Preoperative Endovascular Abdominal Aortic Aneurysm Repair Planning with Centerline Measurement / 대한혈관외과학회지

PURPOSE: Sometimes, there are endograft shortenings during endovascular aneurysm repair (EVAR). They are associated with various changes of endograft position in a 3-dimensional (3D) space. The purpose of this study is to evaluate the accuracy of central luminal line (CLL) measurements and understand the degree of endograft shortenings. METHODS: Preoperative 3D computed tomographic (CT) scans were evaluated for every EVAR case. Preoperative working lengths were measured with computerized software that allowed for centerline measurements on 3D reconstructions based on CT data. We compared preoperative CLL measurements and used the endograft length. In this study, the ipsilateral limb length comparisons were excluded, because the overlapped stent-graft length can influence the total ipsilateral limb length. Hence, only the contralateral limb lengths were compared with each other. RESULTS: Preoperative contralateral lengths in the 9 limbs were studied. There was no large difference (below 10 mm) in almost all cases except for one (15 mm shortening), which was very tortuous aortoiliac anatomy. The mean difference between preoperative CLL measurements and the used stent-graft length was 4.48 mm. CONCLUSION: Although these shortenings can be overcome with the deployment technique, the operator should prepare various length extensions in tortuous anatomy.

Ischemic Colitis after Iliac Stenting / 대한혈관외과학회지

An ischemic colitis of the sigmoid colon and rectum following iliac balloon and stenting can be caused by embolism. The patient was 60 years old with a 20 year history of smoking. She had chief complaints of right calf claudication. From a lower extremity computed tomography (CT) scan, right iliac total occlusion (Trans-Atlantic Inter-Society Consensus C) and internal iliac artery occlusion were both observed. The patient had a hysterectomy history about 30 years ago. To improve right leg claudication, endovascular treatment was attempted through the right common femoral artery. There was no severe resistance to pass the occluded lesion. About 5 hours after successful stenting, she complained of a vague low abdominal discomfort and pain. There were no specific changes in the intraperitoneal organ in the follow-up CT scan. On postoperative day 1, she complained of aggravated lower abdominal pain. To confirm ischemic colitis, we performed a colonoscopy and both erythematous mucosal swelling and pethechia were present. On laparotomy, transmural infarction of the sigmoid colon and rectum were found and resected. A high level suspicion and a low threshold for performing colonoscopy are important in any patient thought to have ischemic colitis after iliac stenting.

Endograft Limb Occlusion after Endovascular Aneurysm Repair / 대한혈관외과학회지

Endovascular aneurysm repair (EVAR) has been increasingly used in order to treat infrarenal aortic aneurysms. However, there have been various complications and adverse events such as endoleak, graft migration, continued aneurysm expansion, and endograft limb occlusion (ELO). I have experienced a case of ELO. In order to treat it, I performed a thrombectomy using a 5F Fogarty catheter and a 12 mm balloon angioplasty. Thus, I report the results of treatment with the review of journals. The case involves a 54 year-old male who was treated Abdominal Aovtic Aneurysm (AAA) through EVAR. There was no definite anatomic contraindication for EVAR. The Zenith Flex was used and there was no specific problem during the EVAR procedure. At 6 months following EVAR, acute onset of cyanosis and coldness developed in the left leg. To minimize arterial wall injury and avoid endograft migration during balloon cather thrombectomy, fluoroscopically assisted thromboembolectomy was completed. After thromboembolectomy, balloon angioplasty was done in the stenotic lesion of the endograft. The ischemic symptoms (cyanosis, rest pain, coldness) improved after the procedures.

Results of Simultaneous Hybrid Operation in Multi-level Arterial Occlusive Disease

PURPOSE: Hybrid procedure in lower extremity arterial disease is composed of open bypass and endovascular treatment. For proximal inflow bypass operations for distal lesions used to be performed 1 or 2 weeks after endovascular therapy. Since Aug 2005, all hybrid operations have been performed simultaneously in the operation room in our center. In this study, we compared the results of the staged hybrid operations with those of simultaneous procedures. METHODS: From Jan 1999 to Dec 2009, 115 endovascular treatments and 139 bypass operations were performed. 44 bypasses were performed 1 day to 14 days after angioplasty in inflow lesions (group I) and 95 bypasses were performed simultaneously in the operation room with mobile fluoroscopy (group II). In both groups, inflow procedures included 3 femoral balloon angioplasties, 3 femoral stents, 24 iliac balloon angioplasties and 85 iliac stents. Bypass operations were composed of 39 femorofemoral and 102 infrainguinal bypasses including 60 femoropopliteal and 42 other bypasses. RESULTS: The 3-year patency rate of bypass graft is 71.5%. There is no difference in either group. But in endovascular treatment lesion, the 3-year patency rate is 80% and that of the simultaneous group is higher than that of the staged group (P<0.05). CONCLUSION: Hybrid operation is a less invasive therapy for revascularization in multilevel peripheral arterial occlusive disease. With development of endovascular therapy, simultaneous hybrid operations become more efficient.

