Chimney technique for a solitary pelvic kidney.

The combination of a solitary pelvic kidney and an abdominal aortic aneurysm is extremely rare. We demonstrate a chimney graft implant in a patient with a solitary pelvic kidney. A 63-year-old man was diagnosed with an abdominal aortic aneurysm found incidentally. Preoperative computed tomography illustrated a fusiform abdominal aortic aneurysm accompanying a solitary ectopic kidney in the pelvis with an aberrant renal artery. A bifurcated endograft was implanted, and a covered stent graft was placed into the renal artery using the chimney technique. Good patency of the chimney graft was documented with early postoperative and first month scans. To the best of our knowledge, this is the first report of the chimney technique used for a solitary pelvic kidney.

Nonoperative Management of Leaks After Laparoscopic Sleeve Gastrectomy With Endoscopic Stents in a Tertiary Referral Center.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a frequently performed operation. Leaks are formidable complications; however, the optimal management of these leaks is controversial. METHODS: We retrospectively reviewed the medical records of 15 patients referred to our tertiary center between 2012 and 2016 with leaks after LSG. RESULTS: In 12 patients with whom ongoing leaks were identified, stents were inserted with the intent of definitive therapy. In addition to attempts at source control, percutaneous drainage was carried out for intraabdominal collection in 9 patients and pleural effusion in 4 patients. The length of stay in the intensive care unit was significantly shorter in patients referred earlier or in those without any intervention. CONCLUSION: LSG leaks can be treated nonoperatively in well-organized centers under meticulously designed protocols, depending on the clinical condition of the patient.

Comparison of the multi-epitope recombinant antigen DIPOL and hydatid fluid for the diagnosis of patients with cystic echinococcosis.

The use of serological tests containing multiple immunodominant antigens rather than single antigens have the potential to improve the diagnostic performance in Cystic Echinococcoses (CE) as a complement tool to clear the inconclusive imaging data. Here, we comparatively evaluated the diagnostic value of Hydatid Fluid (HF) and the recently described recombinant multi-epitope antigen DIPOL in IgG-ELISA in a clinically defined cohort of CE patients. The serum samples from 149 CE patients were collected just before surgical or Percutaneous- Aspiration- Injection- Reaspiration (PAIR) procedures. Additionally, serum samples of patients with other parasitic infections (n=49) and healthy individuals (n=21) were also included in the study as controls. To investigate the association between the genotype of the parasite and DIPOL, cyst materials from 20 CE patients were sequenced. In terms of overall sensitivity, HF was higher than DIPOL (82.55%,78.52%, respectively). However, while the sensitivity of HF was higher than DIPOL in patients with active and transitional cysts (83.3%, 75.4%, respectively), sensitivity of DIPOL in inactive cysts was higher compared to HF (95.6%, 78.3%, respectively). The sensitivity of DIPOL depending on cyst stage was statistically significant (P= 0.041). In terms of specificity, DIPOL was found to be better than HF (97.71%, 91.43%, respectively). By genotyping, the majority of 20 patients showed G1 genotype (80%). All patients harboring G3 and G1/G3 cyst genotypes were positive with both antigens, while 87.5% of patients with G1 genotype were seropositive with HF and 75% with DIPOL. The overall sensitivity and high specificity of DIPOL suggest that this recombinant protein containing immunodominant epitopes is a potential substitute for the HF by serological tests for the diagnosis of CE.

Comparison of the New Multiepitope Recombinant Peptide Antigen with Cyst Fluid Antigen in the Follow-up of Patients with Cystic Echinococcosis

Objective: The follow-up of patients with cystic echinococcosis (CE) offers the opportunity of evaluating the prognosis of the infection as well as detecting relapse. This study aimed to evaluate the performance of the new multiepitope recombinant peptide (recDipol) antigen in the follow-up of CE patients treated by surgery or percutaneous aspiration injection respiration. Methods: A total of 137 blood samples from 28 patients were evaluated by IgG-ELISA method using recDipol and hydatid fluid (HF) antigens. The patients were simultaneously checked for recurrence by ultrasonography. Results: The seropositivity rate of the 28 patients varied considerably during the follow-up. When the first blood of the patients was evaluated, 4 (14.28%) were seronegative by HF-ELISA and 9 (32.14%) were recDipol-ELISA. During the entire follow-up, only 1 (3.5%) and 6 (21.4%) patients were seronegative by HF-ELISA and recDipol ELISA, respectively. Conclusion: We found that recDipol did not perform as expected in the follow-up due to the higher number of seronegative patients compared to HF-ELISA in the first blood and during the entire follow-up. Our results suggest that imaging methods are gold standards in the diagnosis and that, in parallel, longer-term patient follow-up is required with recombinant antigens that have an improved diagnostic performance.

Chimney technique for solitary pelvic kidney.

