Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

Background/Aims@#Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. @*Methods@#We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. @*Results@#The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). @*Conclusions@#Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Effects of Intracoronary Administration of Autologous Adipose Tissue-Derived Stem Cells on Acute Myocardial Infarction in a Porcine Model

PURPOSE: Adipose-derived stem cells (ADSCs) are known to be potentially effective in regeneration of damaged tissue. We aimed to assess the effectiveness of intracoronary administration of ADSCs in reducing the infarction area and improving function after acute transmural myocardial infarction (MI) in a porcine model. MATERIALS AND METHODS: ADSCs were obtained from each pig's abdominal subcutaneous fat tissue by simple liposuction. After 3 passages of 14-days culture, 2 million ADSCs were injected into the coronary artery 30 min after acute transmural MI. At baseline and 4 weeks after the ADSC injection, 99mTc methoxyisobutylisonitrile-single photon emission computed tomography (MIBISPECT) was performed to evaluate the left ventricular volume, left ventricular ejection fraction (LVEF; %), and perfusion defects as well as the myocardial salvage (%) and salvage index. At 4 weeks, each pig was sacrificed, and the heart was extracted and dissected. Gross and microscopic analyses with specific immunohistochemistry staining were then performed. RESULTS: Analysis showed improvement in the perfusion defect, but not in the LVEF in the ADSC group (n=14), compared with the control group (n=14) (perfusion defect, -13.0+/-10.0 vs. -2.6+/-12.0, p=0.019; LVEF, -8.0+/-15.4 vs. -15.9+/-14.8, p=0.181). There was a tendency of reducing left ventricular volume in ADSC group. The ADSCs identified by stromal cell-derived factor-1 (SDF-1) staining were well co-localized by von Willebrand factor and Troponin T staining. CONCLUSION: Intracoronary injection of cultured ADSCs improved myocardial perfusion in this porcine acute transmural MI model.

Effects of Low Dose Pioglitazone on Restenosis and Coronary Atherosclerosis in Diabetic Patients Undergoing Drug Eluting Stent Implantation

PURPOSE: Thiazolidinediones are insulin-sensitizing agents that reduce neointimal proliferation and the adverse clinical outcomes associated with percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). There is little data on whether or not low dose pioglitazone reduces adverse clinical outcomes. MATERIALS AND METHODS: The study population included 121 DM patients with coronary artery disease and they were randomly assigned to 60 patients taking 15 mg of pioglitazone daily in addition to their diabetic medications and 61 patients with placebo after the index procedure with drug-eluting stents (DESs). The primary end points were rate of in-stent restenosis (ISR) and change in atheroma volume and in-stent neointimal volume. The secondary end points were all-cause death, myocardial infarction (MI), stent thrombosis and re-PCI. RESULTS: There were no statistical differences in the clinical outcomes and the rate of ISR between the two groups [all-cause death; n=0 (0%) in the pioglitazone group vs. n=1 (1.6%) in the control group, p=0.504, MI; n=2 (3.3%) vs. n=1 (1.6%), p=0.465, re-PCI; n=6 (10.0%) vs. n=6 (9.8%), p=0.652, ISR; n=4 (9.3%) vs. n=4 (7.5%), p=1.000, respectively]. There were no differences in changes in neointimal volume, percent neointimal volume, total plaque volume and percent plaque volume between the two groups on intravascular ultrasonography (IVUS) study. CONCLUSION: Our study demonstrated that low dose pioglitazone does not reduce rate of ISR, neointimal volume nor atheroma volume in DM patients who have undergone PCI with DESs, despite the limitations of the study.

Thoracic Endovascular Aortic Repair of a Penetrating Aortic Ulcer in the Thoracic Aorta Combined with an Abdominal Aortic Aneurysm / 대한내과학회지

Penetrating aortic ulcers (PAUs) are part of acute aortic syndrome and can cause aortic rupture. We report a case of abdominal aortic aneurysm (AAA) with a PAU in the thoracic aorta. The patient was treated with thoracic aortic endovascular repair (TEVAR) for the PAU and open repair for the AAA. A 78-year-old man was admitted due to abdominal discomfort. Computed tomography (CT) showed a 6.8-cm AAA with a short neck and a large (4.2 x 3.3 cm) thoracic PAU. The patient was scheduled for AAA repair. Due to the risk of rupture of the thoracic PAU, TEVAR was performed in the PAU before surgery for the AAA. After stent graft insertion, the patient underwent surgery to repair the AAA. A follow-up CT scan showed no endoleakage or thrombus formation in the PAU. The patient had no specific symptoms during 1 year of follow-up.

A Case of Ectopic Thyroid Tissue Diagnosed by Fine Needle Aspiration in the Lateral Neck

Ectopic thyroid glands generally occur in the midline as a result of abnormal median migration and their presence in lateral to the midline is rare. Embryologically, the thyroid gland is derived from two anlages: a large median endodermal anlage and two lateral anlages. The median anlage produces most of the thyroid parenchyma, whereas the lateral anlage is derived from the fourth pharyngeal pouch and contributes 1-30% of the thyroid weight. In rare cases, failure of the lateral anlage to fuse with the median anlage can result in lateral ectopic thyroid gland. For many years, lateral, aberrant thyroid tissue in adults was a term used almost exclusively for metastatic thyroid carcinoma. However, aberrant, benign ectopic thyroid tissue rarely occurs. We present a 47-year-old man who had incidentally detected mass on the right lateral neck. He was clinically in a euthyroid status and the thyroid function test results were normal as well. Neck ultrasonography revealed a mild diffuse goiter and a 1.22 x 0.65 cm sized ovoid mass like lesion was located in the right level IV of the neck. The result of fine needle aspiration cytology was adenomatous goiter without lymphoid tissue or any malignancy. We rarely report aberrant, benign ectopic thyroid presence as a lateral neck mass.

