Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries

Purpose@#Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology. @*Materials and Methods@#Patients diagnosed with symptomatic SID-CA and SIDSMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed. @*Results@#Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period. @*Conclusion@#Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SIDCA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-yearold man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries

Purpose@#Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology. @*Materials and Methods@#Patients diagnosed with symptomatic SID-CA and SIDSMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed. @*Results@#Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period. @*Conclusion@#Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SIDCA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

Paraplegia after Open Repair of Suprarenal Abdominal Aortic Aneurysm

Spinal cord ischemia after open repair of abdominal aortic aneurysm (AAA) is an unpredictable and devastating complication. We present a case report of a patient who developed paraplegia 6 hours after open repair of suprarenal AAA. A 74-yearold man presented with asymptomatic 5.5-cm suprarenal AAA, for which he underwent open repair under general anesthesia. The paraplegia was identified 6 hours after the operation. Postoperative magnetic resonance imaging showed T2 signal hyperintensity and swelling of the spinal cord, which were consistent findings with subacute spinal cord infarction. Although intravenous steroid was administered and lumbar cerebral spinal fluid drainage was instituted, his neurological outcome did not improve. He was discharged after vigorous rehabilitation but still has paraplegia and requires wheelchair for ambulation.

Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases

PURPOSE: Pseudoaneurysms after percutaneous vascular access are common and potentially fatal if left untreated. The aim of this study was to determine the incidence and risk factors associated with access site pseudoaneurysms after endovascular intervention for peripheral arterial disease (PAD) under a routine postintervention ultrasound (US) surveillance protocol. METHODS: A total of 254 PAD interventions were performed in a single center between January 2015 and November 2016, and puncture site duplex US surveillance was routinely performed within 48 hours of the procedure. Clinical, procedural and follow-up US data were analyzed. RESULTS: The overall incidence of pseudoaneurysm was 2.75% (6 cases in the femoral artery and 1 in the brachial artery). There was no difference between retrograde and antegrade approach, but there was a higher rate of pseudoaneurysm formation after manual compression compared to arterial closure device (ACD) use (4.3% vs. 0.87%). Manual compression was more commonly used for antegrade punctures (79.0%) and ACD for retrograde punctures (67.7%). Calcification was more frequently found in antegrade approach cases (46.8% vs. 16.9% for retrograde cases) and manual compression was preferred in its presence. All pseudoaneurysms were treated successfully at the time of diagnosis by US-guided compression repair and there were no cases of rupture. CONCLUSION: Pseudoaneurysm rates after therapeutic endovascular intervention for PAD were comparable to other cardiologic or interventional radiologic procedures despite the higher possibility of having a diseased access vessel. Routine US surveillance of access sites allowed for early diagnosis and noninvasive treatment of pseudoaneurysms, preventing potentially fatal complications.

Implementation of a resident night float system in a surgery department in Korea for 6 months: electronic medical record-based big data analysis and medical staff survey

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.

Early experiences of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

PURPOSE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea. METHODS: We retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed. RESULTS: We identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS. CONCLUSION: Despite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Early Experiences of Sandwich Technique to Preserve Pelvic Circulation during Endovascular Aneurysm Repair

PURPOSE: To report experiences of the sandwich technique (ST) for preservation of pelvic flow during endovascular repair of complex aortic or aortoiliac aneurysms. MATERIALS AND METHODS: Eight patients underwent elective endovascular aneurysm repair (EVAR) using the ST between March 2013 and February 2017. The anatomic indications for the ST were complex aortoiliac aneurysms (5 cases), abdominal aortic aneurysms (AAA) with non-diseased short common iliac arteries (2 cases) and AAA with unilateral occluded iliac artery (1 case). The ST was performed through both femoral and brachial approach. Patient clinical and radiologic data were collected and analyzed. RESULTS: Eight patients (7 male; mean age, 73.4 years) were followed over a mean period of 277 days (range, 9–1,106 days). The technical success rate was 100%. The primary patency rate of the iliac stent-grafts was 88% (14/16 cases). One internal iliac and 1 external iliac stent-graft occlusion was observed during the early postoperative period. There was 1 gutter endoleak which disappeared spontaneously within 4 days, and there were 2 type II endoleaks: one treated by coil embolization after 13 months, and the other observed without treatment. There were no cases of sac growth or aneurysm-related deaths, and no cases of buttock claudication or impotence. CONCLUSION: The ST is a safe and feasible technique to preserve pelvic circulation during endovascular treatment of complex aortoiliac aneurysms. The need to expand the indications for complex EVARs with adjunctive procedures, such as the ST is highlighted in situations where branched/fenestrated device availability is limited.