The combination of solitary pelvic kidney and abdominal aortic aneurysm is extremely rare. In this report, we present chimney graft implantation in a patient with solitary pelvic kidney. A 63-year-old man had the diagnosis of infrarenal abdominal aortic aneurysm made incidentally. Preoperative computed tomography illustrated a fusiform abdominal aortic aneurysm accompanying a solitary ectopic kidney in the pelvis with aberrant renal artery. A bifurcated endograft was implanted, and a covered stent graft was placed into the renal artery by use of the chimney technique. Good patency of the chimney graft was documented with early postoperative and first month scans. To the best of our knowledge, this is the first report of the chimney technique used in a solitary pelvic kidney.

Management of iatrogenic bile duct injuries: Multiple logistic regression analysis of predictive factors affecting morbidity and mortality.

OBJECTIVE: Iatrogenic bile duct injuries remain a challenge for the surgeons to overcome. The predictive factors affecting morbidity and mortality are important for determining the best management modality. MATERIAL AND METHODS: The patients who referred to Ege University Faculty of Medicine after laparoscopy associated iatrogenic bile duct injury are grouped according to Strasberg-Bismuth classification system. The type and number of prior attempts, concomitant complications, and treatment modalities are analyzed using the SPSS version 18 (IBM, Chicago, IL, USA). The variables with p<0.10 were considered for univariate analysis and then evaluated for predictive factors by forward Logistic Regression method using multiple logistic regression analysis. RESULTS: According to the analysis of 105 patients who were referred during 2004-2014, the type and number of prior attempts are considered predictive factors in sepsis. In multiple logistic regression analysis, abscess formation, concomitant vascular injury, and serum bilirubin level are significantly effective in predicting mortality. CONCLUSION: The management of iatrogenic bile duct injuries should be carefully planned with a multidisciplinary approach. The predictive factors affecting morbidity and mortality are important in determining the best modality for managing iatrogenic bile duct injuries. Abscess formation, vascular injury, and serum bilirubin level are the potential risk factors. Therefore, we can strongly recommend immediate assessment of patients for prompt diagnosis and referring to an HPB center, to avoid further injuries.

Snorkel Technique for Inferior Mesenteric Artery During Endovascular Repair of Abdominal Aortic Aneurysm.

PURPOSE: The snorkel technique is commonly used to preserve renal arteries in juxta renal aneurysm during endovascular repair. Herein, we present a patient who underwent bifurcated endograft implantation with snorkel technique for inferior mesenteric artery (IMA) in order to preserve the major source of bowel circulation. CASE REPORT: A 69-year-old male patient was diagnosed with abdominal aortic aneurysm. His history revealed that he had bowel resection due to a car accident 30 years ago. In addition, he was given relaparotomy 4 times due to intestinal complications. Computed tomography showed fusiform aneurysm with a maximal diameter of 60 mm and chronical occlusion of the superior mesenteric artery. Inferior mesenteric artery was found to be hypertrophic. During EVAR, 6 mm × 10 cm covered VIABAHN Endoprosthesis (Gore Medical) was implanted to the IMA over a 0.018 guidewire via puncture of the left axillary artery. Initially, the main body of the aortic stent-graft (Gore C3, size 23-14-16) was implanted to the infra renal segment of the aorta (below the renal arteries and the orifice using VIABAHN) via the right femoral artery. Next, the contralateral leg (Gore, 14-12-00) was implanted. Computed tomography was examined at 1- and 32-month postoperatively, and no endoleak or patency of IMA stent was detected. CONCLUSION: In this case of IMA-dependent circulation of the intestinal system, the protection of IMA via snorkel technique was successful.

Eagle Syndrome Presenting with Neurological Symptoms.

AIM: Eagle syndrome is a rare entity that causes recurrent throat pain, neck pain, dysphagia, or facial pain due to an elongated styloid process or calcified stylohyoid ligament. Clinical findings related to lower cranial nerve compression have also been reported. In some cases, it is reported that carotid artery compression or dissection can be seen due to elongated styloid process and this is called carotid artery syndrome. Carotid artery compression causes flow reduction and carotidynia or neurological symptoms can be seen. Dural sinuses and the jugular vein can be compressed. Eagle syndrome with neurological symptoms has been rarely reported. MATERIAL AND METHODS: The data of 5 patients (aged between 22 and 68 years), who presented to the hospital with various neurological symptoms, were retrospectively reviewed. Each patient underwent computed tomography (CT) that revealed a long styloid process. RESULTS: An elongated styloid process caused neurological symptoms. Two patients had venous compression by the styloid process and the other patients had transient ischemic attacks due to internal carotid artery compression by the styloid process. Only one patient underwent surgical removal. All patients" outcomes were good after treatment and no symptoms remained. CONCLUSION: Eagle syndrome may be presented with neurological symptoms. It should be kept in mind in the differential diagnosis of patients who have neurological symptoms without any objective etiological factors. To the best of our knowledge, Eagle syndrome with arterial and venous compression due to elongated styloid process has not been previously presented in the literature.