Experience with Transobturator Foramen Bypass Surgery: a Case Report

The obturator bypass operation is not a common procedure. In 1963, Shaw and Baue first described performing bypass surgery through the obturator foramen as a technique to deal with infected arterial prostheses in the groin. This operation has been used to reconstruct patients with groin infection, irradiation ulcer, mycotic aneurysm, trauma and excessive scar tissue in the femoral region. We experienced one case of transobturator foramen bypass surgery from a Dacron iliac limb to the popliteal artery.

Placement of an Inferior Vena Cava Filter usingTransabdominal Duplex Scan Guidance: Report of Two Cases

An inferior vena cava (IVC) filter is a useful treatment to prevent a pulmonary embolism (PE) in patients with DVT. Since the introduction of IVC filters more than 30 years ago, there has been a steady improvement in the design, ease and safety of the delivery system. The use of a temporary filter has also increased as performing thrombolysis and thrombectomy has increased. Today all of the commonly used filters can be placed via a peripheral vein by using the standard percutaneous Seldinger (Ed note: check the spelling) technique. However this typically requires fluoroscopy, intravenous contrast agents, radiation exposure and transport of the patient to the interventional or operating suite. As the multiple trauma injured or critically-ill intensive care unit patients often require inotropic and ventilator support, transporting these patients to these facilities can be hazardous. The following report describes two cases of VTE patients who underwent percutaneous placement of an IVC filter with using duplex ultrasound guidance. Identification of the renal vein and artery is important to decide the infrarenal level. The first case was an 84 years female with right ilio-femoral DVT and pulmonary embolism. To prevent recurrence of PE, we decided to insert an IVC filter. The second case was a 47 years female with right femoral DVT together with left pulmonary embolism and infarction. She also had thrombocytopenia, which is a contraindication for anticoagulation. IVC filter insertion can be safely performed under ultrasound guidance. This technique will reduce the risk and complexity of inserting an IVC filter in selected multiple injured trauma patients.

Transesophageal Echocardiography in Patients withPeripheral Artery Embolization and Cardiac Disease

PURPOSE: In this study, we analyzed the results of transesophageal echocardiography (TEE) in acute peripheral arterial occlusion patients. METHOD: Over the course of eight years, 124 patients were treated for acute peripheral artery occlusion, and 51 patients underwent transthoracic echocardiogram (TTE) and TEE postoperatively to evaluate for a possible cardiac source of thromboemboli. TEE findings in atrial fibrillation (AF) patients were compared with TEE findings in patients who had AF without thromboembolic events. RESULT: AF was the most common cardiac pathology (35/51). Remnant cardiac thrombi were found in 15 patients, all in the left atrium. The average thrombus size was 1.22x0.99 cm. Surgical thrombectomy was performed in two patients, and oral anticoagulation was performed in the others. During a mean follow-up period of 38 months, 7 patients (13.7%) had recurrent thromboembolic events, even while being treated with anticoagulation. Eleven of 15 patients with remnant cardiac thrombus showed no specific clinical events during the follow-up period. CONCLUSION: Remnant cardiac thrombus was found in 1/3 of patients with acute peripheral arterial occlusion caused by AF. The remnant thrombus could be safely treated with anticoagulation. Left atrial enlargement and spontaneous echogenicity were found to be risk factors for thromboembolism in AF.

The Effect of Preoperative Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma (prospective study) / 한국간담췌외과학회지

BACKGROUND/AIMS: The effect of preoperative Transcatheter Arterial Chemoembolization (TACE) in the management of Hepatocellular carcinoma (HCC) has remained controversial and lack of prospective study. To investigate the impact of preoperative TACE, we have performed a prospective study in HCC patients with tumor size below 5 cm. METHODS: From November 1998 through March 2002, 126 patients with HCC who had been referred for surgical resection were prospectively allocated to Group I (preoperative TACE, n=42) and Group II (simple hepatic angiography only, n=38). Patients who were underwent noncurative hepatic resection (n=4) were excluded and the groups with large tumor mass (above 5 cm) with or without TACE (n=64) were excluded from this analysis due to insufficient number. The impact of preoperative TACE on incidence of complication as well as long term overall and disease free survival rate were analyzed. RESULTS: Preoperative demographics and intraoperative data were compatible between two groups. There were no difference in complication rates between two groups. The 3 year survival rate of Group I and Group II were 88.10% and 58.32% respectively. The 3 year disease-free survival rate of Group I and Group II were 40.14% and 34.89% respectively. The 3 year overall rate was significantly high in Group I (p=0.0348), disease-free survival rate did not show difference between two groups (p=0.6132). CONCLUSION: Preoperative TACE can be done safely and showed improved overall survival rate in this prospective study, however fruther prospective study with longer period of follow up will be necessary to prove the effect of preoperative TACE.