Chronological Change of the Sac after Endovascular Aneurysm Repair

PURPOSE: The purpose of this study was to evaluate the potential risk factors of type II endoleak and sac growth after endovascular aneurysm repair (EVAR) and the outcomes of secondary interventions. MATERIALS AND METHODS: Ninety seven patients underwent elective EVAR for infrarenal abdominal aortic aneurysms in two tertiary centers between April 2005 and July 2013. Clinical and imaging parameters were compared among sac growth (>5 mm) and non-growth groups. Risk factors associated with sac growth and persistent type II endoleak were analyzed. The outcomes of reinterventions for persistent type II endoleak were determined. RESULTS: Sac growth was observed in 20 cases (20.6%) and endoleak was found in 90% of them compared to 28.6% (22/77) in the non-growth group (P<0.001). The majority of endoleaks were type II (36/40) and 80.5% were persistent. Sac diameter, neck diameter and number of patent accessory arteries were also statistically significant for sac growth. On multivariate analysis, grade of calcification at the neck, grade of mural thrombus at the inferior mesenteric artery and number of patent accessory arteries were risk factors of persistent type II endoleak. Twenty six reinterventions were done for 16 patients with persistent type II endoleak, with a technical success rate of 88.5%, yet 55.5% showed sac growth regardless of technical success. There were no ruptures during the follow-up period. CONCLUSION: Sac growth after EVAR was mostly associated with persistent type II endoleak. Secondary interventions using transarterial embolization is partially effective in achieving clinical success.

Rescue Therapy of Inadvertent Coil Migration for Endovascular Treatment of Type II Endoleak

Coil migration during endovascular procedures is not an unusual complication, but there is no standard management strategy for bailout. Here, we describe a technique for removal of a migrated coil using a snare. During embolization of type II endoleak from the inferior mesenteric artery in a post-endovascular aneurysm repair patient, the coil migrated to the sigmoidal artery causing an occlusion. We used a microsnare loop and successfully retrieved the migrated coil. This is the first case in Korea that uses a loop snare for the removal of a migrated coil during visceral endovascular treatment to our knowledge. This technique of using a microsnare for removal of displaced coils can be a good resort in selected cases.

Spontaneous Renal Artery Dissection Complicated by Renal Infarction: Three Case Reports

Spontaneous renal artery dissection (SRAD) is a rare disease entity. The diagnosis is usually delayed because clinical presentation is non-specific. We report three cases of symptomatic SRAD complicated by renal infarction which occurred in previously healthy middle-aged male patients. They visited the hospital due to acute abdominal or flank pain. They had no specific underlying disease or trauma history. The laboratory tests and physical examination were normal. They were not suspected of having SRAD initially, but computed tomography (CT) revealed dissection of the renal artery with distal hypoperfusion leading to renal infarction. They were treated conservatively with anticoagulation and/or antiplatelets for 6 months. They had a 6-month regular follow-up with CT, where resolution was confirmed in one patient and all patients remained asymptomatic. These cases emphasize the importance of clinical suspicion of SRAD in previously healthy patients who complain of abdominal pain without specific findings on initial investigation.

Spontaneous Iliac Vein Rupture

Spontaneous iliac vein rupture (SIVR) is a rare entity, which usually occurs without a precipitating factor, but can be a life-threatening emergency often requiring an emergency operation. This is a case report of SIVR in a 62-year-old female who presented to the emergency room with left leg swelling. Workup with contrast-enhanced computed tomography revealed a left leg deep vein thrombosis with May-Thurner syndrome and a hematoma in the pelvic cavity without definite evidence of arterial bleeding. She was managed conservatively without surgical intervention, and also underwent inferior vena cava filter insertion and subsequent anticoagulation therapy for pulmonary thromboembolism. This case shows that SIVR can be successfully managed with close monitoring and conservative management, and anticoagulation may be safely applied despite the patient presenting with venous bleeding.

Recent Advances in the Development of Experimental Animal Models Mimicking Human Aortic Aneurysms

Aortic aneurysm is a common and life-threatening disease that can cause death from rupture. Current therapeutic options are limited to surgical or endovascular procedures because no pharmacological approaches have been proven to decrease the chance of expansion or rupture. The best approach to the management of aortic aneurysm would be the understanding and prevention of the processes involved in disease occurrence, progression, and rupture. There is a need for animal models that can reproduce the pathophysiological features of human aortic aneurysm, and several such models have been studied. This review will emphasize recent advances in animal models used in the determination of mechanisms and treatments of aortic aneurysms.

