UNASSIGNED: Left atrial appendage (LAA) thrombus is a contraindication for LAA closure (LAAC). However, in selected cases, oral anticoagulants are strictly contraindicated because of a history of life-threatening bleeding, and LAAC remains the only possible therapy to avoid systemic and especially cerebral embolization.
UNASSIGNED: We report a case of LAAC despite a massive proximal thrombus in a patient who had an absolute contraindication to anticoagulant therapy, with thorough pre-planning using CT scan, device modelling and thrombus trapping techniques to reduce the risk of systemic embolic events and perform LAAC safely.
UNASSIGNED: Although LAAC remains at high risk in this setting, the use of cautious techniques and tools, from pre-procedure planning to systemic embolization prevention systems associated to a precise transoesopheageal echocardiography guiding throughout the procedure, allows it to be performed as safely as possible when no other option is available.

BACKGROUND: Complex thoracolumbar fractures require reduction and stabilization. Posterior instrumentation alone and standard cement augmentation may represent undertreatment, while corpectomy has significant morbidity. In a series of unstable thoracolumbar fractures, we assessed the feasibility, safety, and results of \'armed kyphoplasty\' (AKP) and surgical posterior stabilization (PS).
METHODS: A total of 24 consecutive patients were treated with combined AKP and PS. Minimally invasive and open surgery techniques were used for PS. AKP was performed with C-arm or biplane fluoroscopic guidance, and screws were placed under navigation or fluoroscopic guidance. A postoperative CT scan and standing plain films were obtained. Patients were followed up according to clinical standards. Kyphosis correction (measured with regional Cobb angle), pain (measured with the Numeric Rating Scale), neurological status (measured with Frankel grade) were assessed.
RESULTS: A total of 25 fractures of neoplastic (40%), traumatic (32%), and osteoporotic (28%) nature were treated. Open surgery and minimally invasive techniques were applied in 16/24 and 8/24 patients, respectively. Decompressive laminectomy was performed in 13 cases. No intraprocedural complications occurred. Two patients (8%) died due to underlying disease complications and three complications (12%) required re-intervention (one surgical site infection, one adjacent fracture, and one screw pull-out) in the first month. The mean Cobb angle was 20.14±6.19° before treatment and 11.66±5.24° after treatment (P<0.0001). No re-fractures occurred at the treated levels.
CONCLUSIONS: Combined AKP and PS is feasible and effective in the treatment of complex thoracolumbar fractures of all etiologies. AKP avoided highly invasive corpectomy. Anterior and posterior support ensured stability, preventing implant failure and re-fracture. The complication rate was low compared with more invasive traditional 360° open surgical approaches.

UNASSIGNED: Percutaneous pedicle screw fixation is a common minimally invasive treatment for traumatic thoracolumbar and lumbar fractures; however, research on hardware removal after successful healing is limited. We aimed to introduce a rapid, safe, minimally invasive, and cost-effective method for percutaneous pedicle screw removal.
UNASSIGNED: We conducted a retrospective analysis of demographic (age, sex, body mass index, alcohol use, and current smoking), clinical (hypertension and diabetes mellitus), surgical (affected levels, number of screws, time of surgery, and blood loss), and treatment cost characteristics of 92 patients who had undergone percutaneous pedicle screw removal between May 2016 and February 2023. The first 57 patients underwent the conventional method, and the remaining 35 underwent the modified method. Independent-sample t-tests and chi-square tests were used to compare continuous and categorical variables, respectively, between the two groups.
UNASSIGNED: No significant differences were observed in the demographic parameters, complications, or affected levels between the groups. However, the average surgical time (P=0.000) was significantly shorter, and the average blood loss volume (P=0.002) and total cost (P=0.000) were significantly lower in the modified group than in the conventional group.
UNASSIGNED: Compared with the conventional method, our modified method can shorten the surgical time, reduce blood loss, and reduce the total cost of treatment. It is a quick and safe minimally invasive method that does not require additional surgical instruments and is suitable for implementation in primary hospitals.

BACKGROUND: Endovascular embolization of wide-necked aneurysms can be challenging. The development of intrasaccular devices like the Contour has enabled us to approach these aneurysms effectively by reducing recanalization rates and eliminating the need for dual antiplatelet therapy, which is particularly beneficial in the case of ruptured aneurysms. Although complications from using these devices are rare, it is crucial to address them properly. In this case, the authors highlight how to manage artery thrombosis caused by device protrusion during aneurysm embolization.
METHODS: This report describes a complication in a male patient with a ruptured anterior communicating artery wide-necked aneurysm. Following Contour-assisted coiling of the aneurysm, a realignment of the detachable apex of the device occluded the A2 segment of the right anterior cerebral artery. After the failure of intra-arterial and intravenous tirofiban infusion as well as mechanical thrombectomy, a self-expanding open-cell stent was deployed in the involved vessel, achieving successful reperfusion.
CONCLUSIONS: The Contour device has a detachable zone that can cause occlusion of the parent vessel after deployment. The use of a stent as a rescue maneuver may be useful if reperfusion of the vessel cannot be achieved through other methods such as aspiration or full-dose antiplatelet therapy.

UNASSIGNED: Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus.
UNASSIGNED: A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this \"complex\" anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich™ EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test.
UNASSIGNED: We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices.

