Outcome-Based Decision-Making Algorithm for Treating Patients with Primary Aldosteronism

Background@#Optimal management of primary aldosteronism (PA) is crucial due to the increased risk of cardiovascular and cerebrovascular diseases. Adrenal venous sampling (AVS) is the gold standard method for determining subtype but is technically challenging and invasive. Some PA patients do not benefit clinically from surgery. We sought to develop an algorithm to improve decision- making before engaging in AVS and surgery in clinical practice. @*Methods@#We conducted the ongoing Korean Primary Aldosteronism Study at two tertiary centers. Study A involved PA patients with successful catheterization and a unilateral nodule on computed tomography and aimed to predict unilateral aldosterone-producing adenoma (n=367). Study B involved similar patients who underwent adrenalectomy and aimed to predict postoperative outcome (n=330). In study A, we implemented important feature selection using the least absolute shrinkage and selection operator regression. @*Results@#We developed a unilateral PA prediction model using logistic regression analysis: lowest serum potassium level ≤3.4 mEq/L, aldosterone-to-renin ratio ≥150, plasma aldosterone concentration ≥30 ng/mL, and body mass index <25 kg/m2 (area under the curve, 0.819; 95% confidence interval, 0.774 to 0.865; sensitivity, 97.6%; specificity, 25.5%). In study B, we identified female, hypertension duration <5 years, anti-hypertension medication <2.5 daily defined dose, and the absence of coronary artery disease as predictors of clinical success, using stepwise logistic regression models (sensitivity, 94.2%; specificity, 49.3%). We validated our algorithm in the independent validation dataset (n=53). @*Conclusion@#We propose this new outcome-driven diagnostic algorithm, simultaneously considering unilateral aldosterone excess and clinical surgical benefits in PA patients.

Percutaneous Transhepatic Treatment of Benign Bile Duct Strictures Using Retrievable Covered Stents: Long-Term Outcomes in 148 Patients

Objective@#To investigate the long-term outcomes of percutaneous treatment of benign biliary strictures using temporary placement of a retrievable expanded polytetrafluoroethylene (PTFE) covered stent. @*Materials and Methods@#We retrospectively analyzed the outcomes of 148 patients (84 male and 64 female; age range, 11–92 years) who underwent percutaneous transhepatic placement and removal of a retrievable PTFE-covered stent for the treatment of benign biliary strictures between March 2007 and August 2019 through long-term follow-up. Ninety-two patients had treatment-naïve strictures and 56 had recurrent/refractory strictures. @*Results@#Stent placement was technically successful in all 148 patients. The mean indwelling period of the stent was 2.4 months (median period, 2.3 months; range, 0.2–7.7 months). Stent migration, either early or late, occurred in 28 (18.9%) patients. Clinical success, defined as resolution of stricture after completing stent placement and removal, was achieved in 94.2% (131 of 139 patients). The overall complication rate was 15.5% (23 of 148 patients). During the mean follow-up of 60.2 months (median period, 52.7 months; range, 1.6–146.1 months), 37 patients had a recurrence of clinically significant strictures at 0.5–124.5 months after removal of biliary stent and catheter (median, 16.1 months). The primary patency rates at 1, 3, 5, 7, and 10 years after removal of biliary stent and catheter were 88.2%, 70.0%, 66.2%, 60.5%, and 54.5%, respectively. In the multivariable Cox proportional hazard regression analysis, sex, age, underlying disease, relation to surgery, stricture type, biliary stones, history of previous treatment, and stricture site were not significantly associated with the primary patency. @*Conclusion@#Long-term outcomes suggest that percutaneous treatment of benign biliary strictures using temporary placement of retrievable PTFE-covered stents may be a clinically effective method.

Diagnostic Accuracy of Computed Tomography in Predicting Primary Aldosteronism Subtype According to Age

Background@#Guidelines by the Endocrine Society Guideline on bypassing adrenal vein sampling (AVS) in patients 15.9 ng/dL) and unilateral lesion, accuracy of CT was 84.6% (11/13) in patients aged 29.6 ng/dL, respectively. The significant difference in accuracy of CT in 198 patients with marked PA and a unilateral lesion between the 30.0 ng/dL (91.9% vs. 87.7%, P=0.590). @*Conclusion@#Patients with hypokalemia, PAC >30.0 ng/dL, and unilateral lesion were at high risk of unilateral PA regardless of age.