A Case of Actinomycotic Thyroiditis in an Adult with Piriform Sinus Fistula

Acute suppurative thyroiditis is an uncommon infectious thyroid disease affecting mainly children and young adults. The route of infection is frequently a pyriform sinus fistula. The major pathogens responsible for acute bacterial suppurative thyroiditis are the Streptococcus and Staphylococcus species. In contrast, Actinomyces species are a very rare cause of acute suppurative thyroiditis. We experienced a case of a 23-year-old man who has presented general weakness and neck pain. Thyroid ultrasonography showed an ill-defined area of heterogeneous hypoechogenicity in the left lobe of the thyroid gland. Histologic examination by fine needle aspiration demonstrated gram-positive, filamentous-like organisms with branching hyphae and characteristic sulfur granules. Barium esophagogram showed a linear barium-filled track at the left pyriform sinus. We report a case of actinomycotic thyroiditis in a young adult with pyriform sinus fistula along with a brief review of related literature.

The Modified Chimney Technique With a Thoracic Aortic Stent Graft to Preserve the Blood Flow of the Left Common Carotid Artery for Treating Descending Thoracic Aortic Aneurysm and Dissection

While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

Thoracic Endovascular Aortic Repair of a Penetrating Aortic Ulcer in the Thoracic Aorta Combined with an Abdominal Aortic Aneurysm / 대한내과학회지

Penetrating aortic ulcers (PAUs) are part of acute aortic syndrome and can cause aortic rupture. We report a case of abdominal aortic aneurysm (AAA) with a PAU in the thoracic aorta. The patient was treated with thoracic aortic endovascular repair (TEVAR) for the PAU and open repair for the AAA. A 78-year-old man was admitted due to abdominal discomfort. Computed tomography (CT) showed a 6.8-cm AAA with a short neck and a large (4.2 x 3.3 cm) thoracic PAU. The patient was scheduled for AAA repair. Due to the risk of rupture of the thoracic PAU, TEVAR was performed in the PAU before surgery for the AAA. After stent graft insertion, the patient underwent surgery to repair the AAA. A follow-up CT scan showed no endoleakage or thrombus formation in the PAU. The patient had no specific symptoms during 1 year of follow-up.

A Case of a Neuroendocrine Carcinoma in the Minor Papilla / 대한소화기학회지

Neuroendocrine tumors are usually found in the ileum, appendix, rectum, colon and stomach. Ampullary neuroendocrine tumor is extremely rare and only a few cases of neuroendocrine carcinoma of the minor papilla have been reported. The preoperative diagnosis is very challenging because either asymptomatic or manifests as nonspecific abdominal pain. The tumor is relatively small and located at the deep mucosa and submucosa. Endoscopy with deep biopsy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography are good diagnostic tools. The best therapeutic choice is surgery. We report an unusual case of a 55-year-old woman who underwent endoscopy as part of a regular health checkup and was diagnosed a neuroendocrine carcinoma in the minor papilla, which was successfully resected by pancreaticoduodenectomy.

Endovascular Management of Acute Total Occlusion of the Aorta

Acute total occlusion of the aorta is a rare and clinically critical condition requiring aggressive immediate diagnosis and treatment. A 73-year-old male was seen at our hospital complaining of pain sensation in both legs. Under the likely impression of an acute total occlusion of the aorta, emergency abdominal aortogram was done, which revealed total occlusion of the distal aorta and both iliac arteries. Intra-arterial thrombolysis with urokinase was attempted for 48 hours as intervention during the acute stage is highly related to distal thromboembolic events. Follow-up angiography showed improved arterial flow but residual stenosis at both the common iliac arteries. Self-expandable nitinol stents were inserted at both the iliac arteries by the v-kissing technique resulting in a satisfying outcome as seen on angiography without complications. The patient was discharged without additional medical problems. From our experience, we conclude that the use of intra-arterial thrombolysis with percutaneous transluminal angioplasty is an alternative to the conventional surgical approach in treating acute total occlusion of the aorta.

A Case of Primary NK/T Cell Lymphoma of the Testis

Primary testicular lymphoma account for 1~5% of all testicular neoplasms. The majority of these tumors are diffuse large B-cell non-Hodgkin lymphoma. Primary NK/T cell lymphoma of the testis is a rare entity. Regardless of treatment, the majority of these patients have exhibited a highly aggressive clinical course and they have died within 1 year because of early dissemination. We report here on a case of the aggressive 'nasal type' natural killer (NK)/T cell lymphoma that initially presented as a testicular tumor. A 63-year-old man presented with painless left testicular swelling, and so a left orchiectomy was performed. A biopsy specimen of the testis revealed an extranodal NK/T cell lymphoma of the nasal type. In-situ hybridization for Epstein-Barr virus proved positive. The patient received systemic chemotherapy with 3 courses of a combination regimen.