Type IIIb endoleak after elective endovascular aneurysm repair: a systematic review.

INTRODUCTION: The aim of this article is to investigate the presentation, etiology, management and outcomes of type IIIb endoleak after endovascular aneurysm repair (EVAR). EVIDENCE ACQUISITION: Electronic bibliographic databases were searched to identify published reports of type IIIb endoleak after EVAR, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. EVIDENCE SYNTHESIS: In total 33 articles were identified reporting on a total of 50 patients spanning 19 years of EVAR (1998-2017). Some 11 device-types were used. The median time from implantation to intervention was 27 months (0-168). There was a significant aneurysm sac expansion in 69% of reported cases. Thirteen patients (26%) presented with aneurysm rupture. A definitive diagnosis of type IIIb endoleak made on computed tomographic angiography (CTA) in only 20% of cases. Proposed failure modes included suture breakage, graft erosion by stents, iatrogenic, graft infection and presumed manufacturing faults. Endoleak location was in the main body in 81% of reported cases. Almost one third (31%) of patients were treated with open repair. The remaining patients were treated with endovascular techniques or hybrid procedures. Some novel off-label endovascular solutions were proposed to maintain a bifurcated configuration. Thirty-day mortality in patients treated for aneurysm rupture was 50%. The 30-day mortality rate in non- rupture cases was 2% (endovascular 0% treatment, open 2%). CONCLUSIONS: Type IIIb endoleak is a serious condition associated with a significant risk of rupture. Definitive diagnosis is challenging and has been described in almost all conventional devices. Most patients can be treated successfully by endovascular means, though maintaining a bifurcated configuration may require non-standard techniques or off-label use.

Merkel-cell carcinoma of the upper limb.

Merkel-cell carcinoma is a rare form of aggressive cutaneous cancer that is associated with a poor prognosis. Despite significant advances, its pathogenesis is still poorly understood, and treatment remains controversial. Timely diagnosis and early management is essential in improving survival rate. We present a case of a 63-year-old patient with a rapidly growing upper limb Merkel-cell carcinoma. It was treated with wide-local excision and adjuvant radiotherapy.

Loco-regional versus general anaesthesia for elective endovascular aneurysm repair - results of a cohort study and a meta-analysis.

BACKGROUND: The aim of this study was to investigate whether patients undergoing elective endovascular aneurysm repair (EVAR) with loco-regional anaesthetic techniques have better outcomes than those treated with general anaesthesia (GA). PATIENTS AND METHODS: We retrospectively evaluated outcomes of EVAR performed with regional anaesthesia (RA) or GA over a five-year period. Furthermore, we searched electronic bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) to identify studies comparing different anaesthetic methods in EVAR. We defined perioperative mortality and morbidity as well as length of hospital stay (LOS) as the primary outcome measures. Pooled effect estimates were calculated using fixed-effect or random-effects models. Results are reported as the odds ratio (OR) or mean difference (MD) and 95 % confidence interval (CI). RESULTS: Three hundred and fifty-five patients underwent standard EVAR over the study period (RA, 215 patients; GA 140 patients). Patients in both groups had comparable baseline demographics and clinical characteristics. Perioperative mortality was significantly lower in the RA group (0.5 % vs. 4.3 %, P = 0.017). No difference was found in perioperative morbidity (P = 0.370), LOS (P = 0.146), postoperative destination (P = 0.799), reoperation (P = 0.355) or readmission within 30 days (P = 0.846). Meta-analysis of data on 15,472 patients from 15 observational studies found a significantly lower perioperative mortality (OR 0.70, 95 % CI 0.52-0.95, P = 0.02) and morbidity (OR 0.73, 95 % CI 0.55-0.96, P = 0.02) in patients treated with loco-regional anaesthetic techniques compared to those treated with GA. Our sub-group analysis demonstrated that both local anaesthesia (LA) (P = 0.003) and RA (P < 0.0001) were associated with a significantly shorter LOS compared to GA. CONCLUSIONS: Local and/or regional anaesthetic techniques may be advantageous over GA in elective EVAR, as indicated by reduced perioperative mortality and morbidity and a shorter hospital stay. Considering the current level of evidence, LA or RA should be considered in selected patients. Further clinical research is required to provide high level evidence on the optimal anaesthetic technique in EVAR.

