Preservation of Stent Graft after Iatrogenic Type III Endoleak during Open Transperitoneal Surgical Intervention for Complicated Type II Endoleak.

BACKGROUND: The use of an endovascular approach for treatment of abdominal aortic aneurysms has gained traction over the past 2 decades. One of the major drawbacks of the endovascular approach is the increased rates of reintervention, with the majority arising from endoleaks that occur up to 20% of the time. Although type II endoleak is the most common subtype (25-45% of all endoleaks), it is associated with the greatest dilemma and debate with regard to indications and modalities of treatment. The open surgical approach to management of type II endoleak has gained interest and popularity over the years because of issues associated with the endovascular approach. METHODS: We present a case of a patient with type II endoleak undergoing transperitoneal sacotomy, endoaneurysmorrhaphy, and stent-graft preservation, after having failed endovascular intervention. In addition, we describe the difficulties associated with posteriorly located backbleeding lumbar arteries and a unique case of iatrogenically created type III endoleak intraoperatively. RESULTS: A literature review was performed with regard to the risk factors, indications for intervention, and modalities of treatment for type II endoleaks. In addition, suggestions are provided for future improvements in surgical technique. CONCLUSIONS: Type II endoleak is a common complication of endovascular aortic repair. In spite of this, management strategies are poorly standardized with no definitive gold standard. More collective data and pooled experience will be needed to further refine the open surgical technique and objectively assess its benefits and shortcomings vis-à-vis other alternatives.

Surgical Management of Axillary Artery Aneurysms with Endovascular Stenting versus Open Repair: A Report of Two Cases and Literature Review.

BACKGROUND: Axillary artery aneurysms necessitate repair due to potential neurovascular complications. With increasing endovascular interventions for these uncommon lesions, there is a need to evaluate their usage against conventional open repair. CASE: We discuss the management of 2 patients with symptomatic axillary artery aneurysms who presented to our institution. The first case is a 52-year-old lady with an enlarging left pulsatile mass, later found to be an axillary artery aneurysm, who underwent an open aneurysmal resection and interposition grafting. Meanwhile, endovascular stenting was performed for the second patient, a 65-year-old gentleman with a left axillary aneurysm. DISCUSSION: While open repair remains the standard treatment of care for aneurysmal axillary arteries, endovascular interventions have gained popularity as a perceived less-invasive approach with possibly reduced morbidity risks. CONCLUSIONS: Meticulous preoperative evaluation is required for patients with axillary artery aneurysms. Both methods of repair are viable options, and the most optimal surgical approach is dependent on a myriad of surgical and patient factors.

Fenestrated Endovascular Repair of Zones 1 and 2 Aortic Arch Pathologies.

BACKGROUND: Surgical management of aortic arch pathologies is complex, and endovascular developments have now enabled total or hybrid endovascular aortic arch repair. We present our early experience with fenestrated aortic arch repairs in Ishimaru zones 1 and 2 pathologies. METHODS: In a single tertiary institution, all consecutive endovascular aortic arch repairs were reviewed. A preoperative computed tomography aortogram was performed to assess anatomic suitability, which we defined as having a proximal sealing zone with a maximum diameter of 38 mm and minimum length of 20 mm, absence of significant aortic tortuosity, and suitable sealing zones in target vessels. RESULTS: From September 2015 to February 2018, 5 cases of fenestrated aortic arch endovascular repairs were performed. There were 3 male patients. The patients were between 57 and 83 years old, all of whom were American Society of Anesthesiologists (ASA) class II or III. Indications for surgery included aortic arch aneurysms (n = 3), a symptomatic aortic dissection, and a left subclavian artery aneurysm. Three patients had a scallop to the innominate artery, and one patient had a scallop to the left common carotid artery. Fenestrations were made to 3 left common carotid arteries and 3 left subclavian arteries. In 2 patients, a left carotid-subclavian bypass was performed, and the left subclavian artery origin occluded with a vascular plug. Technical success was 100%. One patient developed a right occipital infarct and acute myocardial infarction. The mean duration of surgery was 164 min, and the mean length of stay was 4.2 days. The mean follow-up period was 14.4 months. CONCLUSIONS: The use of fenestrated grafts in the aortic arch is a feasible treatment option. However, certain limitations still exist, and preoperative planning is important in ensuring clinical success. Although this procedure appears feasible in the short term, long-term results and durability remain to be seen.

Carotid Artery Involvement in Advanced Recurrent Head and Neck Cancer: A Case Report and Literature Review.