The fate of a thoracoabdominal aortic bypass graft 10 years after surgery in a child with the middle aortic syndrome.

A 13-year-old boy who underwent thoracoabdominal aortic bypass when he was three years old for middle aortic syndrome was admitted with fatigue and need for an increased dose of antihypertensive mediations. The graft was patent, but there were stenoses at the juxta-proximal and juxta-distal anastomosis sites. A partial benefit was gained with endovascular stenting. Although postponement of surgery, until the child reaches full growth is preferred, surgery remains the inevitable treatment of choice in patients with middle aortic syndrome. In contrary, it is important to use the graft as large as possible during the initial operation to avoid patient-graft mismatch in the future.

Necrotizing Liver Granuloma/Abscess and Constrictive Aspergillosis Pericarditis with Central Nervous System Involvement: Different Remarkable Phenotypes in Different Chronic Granulomatous Disease Genotypes.

Chronic granulomatous disease (CGD) is a primary immune deficiency causing predisposition to infections with specific microorganisms, Aspergillus species and Staphylococcus aureus being the most common ones. A 16-year-old boy with a mutation in CYBB gene coding gp91phox protein (X-linked disease) developed a liver abscess due to Staphylococcus aureus. In addition to medical therapy, surgical treatment was necessary for the management of the disease. A 30-month-old girl with an autosomal recessive form of chronic granulomatous disease (CYBA gene mutation affecting p22phox protein) had invasive aspergillosis causing pericarditis, pulmonary abscess, and central nervous system involvement. The devastating course of disease regardless of the mutation emphasizes the importance of early diagnosis and intervention of hematopoietic stem cell transplantation as soon as possible in children with CGD.

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study.

BACKGROUND AND STUDY AIM: We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet. PATIENTS AND METHODS: The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients. RESULTS: A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %. CONCLUSIONS: The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

Endovascular treatment of intracranial infectious aneurysms.

INTRODUCTION: Intracranial infectious aneurysm (IIA) accounts for less than 5% of all intracranial aneurysms. The aim of this study was to evaluate the role of endovascular treatment for IIA. METHODS: During a 14-year period, 15 patients (age range, 2-68 years; mean, 42.8 years) with 17 aneurysms were diagnosed with IIA and treated via an endovascular route at our institution. The IIA diagnosis was based on clinical and laboratory findings of infection, echocardiography results, and digital subtraction angiography that were collected retrospectively. All patients were clinically and radiologically followed. The modified Rankin scale was used to evaluate clinical outcome. RESULTS: Among 15 patients, 12 presented with ruptured aneurysms (7 intraparenchymal hematoma, 4 subarachnoid hemorrhage, 1 subdural hematoma), 2 with cerebral infarcts, and 1 with pansinusitis and epidural abscess. All but one aneurysm were distally located in intracranial circulation, 14 were in anterior, and the remaining 3 were in posterior circulation. The final diagnosis was based on aneurysm morphology, location, and clinical laboratory findings. Endovascular treatment was scheduled initially for all IIAs; 13 of 17 IIAs underwent endovascular parent vessel occlusion, 3 underwent spontaneous parent vessel occlusion while waiting for intervention, and the remaining patient was treated by intrasaccular coil occlusion. There were no instances of perioperative neurological complications. Late clinical and radiological outcomes included absence of endovascular treatment related to mortality and aneurysm recurrence. CONCLUSION: Endovascular treatment may be performed safely at the time of diagnosis for at least symptomatic IIAs under the protective effect of antibiotic treatment.

Imaging findings and endovascular management of iatrogenic hepatic arterial injuries.

Iatrogenic hepatic arterial injuries (IHAIs) include pseudoaneurysm, extravasation, arteriovenous fistula, arteriobiliary fistula, and dissection. IHAIs are usually demonstrated following percutaneous transhepatic biliary drainage, percutaneous liver biopsy, liver surgery, chemoembolization, radioembolization, and endoscopic retrograde cholangiopancreatography. The latency period between the intervention and diagnosis varies. The most common symptom is hemorrhage, and the most common lesion is pseudoaneurysm. Computed tomography angiography (CTA) is mostly performed prior to angiography, and IHAIs are demonstrated on CTA in most of the patients. Patients with IHAI are mostly treated by coils, but some patients may be treated by liquid embolic materials or stent-grafts. CTA can also be used in the follow-up period. Endovascular treatment is a safe and minimally invasive treatment option with high success rates.

Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome: Angioplasty and Stenting with or without Manual Aspiration Thrombectomy and Catheter-Directed Thrombolysis.