Tracking the Fate of Muscle-derived Stem Cells: an Insight into the Distribution and Mode of Action

PURPOSE: To examine the fate of muscle-derived stem cells (MDSC) after injection into different host conditions and provide an insight for their mechanism of action. MATERIALS AND METHODS: MDSCs differentiated in vitro towards the endothelial lineage and transfected with lentivirus tagged with green fluorescent protein (GFP) were injected into two animal models mimicking vascular diseases: hindlimb ischemia and carotid injury models. Injected cells were tracked at the site of injection and in remote organs by harvesting the respective tissues at different time intervals and performing immunofluorescent histological analyses. Stem cell survival was quantified at the site of injection for up to 4 weeks. RESULTS: MDSCs were successfully tagged with fluorescent material GFP and showed successful implantation into the respective injection sites. These cells showed a higher affinity to implant in blood vessel walls as shown by double fluorescent co-stain with CD31. Quantification of stem cell survival showed a time-dependent decrease from day 3 to 4 weeks (survival rate normalized against day 3 was 72.0% at 1 week, 26.8% at 2 weeks and 2.4% at 4 weeks). Stem cells were also fo und in distant organs, especially the kidneys and liver, which survived up to 4 weeks. CONCLUSION: MDSCs were successfully tracked in different vascular disease models, and their fate was assessed in terms of cell survival and distribution. Better understanding of the donor cell properties, including their interaction with the host conditions and their mechanism of action, are needed to enhance cell survival and achieve improved outcomes.

Prospective nonrandomized comparison of quality of life and recurrence between high ligation and stripping and radiofrequency ablation for varicose veins / 대한외과학회지

PURPOSE: Varicose veins are a major problem worldwide and improvement in quality of life (QoL) is the ultimate goal after treatment of this benign disease. However QoL is highly dependent on personal and social factors. This study compares high ligation and stripping (HS) and radiofrequency ablation (RFA) in terms of QoL and recurrence in Korea. METHODS: A retrospective analysis of prospectively collected data between August 2006 and October 2008 was performed for patients undergoing HS and RFA at a single institution. QoL was assessed with a questionnaire preoperatively, at 3 months postoperatively and annually thereafter. Recurrence was assessed by Duplex ultrasound annually after surgery. RESULTS: A total of 272 patients completed the questionnaire at 3 months. Among these patients, 155 patients returned for their annual follow-up. There were no significant differences between HS and RFA in global QoL scores, although RFA showed less pain. However, paresthesia rates were also higher after RFA. Recurrence rates were similar between the two modalities, although technical failures were more common after RFA. CONCLUSION: Overall QoL and recurrence rates were similar between the two modalities. The benefits of RFA do not seem to be enough to overcome the higher costs of HS in Korea.

Total Laparoscopic Abdominal Aortic Aneurysm Repair: A Case Report / 대한혈관외과학회지

Open surgical repair has long been considered a mainstream treatment for abdominal aortic aneurysm (AAA). Although endovascular aneurysm repair is minimally invasive and yields satisfying short-term results, there has been concerns about it's the long-term durability. Recent studies showed that laparoscopic AAA repair is a feasible technique and that the benefits of laparoscopy can be consistent with open repair. In particular, total laparoscopic AAA repair has the advantage of reducing postoperative problems in abdominal wall and intestine, and increasing the patient's respiratory recovery and general comfort. In this paper, we report a successful case of total laparoscopic AAA repair. To our knowledge, this is the first report of total laparoscopic AAA repair in Korea.

Clinical Manifestations of BK Virus Infection in Kidney Transplant Recipients: A Single Center Experience / 대한이식학회지

