Intraoperative endoprosthesis customization for repair of an aortoenteric fistula in an emergency context: a case report.

Aortoenteric fistula is a severe clinical condition and its management remains a major technical challenge for surgeons. In these cases, the conventional surgical approach is associated with high rates of morbidity and mortality. Endovascular surgery is an excellent option in these cases, but considering that the aorta has been treated previously, anatomy may not be compatible with commercially available endovascular devices and so physician-modified endografts may be needed in urgent cases. The case reported involves a secondary aortoenteric fistula, treated on an emergency basis with endovascular techniques, using a physician-modified endograft.

Customização intraoperatória de endoprótese para correção de fístula aortoentérica em contexto de urgência: um relato de caso / Intraoperative endoprosthesis customization for repair of an aortoenteric fistula in an emergency context: a case report

Resumo A fístula aortoentérica é uma grave condição clínica, e seu manejo permanece sendo um grande desafio técnico aos cirurgiões. A abordagem por cirurgia convencional nesses casos está relacionada a altos índices de morbimortalidade. A cirurgia endovascular apresenta-se como uma ótima alternativa nesses casos; contudo, por não se tratar de aorta nativa, a anatomia pode não ser compatível com os dispositivos endovasculares comercialmente disponíveis, fazendo-se necessário, em casos de urgência, a utilização de dispositivos modificados pelo cirurgião. O caso relatado reporta uma fístula aortoentérica secundária, tratada em situação de urgência por técnica endovascular com dispositivo modificado.

Abstract Aortoenteric fistula is a severe clinical condition and its management remains a major technical challenge for surgeons. In these cases, the conventional surgical approach is associated with high rates of morbidity and mortality. Endovascular surgery is an excellent option in these cases, but considering that the aorta has been treated previously, anatomy may not be compatible with commercially available endovascular devices and so physician-modified endografts may be needed in urgent cases. The case reported involves a secondary aortoenteric fistula, treated on an emergency basis with endovascular techniques, using a physician-modified endograft.

Multimodal mechanisms and enhanced efficiency of atrial fibrillation cardioversion by pulmonary delivery of a novel flecainide formulation.

INTRODUCTION: Inhaled flecainide significantly alters atrial electrical properties with the potential to terminate atrial fibrillation (AF) efficiently by optimizing dose and drug formulation. METHODS: Seventeen Yorkshire pigs were studied. Intrapericardial acetylcholine and burst pacing were used to induce AF. Effects of a novel cyclodextrin formulation (hydroxypropyl-ß-cyclodextrin [HPßCD]) of flecainide (75 mg/mL, 0.5 or 1.0 mg/kg, bolus) instilled intratracheally at 2 minutes after AF initiation were studied. Concentration time-area analyses of flecainide HPßCD were compared to the traditional acetate formulation. RESULTS: Intratracheal instillation of flecainide HPßCD accelerated the conversion of AF to sinus rhythm in a dose-proportional manner, shortening AF duration by 47% (P = .014) and 79% (P = .002) at the lower and higher doses, respectively, compared to intratracheal sterile water placebo. AF dominant frequency was reduced by 11% (P = .04) and 29% (P = .004) respective to dose. At 2 minutes after intratracheal flecainide HPßCD, atrial depolarization (Pa ) duration increased by 12% (P = .02) and 17% (P = .009) at the lower and higher doses, respectively. At this time, the PR interval was prolonged by 9% (P = .04 for the higher dose) and AV node conduction was slowed, decreasing the ventricular rate during AF by 16% (P = .002) and 28% (P = .007) for the lower and higher doses. Flecainide HPßCD achieved the more efficient conversion of AF than the acetate formulation, reflected in a markedly reduced area under the curve (P = .04). CONCLUSION: Intratracheal instillation of the new flecainide HPßCD formulation effectively terminates AF through efficient multimodal actions including slowing of atrial conduction velocity and decreasing AF dominant frequency, allowing reduced net drug delivery and inhalation time.

Thoracoabdominal branched repositionable device for an urgent complex aortic aneurysm.

The successful use of customized branched or fenestrated devices to treat elective thoracoabdominal aneurysm (TAAA) has already been described. However, the device customization is a lengthy process that necessitates a delay in treatment of more than a month. This case reports an emergency treatment of TAAA, in a 80-year-old patient, refused to open repair, admitted with abdominal pain using a new technique, modifying Gore C3 Excluder (WL Gore & Associates, Flagstaff, AZ) including branches to enable the emergency endovascular treatment of TAAA preserving visceral artery flow and excluding aneurysm.

The design and performance of the exubera pulmonary insulin delivery system.

The Exubera system (Pfizer, New York, NY/Nektar Therapeutics, San Carlos, CA) is an integration of five major new technologies: protein formulation, powder processing, powder filling, drug packaging, and delivery device. The product provides a simple interface, where the patient interacts only with the delivery device and powder packaging. These components were designed together to assure repeatable dosing when used by a wide range of patients under real-world life-style and handling conditions. The device design is purely mechanical, using patient-generated compressed air as the energy source. Upon actuation, a sonic discharge of air through the novel release unit reproducibly extracts, de-agglomerates, and disperses the inhalation powder into a respirable aerosol. A clear holding chamber allows for patient feedback via dose visualization and separates aerosol cloud generation from the inspiratory effort. The Exubera product was tested under a wide range of typical use conditions and potential misuse scenarios and following long-term usage in clinical trials. These comprehensive characterization programs demonstrated robust aerosol and mechanical performance, confirming the design intent of the inhaler. These studies provide assurance of consistent and reliable dose delivery in a real-world use of the product.

The effect of biphasic inhalation profiles on the deposition and clearance of coarse (6.5 microm) bolus aerosols.

The influence of particle size upon deposition in the human airways is well understood. Pharmaceutical aerosol formulators strive to generate fine aerosols with the potential to penetrate into the deep lung. However, flow rate can also have a major influence on deposition, particularly with coarse aerosols. This study investigated the use of biphasic flow profiles with low flow in the proximal conducting airway as a means of effecting efficient delivery of a coarse aerosol. The study shows that 6.5-microm MMAD aerosol droplets can be deposited in the lung with high efficiency. The delivery technique achieved greater than 70% of the inhaled dose deposited in the whole lung and greater than 50% deposited in the lung periphery. Furthermore, the biphasic flow profiles used, with initial low flow segments of between 300 mL and 900 mL inhaled volume at 8 L/min, are practical flow regimens that should be acceptable to patients and that can be applied to single-breath dry powder inhalers. Twenty-four-hour clearance and Penetration Index measurements were used as a marker for peripheral deposition, and the data show a clear correlation between Penetration Index and 24-h retention.