PURPOSE: May-Thurner syndrome (MTS) is a rare clinical entity featuring venous obstruction of the left lower extremity. The aim of the present study was to report our experience with MTS and to evaluate the utility of treatment using endovascular techniques. MATERIALS AND METHODS: We retrospectively analyzed data on 23 MTS patients (21 females, two males; mean age 44 ± 15 years). Eighteen patients presented with deep vein thrombosis (DVT) and five with symptoms associated with chronic venous hypertension (CVH). DVT patients were treated via thromboaspiration, catheter-directed thrombolysis, and angioplasty; followed by stent placement. CVH patients were treated with angioplasty and stent placement alone. All patients were followed-up using Doppler ultrasonography and computed tomography venography. RESULTS: Complete left common iliac vein patency was achieved in 21 of the 23 patients (technical success rate: 91,3%). Complete thrombolysis was attained by 14 of the 18 DVT patients (77.7%). The mean clinical and radiological follow-up time was 15.2 ± 16.1 months. Upon follow-up, complete symptomatic regression was observed in 19 of the 23 patients (82.6%). Stent patency was complete in 19 of the 21 patients (90.4%) who received stents. Restenosis occurred in two patients. No treatment-related mortality or morbidity was observed. CONCLUSION: Endovascular treatment of MTS is safe and effective and reduces symptoms in most patients, associated with high medium-term patency rates.

Endovascular management of iatrogenic renal arterial lesions and clinical outcomes.

PURPOSE: We aimed to evaluate iatrogenic renal arterial lesions, including pseudoaneurysm, arteriovenous fistula, and arteriocaliceal fistula, their management by endovascular embolization, and the clinical results. METHODS: Fifty-five patients (forty males, fifteen females) with a median age of 40 years (range, 8-85 years), who underwent endovascular embolization of iatrogenic renal arterial lesions between March 2003 and December 2013 were included in this retrospective study. Types of iatrogenic lesions and details of embolization procedures were reported. Estimated glomerular filtration rate (eGFR), renal function tests, hemoglobin, and hematocrit levels before and after embolization were recorded and compared. RESULTS: Median follow-up was 24 months. We identified 53 pseudoaneurysms, 30 arteriovenous fistulas, and 11 arteriocaliceal fistulas in 55 patients, after percutaneous nephrolithotomy (n=26), renal biopsy (n=21), nephrostomy (n=3), renal surgery (n=3), and extracorporeal shock wave lithotripsy (n=2). Median number of pseudoaneurysms was 1 (range, 1-4) with a median size of 7 mm (range, 1.5-35 mm). Fifty-one patients underwent coil embolization. Median number of coils was 5 (range, 2-21) and median renal parenchymal loss was 5% (range, 1%-50%). There were no significant differences between pre- and postoperative eGFR and serum parameters. CONCLUSION: Iatrogenic renal arterial lesion can be a life threatening condition. Superselective coil embolization is a safe, minimally invasive treatment option with minimal renal parenchymal loss and without significant change in renal function.

The incidence of contrast medium-induced nephropathy following endovascular aortic aneurysm repair: assessment of risk factors.

PURPOSE: The aim of the study was to investigate the incidence of contrast medium-induced nephropathy (CIN) and risk factors for CIN following endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic aneurysm repair. MATERIALS AND METHODS: After exclusion criteria, 139 (121 males, 18 females) patients aged 20-86 (median 65.5) years who underwent endovascular aortic aneurysm repair between January 2002 and September 2013 were included in this retrospective study. CIN, with ≥25% increase in serum creatinine levels within 3 days after contrast medium administration, was compared to the patients' demographics, risk factors, type and complexity of the endovascular operation, parameters regarding to the contrast medium, preoperative estimated glomerular filtration rate (eGFR), and preoperative and early postoperative serum parameters. Statistical analyses were performed with Kolmogorov-Smirnov, χ (2) and Student's t tests. RESULTS: CIN, detected in 39 of 139 patients (28%), was correlated with preoperative eGFR <60 ml/min/1.73 m(2) (P = 0.04) and high preoperative and postoperative serum urea and creatinine levels. Postoperative serum urea levels (P < 0.001) were significant in multivariate analysis. CONCLUSION: In patients undergoing endovascular aortic aneurysm repair, CIN was correlated with preoperative and postoperative renal impairment, while it was not correlated with the contrast medium dose.

Obliteration of a Large Mandibular Arterio-Venous Malformation with Polymethyl Methacrylate Bone Cement.

Mandibular arteriovenous malformations (AVMs) are rare and potentially life-threatening vascular lesions. Surgery, embolization, or bone cement implantation is an option for the treatment of mandibular AVMs. We present a case of huge mandibular AVM refractory to multiple embolizations of the supplying arteries, which was treated with polymethylmethacrylate (PMMA) bone cement implantation after the extraction of a molar tooth.