Innovative hybrid procedure for dissection thoracic aorta in a patient with a previous bentall operation.

AIMS AND OBJECTIVES: In dissection aorta involving the whole aorta from the left subclavian artery surgical repair may be a high risk procedure while an endovascular procedure would not be feasible by itself in view of the absence of a safe landing zone and the risk of blocking the brain and arm circulation. A hybrid procedure is presented to tackle such a problem. METHODS: A 42-year-old Marfan, with a previous history of a Bentall procedure 10 years back, presented with acute thoracic aortic dissection. Investigations revealed a large dissection starting from the left subclavian to the right renal artery. Since a safe landing zone was required which would block off the arch vessels, first a redo sternotomy was performed and under femoro-femoral cardio-pulmonary bypass (CPB), a short segment of Dacron graft was interposed between the previous Bentall graft and the arch of aorta. On to this graft, 2 additional grafts were anastomosed. A 14 X 9 bifurcated graft to go to the right brachiocephalic and the left common carotid, and a 9 mm side arm to facilitate the positioning of the endograft. After coming off CPB, a guide wire was manipulated from the femoral artery into the side graft with a snare and the endograft was inserted. RESULTS: The false lumen was successfully obliterated. The patient made a complete recovery with no neurological deficit. CONCLUSIONS: A hybrid procedure with an innovative technique of preserving the brain and arm circulation and a new technique of facilitating proper positioning of the endostent with a side arm conduit is presented.

Treatment of acute lower gastrointestinal hemorrhage by superselective transcatheter embolization.

AIM: To evaluate the technical feasibility, success of hemostasis and complications of transcatheter embolization in the treatment of acute lower gastrointestinal (GI) bleeding. METHODS: Retrospective review of 63 patients with acute lower GI bleed who had undergone transcatheter selective embolization of mesenteric arteries over a two-year period. Embolization was carried out only if the arteria recta leading to the bleed could be successfully catheterized (n=52). The lesions treated were located in the jejunum (n=13), ileum and ileo-cecal region (n=9), appendicular region (n=2) and colon (n=28). Embolization was performed with only polyvinyl alcohol particles (PVA) (250-500 microns) in 23 patients, only microcoils in 16 patients and both PVA particles and microcoils in 13 patients. Twenty-eight patients were evaluated for objective evidence of ischemia by colonoscopy (n=21) and/or histologic evidence in the surgical specimen (n=7); 23 patients were followed up clinically. RESULTS: Immediate hemostasis was achieved in 61 of 63 patients; of the remaining 2 patients, one underwent surgery whereas the other died during the procedure. Recurrent bleeding occurred in 9 patients - 6 were managed surgically and 3 medically. Endoscopic evaluation showed mucosal ischemia in 7 patients but they remained asymptomatic on follow up. Embolization was the sole modality of treatment in 41 patients (78.9%). CONCLUSION: Transcatheter superselective embolization is an effective and safe modality of treatment for acute lower GI bleeding.

Transcatheter embolization as primary treatment for visceral pseudoaneurysms in pancreatitis: clinical outcome and imaging follow up.

BACKGROUND: Pseudoaneurysm formation is an uncommon but fatal complication of pancreatitis. The morbidity and mortality associated with surgical management is high. Transcatheter embolization is a definitive minimally invasive form of treatment. AIM: To review our experience with transcatheter embolization as a therapeutic modality for pseudoaneurysms complicating pancreatitis. METHODS: This retrospective analysis included data of 30 patients (mean age 37 years, range 25 to 65; 24 men) with visceral pseudoaneurysms secondary to pancreatitis, who underwent diagnostic angiography and transcatheter embolization, during the period March 1993 to February 2003. RESULTS: In 29 patients the pseudoaneurysms were successfully isolated from the circulation, and hemostasis was achieved. Re-bleeding occurred in one patient, for which re-embolization was done. Twenty-nine patients improved clinically. One patient in whom the pseudoaneurysm was successfully embolized died due to septicemic shock. CONCLUSION: Endovascular embolization is a safe and effective non-surgical modality of treatment for visceral pseudoaneurysms complicating pancreatitis.