Diagnostic Accuracy of Computed Tomography in Predicting Primary Aldosteronism Subtype According to Age

Background@#Guidelines by the Endocrine Society Guideline on bypassing adrenal vein sampling (AVS) in patients 15.9 ng/dL) and unilateral lesion, accuracy of CT was 84.6% (11/13) in patients aged 29.6 ng/dL, respectively. The significant difference in accuracy of CT in 198 patients with marked PA and a unilateral lesion between the 30.0 ng/dL (91.9% vs. 87.7%, P=0.590). @*Conclusion@#Patients with hypokalemia, PAC >30.0 ng/dL, and unilateral lesion were at high risk of unilateral PA regardless of age.

Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency

Objective@#To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. @*Materials and Methods@#The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38–90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox’s proportional hazard model. @*Results@#The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78–135 days) and 270 days (95% CI, 95–444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox’s proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157–12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249–450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115–225 days). @*Conclusion@#The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

Update on Transarterial Chemoembolization with Drug-Eluting Microspheres for Hepatocellular Carcinoma

Conventional transcatheter arterial chemoembolization (c-TACE) is a widely used first-line palliative treatment for patients with unresectable hepatocellular carcinoma (HCC). Despite the effectiveness of c-TACE, to date, technique and procedure scheduling has not yet been standardized. Drug-eluting microspheres (DEMs) were therefore introduced to ensure more sustained and tumor-selective drug delivery for permanent embolization. These DEMs can load various drugs and release them in a sustained manner over a prolonged period. This approach ensures the delivery of high concentrations of chemotherapeutic agents to tumors, without increasing systemic concentrations, and promote tumor ischemia and necrosis. This review summarizes the recent advances in the use of DEM-TACE to treat HCC.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

OBJECTIVE: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). MATERIALS AND METHODS: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. RESULTS: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. CONCLUSION: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: The Role of Intra-Procedural Cone-Beam Computed Tomography

OBJECTIVE: To investigate the technical and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) for the treatment of gastric varices (GV) and to evaluate the role of intra-procedural cone-beam computed tomography (CBCT) performed during PARTO to confirm its technical success. MATERIALS AND METHODS: From January 2016 to December 2016, 17 patients with GV who had undergone PARTO were retrospectively evaluated. When the proximal part of the afferent vein was identified on a fluoroscopy, non-contrast CBCT images were obtained. In patients with incomplete embolization of GV, an additional injection of gelatin sponges was performed. Follow-up data from contrast-enhanced CT and upper intestinal endoscopy, as well as clinical and laboratory data were collected. RESULTS: Plug-assisted retrograde transvenous obliteration procedures were technically successful in all 17 patients. Complete embolization of GV was detected on CBCT images in 15 patients; whereas, incomplete embolization was detected in two. Complete embolization of GV was then achieved after an additional injection of gelatin sponges in these two patients as demonstrated on the 2nd CBCT image. The mean follow-up period after PARTO was 193 days (range, 73–383 days). A follow-up CT obtained 2–4 months after PARTO demonstrated marked shrinkage or complete obliteration of GV and portosystemic shunts in all 17 patients. There were no cases of variceal bleeding during the follow-up. CONCLUSION: Plug-assisted retrograde transvenous obliteration is technically and clinically effective for the treatment of GV. In addition, intra-procedural CBCT can be an adjunct tool to fluoroscopy, because it can provide an immediate and accurate evaluation of the technical success of PARTO.

Double-Stent System with Long Duodenal Extension for Palliative Treatment of Malignant Extrahepatic Biliary Obstructions: A Prospective Study

OBJECTIVE: To investigate the technical safety and clinical efficacy of a double-stent system with long duodenal extension in patients with malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: This prospective study enrolled 48 consecutive patients (31 men, 17 women; mean age, 61 years; age range, 31–77 years) with malignant extrahepatic biliary obstructions from May 2013 to December 2015. All patients were treated with a double-stent system with long duodenal covered extension (16 cm or 21 cm). RESULTS: The stents were successfully placed in all 48 patients. There were five (10.4%) procedure-related complications. Minor complications were self-limiting hemobilia (n = 2). Major complications included acute pancreatitis (n = 1) and acute cholecystitis (n = 2). Successful internal drainage was achieved in 42 (87.5%) patients. Median patient survival and stent patency times were 92 days (95% confidence interval [CI], 61–123 days) and 83 days (95% CI, 46–120 days), respectively. Ten (23.8%) of the 42 patients presented with stent occlusion due to food impaction with biliary sludge, and required repeat intervention. Stent occlusion was more frequent in metastatic gastric cancer patients with pervious gastrectomy, but did not reach statistical significance (p = 0.069). CONCLUSION: Percutaneous placement of a double-stent system with long duodenal extension is feasible and safe. However, this stent system does not completely prevent stent occlusion caused by food reflux.

Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Transvenous Lead Extraction via the Inferior Approach Using a Gooseneck Snare versus Simple Manual Traction

BACKGROUND AND OBJECTIVES: The number of patients with cardiac implantable electronic devices needing lead extraction is increasing for various reasons, including infections, vascular obstruction, and lead failure. We report our experience with transvenous extraction of pacemaker and defibrillator leads via the inferior approach of using a gooseneck snare as a first-line therapy and compare extraction using a gooseneck snare with extraction using simple manual traction. SUBJECTS AND METHODS: The study included 23 consecutive patients (43 leads) who underwent transvenous lead extraction using a gooseneck snare (group A) and 10 consecutive patients (17 leads) who underwent lead extraction using simple manual traction (group B). Patient characteristics, indications, and outcomes were analyzed and compared between the groups. RESULTS: The dwelling time of the leads was longer in group A (median, 121) than in group B (median, 56; p=0.000). No differences were noted in the overall procedural success rate (69.6% vs. 70%), clinical procedural success rate (82.6% vs. 90%), and lead clinical success rate (86% vs. 94.1%) between the groups. The procedural success rates according to lead type were 89.2% and 100% for pacing leads and 66.7% and 83.3% for defibrillator leads in groups A and B, respectively. Major complications were noted in 3 (mortality in 1) patients in group A and 2 patients in group B. CONCLUSION: Transvenous extraction of pacemaker leads via an inferior approach using a gooseneck snare was both safe and effective. However, stand-alone transvenous extraction of defibrillator leads using the inferior approach was suboptimal.

Segmental arterial mediolysis: Literature review focused on radiologic findings and management

Segmental arterial mediolysis (SAM) is a rare disease which can have catastrophic consequences due to massive hemorrhage or dissecting hematomas. The pathophysiology of this disease is not well-known, and the symptoms vary according to the organs involved. In many patients the diagnosis is based on the clinical and radiologic features rather than the pathologic confirmation. The catheter-based endovascular technique can be an interventional treatment option for SAM, as well as surgical management.

Post-Operative Hemorrhage after Myomectomy: Safety and Efficacy of Transcatheter Uterine Artery Embolization

OBJECTIVE: To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage. MATERIALS AND METHODS: We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted. RESULTS: The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients. CONCLUSION: Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Covered Stent Placement for the Treatment of Malignant Superior Vena Cava Syndrome: Is Unilateral Covered Stenting Safe and Effective?

OBJECTIVE: To evaluate the safety and efficacy of unilateral covered stent placement in patients with malignant superior vena cava (SVC) syndrome. MATERIALS AND METHODS: Between October 2008 and November 2012, expanded polytetrafluoroethylene-covered stent placement for malignant SVC syndrome was performed in 40 consecutive patients (35 men and five women; mean age, 61.4 years; range, 35-81 years). All covered stents were unilaterally placed within the SVC or across the venous confluence when needed to relieve venous obstruction and prevent tumor overgrowth, regardless of patency of contralateral brachiocephalic veins. RESULTS: Stent placement was technically successful in all patients. There were no major complications. Of the 37 patients symptomatic prior to stent placement, 34 (92%) experienced complete symptomatic relief 1-8 days after stent placement. Of the 29 patients who underwent covered stent placement across the venous confluence, nine patients had patent contralateral brachiocephalic veins prior to stent placement. However, no sign of SVC obstruction or contralateral upper extremity venous thrombosis was observed during the follow-up period. Kaplan-Meier analysis revealed median patient survival of 163 days. Stent occlusion occurred in four (10%) of 40 patents. Cumulative stent patency rates at 1, 3, 6, and 12 months were 95%, 92%, 86%, and 86%, respectively. CONCLUSION: Unilateral covered stent placement appears to be a safe and effective method for treating malignant SVC syndrome, despite the location of SVC occlusion.

Transcatheter Arterial Chemoembolization for Infiltrative Hepatocellular Carcinoma: Clinical Safety and Efficacy and Factors Influencing Patient Survival

OBJECTIVE: To evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) in patients with infiltrative hepatocellular carcinoma (HCC) and to identify the prognostic factors associated with patient survival. MATERIALS AND METHODS: Fifty two patients who underwent TACE for infiltrative HCC were evaluated between 2007 and 2010. The maximum diameter of the tumors ranged from 7 cm to 22 cm (median 15 cm). Of 46 infiltrative HCC patients with portal vein tumor thrombosis, 32 patients received adjuvant radiation therapy for portal vein tumor thrombosis after TACE. RESULTS: The tumor response by European Association for the Study of the Liver criteria was partial in 18%, stable in 47%, and progressive in 35% of the patients. The median survival time was 5.7 months (Kaplan-Meier analysis). The survival rates were 48% at six months, 25% at one year, and 12% at two years. In the multivariable Cox regression analysis, Child-Pugh class (p = 0.02), adjuvant radiotherapy (p = 0.003) and tumor response after TACE (p = 0.004) were significant factors associated with patient survival. Major complications occurred in nine patients. The major complication rate was significantly higher in patients with Child-Pugh B than in patients with Child-Pugh A (p = 0.049, chi2 test). CONCLUSION: Transcatheter arterial chemoembolization can be a safe treatment option in infiltrative HCC patients with Child Pugh class A. Child Pugh class A, radiotherapy for portal vein tumor thrombosis after TACE and tumor response are good prognostic factors for an increased survival after TACE in patients with infiltrative HCCs.

