8 mm from T2E diagnosis. Embolization was performed using Onyx® 18 in all patients with adjunctive coils in 13 patients (50%). After the first embolization, CEUS documented residual T2E in 13 patients (50%). Ten patients (38%) had additional embolization, which successfully eradicated the T2E in seven of them. Technical success was 50% after the first embolization attempt and 77% after additional attempts guided by CEUS (P = 0.080). There was no mortality. Median imaging follow-up was 22 months. Among the 20 patients with no residual T2E on completion CEUS, 16 (80%) had sac stabilization and none required additional interventions for T2E. Of the six patients with residual T2Es on CEUS, three had sac stabilization (50%) and one required additional reintervention for T2E. There was one late aortic rupture at 56 months. CONCLUSION: One in two patients treated by T2E embolization had residual endoleak on intra-operative CEUS after a first embolization attempt, decreasing to one in four patients after multiple attempts. A negative completion CEUS following embolization was associated with higher rates of sac stabilization and no need for additional T2E embolization.

Effect of obesity on radiation exposure, quality of life scores, and outcomes of fenestrated-branched endovascular aortic repair of pararenal and thoracoabdominal aortic aneurysms.

BACKGROUND: The aim of the present study was to assess the effect of obesity on procedural metrics, radiation exposure, quality of life (QOL), and clinical outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms. METHODS: We reviewed the clinical data from 334 patients (236 men; mean age, 75 ± 8 years) enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2019. The patients were classified using the body mass index (BMI) as obese (BMI ≥30 kg/m2) or nonobese (BMI <30 kg/m2). QOL questionnaires (short-form 36-item questionnaire) and imaging studies were obtained preoperatively and at 2 months and 6 months postoperatively, and annually thereafter. The procedures were performed using two different fixed imaging systems. The end points included procedural metrics (ie, total operative time, fluoroscopic time, contrast volume), radiation exposure, technical success, 30-day mortality, and major adverse events, QOL changes, freedom from target vessel instability, freedom from reintervention, and patient survival. RESULTS: The aneurysm extent was a pararenal aortic aneurysm in 117 patients (35%) and a thoracoabdominal aortic aneurysm in 217 patients (65%). Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for a greater incidence of hyperlipidemia and diabetes among the obese patients (P < .05). No significant differences were found in the procedural metrics or intraprocedural complications between the groups, except that the obese patients had greater radiation exposure than the nonobese patients (mean, 2.5 vs 1.6 Gy; P < .001), with the highest radiation exposure in those obese patients who had undergone the procedure using system 1 (fusion alone) instead of system 2 (fusion and digital zoom; mean, 4.1 vs 1.5 Gy; P < .001). Three patients had died within 30 days (0.8%), with no difference in mortality or major adverse events between the groups. The mental QOL scores had improved in the obese group at 2 and 12 months compared with the nonobese patients, with persistently higher scores up to 3 years. At 3 years, the obese and nonobese patients had a similar incidence of freedom from target vessel instability (74% ± 6% vs 80% ± 3%; P = .99, log-rank test), freedom from reintervention (66% ± 6% vs 73% ± 4%; P = .77, log-rank test), and patient survival (83% ± 5% vs 75% ± 4%; P = .16, log-rank test). CONCLUSIONS: FB-EVAR was performed with high technical success and low mortality and morbidity, with no significant differences between the obese and nonobese patients. The procedural metrics and outcomes were similar, with the exception of greater radiation exposure among obese patients, especially for the procedures performed using system 1 with fusion alone compared with system 2 (fusion and digital zoom). Obese patients had higher QOL mental scores at 2 and 12 months, with a similar reintervention rate, target vessel outcomes, and survival compared with nonobese patients.

Characterization of Organic Matter in Water from Oil and Gas Wells Hydraulically Fractured with Recycled Water.