BACKGROUND: Surgical management of advanced head and neck tumors involving the carotid artery remains controversial with compromised survival outcomes and heightened risks of morbidity and mortality. CASE: We describe a case of a 74-year-old lady with previous T1N0M0 left tongue squamous cell carcinoma, who developed a left nodal recurrence encasing the left external carotid artery from the carotid bifurcation. She underwent an extended left radical neck dissection with carotid artery patch plasty and remains well to date, 10 months after surgery. DISCUSSION: Head and neck tumor recurrences are not uncommon, and radical resection of advanced tumors involving the carotid artery is increasingly performed. Various carotid interventions including tumor peeling, ligation, and resection with reconstruction were reported with differences in survival outcomes, morbidity and mortality. CONCLUSION: An aggressive surgical approach to advanced tumors involving the carotid artery may be a viable attempt for survival prolongation but requires proper case selection and has to be weighed against the risks of complications to better optimize patient outcomes.

Extrinsic Compression of the Ovation Stent-Graft Following Glue Embolization for Type II Endoleak: An Unusual Complication.

PURPOSE: To describe a case of extrinsic compression of the Ovation stent-graft following glue embolization for type II endoleak. CASE REPORT: A 75-year-old man with a past history of ischemic heart disease and endovascular aneurysm repair with an Ovation stent-graft was admitted for treatment of type II endoleaks from the right L2 and left L4 lumbar arteries with egress via the inferior mesenteric and right L4 lumbar arteries, respectively. Successful embolization was performed via a translumbar sac puncture with a combination of coils and histoacryl glue. On final angiography severe lumen narrowing of the unsupported portion of the Ovation stent-graft was seen owing to extrinsic compression by the glue. This was successfully salvaged with percutaneous transarterial kissing balloon angioplasty. CONCLUSION: Aortic lumen narrowing caused by extrinsic compression of an Ovation stent-graft following glue embolization of type II endoleak is an unusual and potentially problematic complication.

Renal pelvis squamous cell carcinoma with inferior vena cava infiltration: Case report and review of the literature.

INTRODUCTION: Renal squamous cell carcinoma (RSCC) is a rare tumor that is usually diagnosed late as a locally advanced malignancy with adjacent structure involvement. Radical surgical resection with negative margins is the mainstay of treatment, as it is correlated with improved survival, while other modalities of treatment have been shown to have limited efficacy. PRESENTATION OF CASE: We report a case of a 56 year old gentleman with right RSCC with tumor encasing the inferior vena cava (IVC), treated successfully with surgical resection. DISCUSSION: The surgical management of vascular involvement of similar tumors has not been discussed in-depth in the literature. Surgical resection of the IVC without reconstruction can be done successfully in the circumstance of good collateral circulation; otherwise IVC resection with reconstruction will be necessary. CONCLUSION: Radical resection with clear margins of RSCC tumors with vascular involvement is feasible in selected circumstances.

Intestinal torsion causing chylous ascites: a rare occurrence.

Intestinal torsion and chylous ascites are very rarely associated. We present the case of a 19-year-old man who presented with acute abdomen. Computed tomography of his abdomen showed features suggestive of intestinal torsion. Chylous ascites was incidentally discovered on exploratory laparotomy. The chylous fluid was drained, the small bowel detorted and the coloduodenal adhesion band taken down. The patient's retroperitoneum was explored to exclude occult masses and malformations of the lymphatics. Post surgery, the patient recovered uneventfully. In this case, we postulate that intestinal malrotation had caused the obstruction of the lymphatic flow from the mesenteric lymphatic channels, leading to the exudation of chyle, which then resulted in the accumulation of chylous fluid in the peritoneal cavity. It is important to exclude the more common causes of atraumatic chylous ascites, such as enlarged retroperitoneal lymph nodes or lymphatic malformations.

A rare case of septic deep vein thrombosis in the inferior vena cava and the left iliac vein in an intravenous drug abuser.

The patient was a 41 year-old Chinese female, a known intravenous drug abuser (IVDA), who presented with a left inguinal discharging sinus. A computed tomography (CT) scan showed inflammation in the left groin involving the left femoral vein and resulting in thrombus within the iliac veins extending to the distal portion of the inferior vena cava. Septic deep vein thrombosis is a well-recognized complication in intravenous drug abusers (IVDA) when large proximal veins are used for drug injection. Life threatening complications such as septic pulmonary embolism and right sided infective endocarditis may result. The aims of treatment are to prevent the septic thrombus from further embolisation and also to remove the thrombus. Treatment options include catheter directed thrombolysis, mechanical thrombectomy, endovascular treatment, surgical thrombectomy and excision of the involved venous segment.