BACKGROUND: Although flow diversion (FD) is safe and effective in the treatment of intracranial aneurysms, a subset tends to continue filling on serial angiography. Risk factors for failed flow diversion include old age, large aneurysm size, and overstenting an adjacent end-arterial vessel. The hemodynamic modes of persistent aneurysm filling, or \'endoleaks\', after FD are poorly understood. This study aims to characterize the various types of endoleaks following aneurysmal FD.
METHODS: We performed a retrospective review of a prospectively maintained database of all endovascular procedures performed at a single institution between 2017 and 2021. Patients were included if they demonstrated evidence of unique modes of intracranial aneurysm filling after FD. Data regarding treatment, follow-up angiography, as well as clinical course were collected.
RESULTS: Five patients (mean age 50 years, four females) were included with mean 19-month angiographic follow-up. Five major endoleak types are proposed: Type 1 - due to graft porosity (A - low flow, B - high flow), Type 2 -through an overstented branch vessel, Type 3 - via stent migration no longer covering aneurysmal neck, Type 4 - endoleak due to malapposition of the stent wall, and Type 5 - endoleak via collateralization from adjacent blood vessels. All endoleak types were represented, except for the Type 4 endoleak.
CONCLUSIONS: We propose an endoleak classification scheme to describe the hemodynamic modes of failure following FD of intracranial aneurysms. Future studies are needed to evaluate the natural history of aneurysmal filling following FD and retreatment success according to endoleak type.

Servo-ventilation (SV) was developed for treating central sleep apnea. To date, primarily SV devices manufactured by Philips Respironics and ResMed are used. However, the difference in reaction to sleep-disordered breathing events between bilevel positive airway pressure AutoSV devices from Philips and adaptive SV devices from ResMed in clinical settings is unknown. Herein, we describe a case of central sleep apnea in which sleep-disordered breathing events were successfully controlled and sleepiness, sleep quality, and tolerance of the device were improved by changing from the bilevel positive airway pressure AutoSV device from Philips to the adaptive SV device from ResMed. Changing the SV devices can be a clinical option to appropriately control sleep-disordered breathing events in patients receiving SV therapy who present with persistent sleep-disordered breathing.
Hamada S, Togawa J, Sunadome H, Nagasaki T, Hirai T, Sato S. Good clinical response achieved by changing servo-ventilation devices in a patient with central sleep apnea: a case report. J Clin Sleep Med. 2023;19(8):1557-1561.

Although endovascular embolization has become the main treatment option for intracranial aneurysms,1 2 wide-necked intracranial aneurysms remain difficult to coil.3 Both stent- and balloon-assisted coiling are used for wide-necked aneurysms because they provide a scaffold that protects the parent vessel during coiling.4 5 However, stent-assisted coiling requires dual antiplatelet therapy, which increases the risk of bleeding, whereas balloon-assisted coiling temporarily obstructs blood flow.4 6 7 The Comaneci device (Rapid Medical, Yokneam, Israel) has recently received US Food and Drug Administration approval as a \'temporary coil embolization assist device\'.5 It temporarily covers the aneurysm neck and allows safe coiling, avoiding the disadvantages mentioned above.6-8 A potential complication of Comaneci-assisted coiling is coil retention when it adheres to the device on recapture; this complication should be promptly recognized and managed.5 9 10 In this video, we present an unusual case of coil retention with the Comaneci device (Video 1). neurintsurg;15/12/1286/V1F1V1Video 1 .

We present the first case of fluorescence-guided surgery (FGS) using indocyanine green (ICG) in a pediatric redo-Nissen fundoplication. The patient is a 17-year-old male with recurrent gastroesophageal symptoms who underwent primary antireflux surgery at 10 months of age. During the redo fundoplication, ICG was intravenously administered to help the visualization during the adhesiolysis between liver, stomach and right crus of the diaphragm and to spare small oesophageal vessels and the left gastric artery. In this case, FGS made the surgery easier than usual and likely reduced the risk of intra-operative complications. Therefore, we believe that this new technology should be regularly used in these types of complex intra-abdominal redo operations.

The kinetics of carbon dioxide elimination (VCO 2 ) may be used as a surrogate for pulmonary blood flow. As such, we can apply a novel use of volumetric capnography to assess hemodynamic stability in patients requiring extracorporeal membrane oxygenation (ECMO). We report our experience of pediatric patients requiring ECMO support who were monitored using volumetric capnography. We describe the use of VCO 2 and its association with successful decannulation. This is a prospective observational study of pediatric patients requiring ECMO support at The Children\'s Hospital at Montefiore from 2017 to 2019. A Respironics NM3 monitor was applied to each patient. Demographics, hemodynamic data, blood gases, and VCO 2 (mL/min) data were collected. Data were collected immediately prior to and after decannulation. Over the course of the study period, seven patients were included. Predecannulation VCO 2 was higher among patients who were successfully decannulated than nonsurvivors (109 [35, 230] vs. 12.4 [7.6, 17.2] mL/min), though not statistically significant. Four patients (57%) survived without further mechanical support; two (29%) died, and one (14%) was decannulated to Berlin. Predecannulation VCO 2 appears to correlate with hemodynamic stability following decannulation. This case series adds to the growing literature describing the use of volumetric capnography in critical care medicine, particularly pediatric patients requiring ECMO. Prospective studies are needed to further elucidate the use of volumetric capnography and optimal timing for ECMO decannulation.