Liquid chromatography quadrupole time-of-flight mass spectrometry was performed to understand how frac fluid with recycled water (RWA) and frac fluid with fresh water (FWA) compare when subjected to downhole temperature and oxidation conditions. Ethylene oxide and propylated glycol functional units were quantified from both RWA and FWA. Qualitative analysis was performed using Agilent qualitative analysis software B.06.00 based on the exact mass of the chemical compound. Acetone, aldol, alkoxylated phenol formaldehyde resin, diethylbenzene, dipropylene glycol, d-Limonene, ether salt, ethylbenzene, n-dodecyl-2-pyrrolidone, dodecylbenzenesulfonate isopropanolamine, polyethylene glycol, and triethylene glycol were detected in FWA and RWA samples. In the van Krevelen diagram, FWA and RWA show a low degree of oxidation and highly saturated organic compounds. Kendrick mass defect (KMD) analysis was applied using ethylene oxide and propylated glycol units. KMD analysis based on ethylene oxide was scattered between 0 and 0.1, while some KMD analyses based on the propylated glycol are close to 1. FWA had an average carbon number of 32.3 and double bond equivalent (DBE) of 9.8 while RWA had average carbon number of 31.5 and DBE of 9.5. RWA contained predominantly C21-C40 compounds, while FWA had a higher concentration in the over C41 range.

Learning curve of fenestrated and branched endovascular aortic repair for pararenal and thoracoabdominal aneurysms.

OBJECTIVE: The objective of this study was to review the learning curve for fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). METHODS: We reviewed the clinical data of 334 consecutive patients (255 males, mean age 75 ± 7 years) who underwent F-BEVAR between 2007 and 2016 in a single institution. Outcomes were analyzed in four quartiles of experience (Q1-Q4). Study outcomes included trends in patient characteristics, device design, procedural variables, 30-day mortality, and major adverse events (MAEs). RESULTS: There were 178 patients (53%) treated for pararenal aneurysms and 156 (47%) for TAAAs. During the study period, there was a statistically significant increase in the proportion of TAAAs and in the number of vessels incorporated. Despite this, there was a steady decrease in 30-day mortality (6% in Q1 to 0% in Q4; P < .04) and in the rate of MAEs (60% in Q1 to 29% in Q4; P<.001). By linear regression analysis, there was significant decline in estimated blood loss (1358 ± 1517 mL in Q1 to 486 ± 520 mL in Q4; P < .001), total operating time (325 ± 116 minutes in Q1 to 248 ± 92 minutes in Q4; P < .001), total fluoroscopy time (121 ± 59 minutes in Q1 to 85 ± 39 minutes in Q4; P < .001), contrast volume (201 ± 92 mL in Q1 to 160 ± 61 mL in Q4; P = .002), and radiation dose (4141 ± 2570 mGy in Q2 to 2543 ± 1895 mGy in Q4; P < .001). Independent predictors of MAEs were total operating time (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.8; P < .001), Society for Vascular Surgery total score (OR, 1.1; 95% CI, 1.02-1.2; P = .009), and quartile 1 (OR, 3.0; 95% CI, 1.7-5.2; P < .001). CONCLUSIONS: This study demonstrates significant improvement in perioperative mortality, MAEs, procedural variables, and secondary interventions in patients treated by F-BEVAR, despite the increase in complexity of aneurysm pathology during the study period. Also, better patient selection contributed to improve outcomes.

Prospective nonrandomized study to evaluate cone beam computed tomography for technical assessment of standard and complex endovascular aortic repair.