BACKGROUND: BK virus (BKV) has emerged as an important cause of graft dysfunction and failure in renal transplant recipients. Reduction of immunosuppressive therapy is accepted as the primary strategy for management of BKV infection in renal transplant recipients, a strategy which frequently results in graft dysfunction and failure. Herein, a single center experience of BKV infection in renal transplant recipients is presented with an emphasis on the management of BKV infection. METHODS: We retrospectively reviewed the medical records of 107 renal transplant recipients who were treated at the outpatient clinic in Seoul National University Bundang Hospital from April 2003 to April 2011. The effects of the modification of immunosuppression on the replication of BKV and graft outcome were analyzed. RESULTS: Of a total of 35 patient evaluated for BKV infection, 20 tested positive in at least one BK virus test. Decoy cells in urine were detected in 13 of the 20 patients. Of these patients, 7 developed BKV nephropathy. Four out of seven of the BKV nephropathy patients were diagnosed with biopsy, and the other three were diagnosed based on a high titer of BKV replication detected in plasma samples. Despite the reduction in immunosuppression and use of leflunomide in the seven BKV nephropathy patients, two patients suffered deterioration of renal function and one patient lost the graft with progressive renal dysfunction. CONCLUSIONS: BK virus nephropathy was not an uncommon disease and was a major cause of graft dysfunction or loss. Appropriate modification of immunosuppressive therapy, early in the course of BK nephropathy or before the occurrence of massive replication of BKV, is essential for the protection of renal allografts.

Feasibility of Superficial Femoral Artery Intervention Using Mobile C-arms Compared to Fixed C-arms / 대한혈관외과학회지

PURPOSE: Endovascular therapy (ET) for peripheral arterial occlusive disease has increased dramatically in the past decade. ET is currently being performed by different specialists with available resources, with some of these resources being far superior to others, yet there have been no studies comparing the interventional outcomes according to the varying resources. The aim of this study was to analyze the outcomes of ET for superficial femoral artery (SFA) atherosclerosis using a mobile C-arm, in comparison to a historical control group. METHODS: Between March 2009 and December 2010, ET for SFA atherosclerosis was performed in 54 limbs from 47 patients using a mobile C-arm in the operation theater (mobile group). In contrast, a historical group for comparison consisted of 60 patients, for whom ET for SFA atherosclerosis was performed in 76 limbs using a fixed C-arm in the angiographic suite, between July 2003 and May 2008 (fixed group). The outcomes of ET for both groups were retrospectively analyzed by a medical chart review. RESULTS: There was no statistically significant difference in gender, age, risk factors, Trans-Atlantic Inter-Society Consensus (TASC) classification, intervention type, and postoperative blood creatinine levels between the two groups. However, procedural time was statistically higher in the mobile group. Patency rates at 1 year were 68.3% and 68.1% in the fixed and mobile group, respectively, which was not statistically significant. Subgroup analysis of 1 year patency rates for TASC A, B lesions and TASC C, D lesions were also similar. CONCLUSION: ET using the mobile C-arm in the operating theater is as effective as using the fixed C-arm, in the treatment of SFA atherosclerosis in terms of the technical success, patency, and early postoperative outcomes.

Experience of non-vascular complications following endovascular aneurysm repair for abdominal aortic aneurysm / 대한외과학회지

Endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA) is a widely used method, and its decreased invasiveness compared to traditional surgical repair has brought about reduced rates of morbidity and mortality. Several vascular complications related to the procedure have been reported, but non-vascular complications have rarely occurred. We report herein the case of a 78-year-old man who underwent EVAR for AAA and presented with active duodenal ulcer bleeding and acute acalculous cholecystitis as complications after the procedure. We must consider that a wide spectrum of complications may occur following EVAR, and therefore it is important to evaluate the risks of complication and to take the necessary measures to minimize them.

Drug-eluting Stent Implantation for a Below-the-knee Chronic Total Occlusion Lesion: A Case Report / 대한혈관외과학회지

For many years, surgical bypass has been considered mainstream therapy of below-the-knee peripheral arterial occlusive disease. The introduction of endovascular techniques and devices has made percutaneous transluminal angioplasty (PTA) and stenting feasible and safe in these patients. However, PTA has a significant risk of restenosis by elastic recoil and stenting is associated with restenosis by neointinal hyperplasia and vessel wall remodeling. With the advent of coronary artery drug eluting stent (DES), these limitations of PTA and stenting have been circumvented. Herein, we report a successful case of DES implantation for below-the-knee chronic total occlusion lesion. A 65-year-old male patient presented with severe claudication on his left leg. Computed tomography angiography showed long segment total occlusion involving the left distal superficial femoral, popliteal and proximal anterior tibial arteries. We tried to treat the lesion using endovascular surgery. During balloon angioplasty, flow limiting dissection developed in the proximal anterior tibial artery and we deployed a DES (Cypher, Cordis, Johnson & Johnson, USA) in that lesion. To our knowledge, this is the first report of DES for the treatment of below-the-knee chronic total occlusion lesion in Korea.