Safety and Efficacy of Transarterial Nephrectomy as an Alternative to Surgical Nephrectomy

OBJECTIVE: To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy. MATERIALS AND METHODS: This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes. RESULTS: The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension. CONCLUSION: Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.

Management of Bleeding Uterine Arteriovenous Malformation with Bilateral Uterine Artery Embolization

PURPOSE: To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM). MATERIALS AND METHODS: Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies. RESULTS: A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure-related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term. CONCLUSION: Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.

Midterm Outcomes of Open Surgical Repair Compared with Thoracic Endovascular Repair for Isolated Descending Thoracic Aortic Disease

OBJECTIVE: This study aimed to assess the surgical morbidity and mortality of thoracic endovascular repair (TEVAR) as compared with open surgical repair (OSR) for isolated descending thoracic aortic disease. MATERIALS AND METHODS: From January 1, 2006 through May 31, 2010, a total of 68 patients with isolated descending thoracic aortic disease were retrospectively reviewed for the presence of perioperative complication, 30-day mortality, and clinical success. The patients were divided into two groups (group 1, OSR, n = 40 vs. group 2, TEVAR, n = 28) and these groups were compared for major variables and late outcomes. RESULTS: The mean age was 58 years (group I = 54 vs. group II = 63 years, p = 0.011). Significant perioperative complications occurred in 12 patients: 8 (20%) in group I and 4 (13%) in group II (p = 0.3). There were five 30 day mortalities of which 4 occurred in group I and 1 in group II (p = 0.23). Clinical success (effective aortic remodeling and complete false lumen obliteration or thrombosis) was achieved in 20 patients (71%). Mean Kaplan-Meier survival rate at 1 year was similar for both groups (group 1 = 87% vs. group 2 = 80%, p = 0.65). CONCLUSION: Thoracic endovascular repair for isolated thoracic aortic disease shows comparable results to OSR. However, the potential for endoleak or rupture remains a challenge that needs to be addressed in the future. Therefore, close follow-up study is needed for the evaluation of satisfactory long-term outcomes.

Incidence and Management of Bleeding Complications Following Percutaneous Radiologic Gastrostomy

OBJECTIVE: Upper gastrointestinal (GI) bleeding is a serious complication that sometimes occurs after percutaneous radiologic gastrostomy (PRG). We evaluated the incidence of bleeding complications after a PRG and its management including transcatheter arterial embolization (TAE). MATERIALS AND METHODS: We retrospectively reviewed 574 patients who underwent PRG in our institution between 2000 and 2010. Eight patients (1.4%) had symptoms or signs of upper GI bleeding after PRG. RESULTS: The initial presentation was hematemesis (n = 3), melena (n = 2), hematochezia (n = 2) and bloody drainage through the gastrostomy tube (n = 1). The time interval between PRG placement and detection of bleeding ranged from immediately after to 3 days later (mean: 28 hours). The mean decrease in hemoglobin concentration was 3.69 g/dL (range, 0.9 to 6.8 g/dL). In three patients, bleeding was controlled by transfusion (n = 2) or compression of the gastrostomy site (n = 1). The remaining five patients underwent an angiography because bleeding could not be controlled by transfusion only. In one patient, the bleeding focus was not evident on angiography or endoscopy, and wedge resection including the tube insertion site was performed for hemostasis. The other four patients underwent prophylactic (n = 1) or therapeutic (n = 3) TAEs. In three patients, successful hemostasis was achieved by TAE, whereas the remaining one patient underwent exploration due to persistent bleeding despite TAE. CONCLUSION: We observed an incidence of upper GI bleeding complicating the PRG of 1.4%. TAE following conservative management appears to be safe and effective for hemostasis.

Hybrid Procedure for a Traumatic Aortic Rupture Consisting of Endovascular Repair and Minimally Invasive Arch Vessel Transposition without Sternotomy

Emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri-procedural mortality rate. Endovascular stent-grafting, as a less invasive procedure, has shown encouraging results. This report describes a patient with a short landing zone, who was treated by transposing the supra-aortic branch without sternotomy, followed by covered stent-grafting with an extended proximal bare portion to enhance fixation.