OBJECTIVE: The objective of this study was to analyze the utility of cone beam computed tomography (CBCT) for technical assessment of standard and complex endovascular aneurysm repair (EVAR). METHODS: Data of consecutive patients who underwent standard or complex EVAR in 2016 and 2017 at our institution were entered into a prospective database and analyzed retrospectively. There were 154 patients (126 male; mean age, 74 ± 8 years) enrolled in a prospective study between 2016 and 2017. A total of 170 aortic procedures were investigated, including 85 fenestrated-branched EVARs (F-BEVARs), 42 abdominal and thoracic EVARs, 32 EVARs with iliac branch devices, and 11 aorta-related interventions. Technical assessment was done using CBCT with and without contrast enhancement, digital subtraction angiography (DSA), and computed tomography angiography (CTA). Patients with stage 3B or stage 4 chronic kidney disease had CBCT without contrast enhancement. Radiation exposure (mean dose-area product), effective dose (ED), and amount of iodine contrast agent were analyzed. End points were presence of any endoleak, positive findings warranting possible intervention (stent kink or compression, type I or type III endoleak, dissection, thrombus), and need for secondary intervention. RESULTS: Radiation exposure and amount of iodine contrast agent were significantly higher (P < .05) for F-BEVAR compared with other aortic procedures (174±101 Gy∙cm2 vs 1135±113 Gy∙cm2 and 144±60 mL vs 122±49 mL). ED averaged 74±36 mSv for the aortic procedure, 18 ± 18 mSv for fluoroscopy, 7 ± 7 mSv for DSA acquisition, 15±7 mSv for CBCT, and 34±17 mSv for CTA imaging (P < .001). Endoleak detection was significantly higher (P < .001) with CBCT (53%) compared with DSA (14%) and CTA (46%). CBCT identified 52 positive findings in 43 patients (28%), higher for F-BEVAR compared with other aortic procedures (35% vs 16%; P = .01). Positive findings included stent compression or kink in 29 patients (17%), type I or type III endoleak in 16 patients (10%), and arterial dissection or thrombus in 7 patients (5%). Of these, 28 patients (18%) had positive findings that prompted an intraoperative (17%) or delayed intervention (1%). Another 15 patients (10%) with minor positive findings were observed with no clinical consequence. DSA alone would not have detected positive findings in 34 of 43 patients (79%), including 21 patients (49%) who needed secondary interventions. CTA diagnosed two (1%) additional endoleaks requiring intervention (one type IC, one type IIIC) that were not diagnosed by CBCT. Replacing DSA and CTA by CBCT would have resulted in 53% ± 13% reduction in amount of iodine contrast agent and 55% ± 12% reduction in ED (P < .05). CONCLUSIONS: CBCT reliably detected positive findings prompting immediate revisions in nearly one of five patients, with the highest rates among F-BEVAR patients. Detection of any endoleak was higher with CBCT compared with DSA or CTA, but most endoleaks were observed. DSA alone failed to detect positive findings warranting revisions.

Impact of onlay fusion and cone beam computed tomography on radiation exposure and technical assessment of fenestrated-branched endovascular aortic repair.

OBJECTIVE: The objective of this study was to analyze the impact of advanced imaging applications and cone beam computed tomography (CBCT) on radiation exposure of the patient and operator and detection of technical problems during fenestrated-branched endovascular aortic repair (F-BEVAR) for treatment of pararenal aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: We reviewed the clinical data of 386 consecutives patients (289 male; mean age, 75 ± 8 years) treated by F-BEVAR for 196 pararenal aneurysms and 190 TAAAs (mean, 3.4 ± 0.9 targeted vessels/patient) between 2007 and 2017. Radiation exposure (cumulative air kerma) was analyzed in three fixed imaging systems used between 2007 and 2011 (system 1), 2012 and 2016 (system 2), and 2016 and 2017 (system 3). Onlay fusion and CBCT were available with systems 2 and 3, whereas digital zoom with fusion overlay was used with system 3. Operator effective dose was measured per month using a radiation dosimeter badge. Computed tomography angiography and CBCT were analyzed for findings requiring immediate revision or secondary interventions. End points were patient radiation exposure; operator effective dose; procedure technical success; and 30-day rates of mortality, major adverse events, and secondary interventions. RESULTS: F-BEVAR was performed using system 1 in 98 patients, system 2 in 198 patients, and system 3 in 90 patients. Use of onlay fusion/CBCT was 0% with system 1, 42% with system 2, and 98% with system 3. Procedures performed with onlay fusion/CBCT had significantly (P < .05) higher technical success (99.4% vs 98.8%) and lower contrast material volume (155 ± 58 mL vs 172 ± 80 mL), fluoroscopy time (83 ± 34 minutes vs 94 ± 49 minutes), and cumulative air kerma (2561 ± 1920 mGy vs 3767 ± 2307 mGy). Despite higher case volume and increasing complexity during the experience, operator effective dose decreased to 9 ± 4 × 10-2 mSv/case with system 3 compared with 26 ± 3 × 10-2 mSv/case with system 1 and 20 ± 2 × 10-2 mSv/case with system 2 (P = .001). Among 219 patients who had no CBCT, 18 (8%) had computed tomography angiography findings that prompted secondary interventions before dismissal. Conversely, among 167 patients who had CBCT, 14 patients (8%) had intraoperative CBCT findings requiring immediate revision, with no additional secondary interventions. Patients treated with onlay fusion/CBCT had significantly (P < .05) lower mortality (4% vs 1%), major adverse events (43% vs 19%), and secondary interventions (10% vs 4%) at 30 days. CONCLUSIONS: Radiation exposure and operator effective dose significantly decreased with evolution of F-BEVAR experience and use of advanced imaging applications such as onlay fusion and CBCT. CBCT allowed immediate assessment and identified intraoperative technical problems, leading to immediate revision and avoiding early secondary interventions.

Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent graft.

Fenestrated-branched endovascular repair has been applied to treat chronic postdissection thoracoabdominal aortic aneurysms (TAAAs). We report a patient with diffuse postdissection aortic aneurysm involving the arch and thoracoabdominal aorta treated in a staged fashion with redo aortic arch repair using the frozen elephant trunk technique, followed by completion endovascular TAAA using preloaded guidewire system and a five-vessel fenestrated and branched stent graft. A technical video illustrates the use of onlay fusion and sequential catheterization with the preloaded guidewire system to facilitate TAAA repair.

Influence of softening sequencing on electrocoagulation treatment of produced water.

Electrocoagulation has been used to remove solids and some metals from both water and wastewater sources for decades. Additionally, chemical softening is commonly employed in water treatment systems to remove hardness. This paper assesses the combination and sequence of softening and EC methods to treat hydraulic fracturing flowback and produced water from shale oil and gas operations. EC is one of the available technologies to treat produced water for reuse in frac fluids, eliminating not only the need to transport more water but also the costs of providing fresh water. In this paper, the influence of chemical softening on EC was studied. In the softening process, pH was raised to 9.5 and 10.2 before and after EC, respectively. Softening, when practiced before EC was more effective for removing turbidity with samples from wells older than one month (99% versus 88%). However, neither method was successful in treating samples collected from early flowback (1-day and 2-day samples), likely due to the high concentration of organic matter. For total organic carbon, hardness, Ba, Sr, and B removal, application of softening before EC appeared to be the most efficient approach, likely due to the formation of solids before the coagulation process.

Role of lipid oxidation, chelating agents, and antioxidants in metallic flavor development in the oral cavity.

This study investigated the production of metallic flavor, which is a combination of taste and retronasal odor. Chemical reactions in the oral cavity and saliva of healthy subjects were investigated after ingesting iron and copper solutions above and near threshold levels. Significant increase in lipid oxidation (p < 0.001) occurred after metal ingestion, detected as TBARS values. Ferrous ion caused the greatest flavor sensation and lipid oxidation, followed by cupric and cuprous ions. Ferric ion did not cause metallic sensation. Occurrence of oxidation was supported by damage to salivary proteins, detected as protein-carbonyls, and by a significant increase of odorous lipid oxidation related aldehydes. Sensory evaluation demonstrated that antioxidants (vitamins E and C) minimally reduced metallic flavor but that chelating agents (EDTA and lactoferrin) removed the metallic flavor. The role of lipid oxidation is essential for the production of a metallic flavor from ingestion of ferrous, cupric, and cuprous ions.

Retronasal perception and flavour thresholds of iron and copper in drinking water.

Drinking water flavour has a strong role in water quality perception, service satisfaction, willingness to pay and selection of water sources. Metallic flavours are often caused by the dissolved iron and copper, commonly found in groundwater or introduced to tap water by corroding infrastructure. Taste thresholds of iron and copper have been investigated by several studies; however, reported results and test methods vary considerably. This study determined the taste thresholds of ferrous and cuprous ions in room temperature reagent water by using the one-of-five test with multi-nation panellists in the United States. For ferrous and cuprous ions, individual thresholds ranged from 0.003 to >5 mg l(-1) and 0.035 to >5 mg l(-1), respectively. Population thresholds were determined by logistic regression and geometric mean methods as 0.031 and 0.05 mg l(-1) for ferrous ion, and 0.61 mg l(-1) for cuprous ion by both methods. The components of metallic sensation were investigated by use of nose-clips while panellists ingested iron and copper solutions. Results showed that metallic sensation has a significant odour component and should be treated as a flavour instead of a taste. Ferrous, cuprous and cupric ions also produced weak bitter and salty tastes as well as astringent mouthfeel. In comparison, ferric ion produced no sensation.

Determining human exposure and sensory detection of odorous compounds released during showering.