Bypass Surgery With Heparin-Bonded Grafts for Chronic Lower Limb Ischemia.

BACKGROUND: Our objective was to assess the effects of heparin-bonded grafts in infrainguinal bypass surgery for patients with peripheral arterial disease of the lower limbs. METHODS: We searched electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic lists of relevant articles to identify studies reporting comparative outcomes of heparin-bonded grafts in patients undergoing infrainguinal bypass. We used the Cochrane collaboration tool for risk of bias assessment of randomized controlled trials (RCTs) and the Newcastle-Ottawa scale to assess the methodological quality of observational studies. Dichotomous outcome measures were calculated using odds ratio (OR) and 95% confidence interval (CI). Summary estimates of ORs were determined using the fixed-effect or random-effects model. The study protocol was registered in PROSPERO (CRD42016039185). RESULTS: We included 11 articles (3 RCTs) in qualitative and quantitative synthesis reporting a total of 2892 bypasses. Seven studies compared heparin-bonded grafts with vein grafts and another four compared heparin-bonded grafts with standard prosthetic grafts. We noted heterogeneity in disease severity and distal anastomotic level. We found a significantly lower perioperative mortality (OR, 2.30; 95% CI: 1.11-4.77), a trend toward better limb salvage at 1 year (OR, 0.50; 95% CI: 0.25-0.99), and a significantly higher limb salvage rate at 3 years (OR, 0.40; 95% CI: 0.23-0.69) in patients undergoing a vein bypass compared to those treated with heparin-bonded grafts. No differences were identified in graft patency or survival between the heparin-bonded and vein bypass graft group. No differences in primary patency were identified between heparin-bonded grafts and standard prosthetic grafts. CONCLUSIONS: Heparin-bonded grafts showed comparable results to autologous vein in terms of graft patency and survival but lower limb salvage rates.

Carotid endarterectomy following thrombolysis for acute ischaemic stroke.

BACKGROUND: Insufficient evidence exists to support the safety of carotid endarterectomy (CEA) following intravenous thrombolysis (IVT) for acute ischaemic stroke. Our study aimed to report a single-centre experience of patients treated over a five-year period. PATIENTS AND METHODS: Departmental computerised databases were interrogated to identify patients who suffered an ischaemic stroke and subsequently underwent thrombolysis followed by CEA. Mortality and stroke within 30 days of surgery were defined as the primary outcome end points. RESULTS: Over a five-year period, 177 out of a total of 679 carotid endarterectomies (26 %) were performed in patients presenting with acute ischaemic stroke. Twenty-five patients (14 %) received IVT prior to CEA in the form of alteplase. Sixty percent of patients were male with a mean age of 68 years. Sixteen patients (64 %) underwent CEA within 14 days of IVT and the median interval between thrombolysis and CEA was 7.5 days (range, 3-50 days). One female patient died of a further intraoperative stroke within 30 days of surgery, yielding a mortality rate of 4 %. Two patients (8 %) suffered from cardiac complications postoperatively resulting in a short high dependency unit stay. Another two patients (8 %) developed local wound complications, which were managed conservatively without the need for re-operation. The median hospital length of stay was 4.5 days (range, 1-33 days). CONCLUSIONS: Our experience indicates that CEA post-thrombolysis has a low incidence of mortality. Further high quality evidence is required before CEA can be routinely recommended following IVT for acute ischaemic stroke.

Endovascular management of a mycotic group A streptococcal abdominal aortic dissection.

Pyrexia of unknown origin can represent a great diagnostic difficulty to clinicians. We present a case of pyrexia with abdominal and back pain, in which blood cultures performed demonstrated group A haemolytic streptococcus. Having recently been abroad, the patient was investigated to find a source. CT scans performed subsequently demonstrated an inflammatory infrarenal abdominal aortic dissection. The patient was treated with intravenous antibiotics and underwent endovascular repair. This case details the unusual presentation of spontaneous abdominal aortic dissection and its management by endovascular means. Emphasis is placed on the often clandestine manner of presentation of this condition and the importance of awareness in the investigating clinician. This case presents a patient infected with group A haemolytic streptococcus, leading to aortitis and spontaneous dissection, previously unreported in the literature.