Modeling of human exposure to aqueous algal odorants geosmin (earthy), 2-methylisoborneol (musty), and (trans,cis)-2,6-nonadienal (cucumber, fishy), and the solvent trichloroethylene (sweet chemical), was investigated to improve the understanding of water-air transfer by including humans as sensors to detect contaminants. A mass-transfer model was employed to determine indoor air concentrations when water was used for showering under varying conditions (shower stall volume, water and air flow rate, temperature, aqueous odorant concentration, shower duration). Statistical application of multiple linear regression and tree regression were employed to determine critical model parameters. The model predicted that concentrations detectable to the human senses were controlled by temperature, odor threshold, and aqueous concentration for the steady-state model, whereas shower volume, air flow, and water flow are also important for the dynamic model and initial detection of the odorant immediately after the showering is started. There was excellent agreement of model predictions with literature data for human perception of algal odorants in their homes and complaints to water utilities. TCE performed differently than the algal odorants due to its higher Henry's law constant, in spite of similar gas and liquid diffusivities. The use of nontoxic odorants offers an efficient tool to calibrate indoor air/water shower models.

Taste and odor abnormalities in cancer patients.

Taste and odor abnormalities are major daily concerns for patients with cancer. This review summarizes the common taste and odor disorders of cancer patients and provides insight into their possible causes. Cancer and its therapy, including chemotherapy and radiotherapy, may directly alter and damage taste and odor perception.These alterations affect the daily quality of life of these patients and may lead to patient malnutrition and, in severe cases, significant morbidity. Cancer patients experience decreases in sensitivity to taste and odor, as well as unpleasant metallic and bitter sensations. Complaints relating to taste and odor are not usually addressed, as few, if any, effective interventions are available for these problems. Understanding the types and causes of taste and odor dysfunctions will enable researchers and physicians to develop treatments for these conditions and thereby improve patient quality of life.

Developing hexanal as an odor reference standard for sensory analysis of drinking water.

There are many analytical and sensory methods to analyze drinking water for flavor and off-flavors before it reaches consumers. Flavor profile analysis (FPA) is one of the most comprehensive methods. A well-trained panel is essential for FPA and although taste standards are well established, FPA training lacks an odor reference standard. In search of an odor reference standard, four different panel groups were trained and tested for n-hexanal at various concentrations (1-1000 microg/L) over 14 months. The Weber-Fechner plots for n-hexanal showed a linear and overlapping relationship for all panels. Analytical measurements demonstrated that the headspace concentration of n-hexanal was constant after 5 sniffs at 45 degrees C and it remained constant during FPA sessions for up to 4 h. The panelists liked the grassy odor of n-hexanal, which did not result in fatigue, and testing demonstrated that approximately 95% of the population can detect n-hexanal's odor. n-Hexanal is proposed as an odor reference standard for FPA training to define odor intensities because it is chemically stable, follows Weber-Fechner law, mimics grassy odors found in drinking water, and was acceptable to the human panelists.

Determination of temperature-dependent Henry's law constants of odorous contaminants and their application to human perception.

A new method was developed to measure Henry's law constants at varying temperatures and from these data determine enthalpies of reactions for volatilization of aqueous compounds. The method was applied to 2-methylisoborneol (2-MIB), geosmin, and trans-2,cis-6-nonadienal, which are three of the major odorous compounds found in natural and drinking water. The method used static headspace equilibrium in standard odor analysis flasks and SPME-GC/MS. Dimensionless Henry's law constants were determined at 20, 25, 32, and 39 degrees C in distilled water. Their values ranged from 0.002 to 0.02 and increased with increasing temperature. The study was continued by determining the effects of different concentrations of fulvic acid added to the aqueous media. Decreases of 5-40% in Henry's law constants were observed when fulvic acid was present; however the decrease was not correlated with the fulvic acid concentration. Fulvic acid at any concentration caused a small decrease in constants for geosmin and 2-MIB, yet a more substantial decrease was obtained for nonadienal. Finally, the gas-phase concentrations were predicted using measured Henry's law constants for known aqueous concentrations of 2-MIB, geosmin, and nonadienal at 25 and 45 degrees C. An increase in the gas-phase concentration was not correlated to an increase in human perception as determined by a trained human panel. It is concluded that, after some point, panelists were not able to perceive an increase in the odorant concentration. This has important implications for controlling nuisance odors in the environment.