Reducing aneurysm sac growth and secondary interventions following endovascular abdominal aortic aneurysm repair by preemptive coil embolization of the inferior mesenteric artery and lumbar arteries.

OBJECTIVE: Type II endoleak (EL-2) is the most common complication following endovascular aneurysm repair (EVAR), leading to continued sac growth and potential rupture. In this study, we examined the association between patency of the inferior mesenteric artery (IMA) and lumbar arteries (LAs) with respect to sac growth. The effect of preemptive embolization of the IMA and/or LAs on the need for secondary interventions for sac growth post-EVAR was also evaluated. METHODS: A retrospective cohort study was performed on consecutive patients who underwent EVAR for non-ruptured, infrarenal abdominal aortic aneurysms (AAAs) from January 2012 to December 2020. A select group of patients underwent preemptive embolization of the IMA and/or LA. Patients with any types I, III, or IV endoleaks were excluded. Patency of the IMA and LA on preoperative computed tomography angiogram (CTA) was evaluated on TeraRecon workstation. All secondary interventions to treat EL-2 were recorded. Sac growth was defined as centerline axial diameter increase of ≥5 mm on follow-up CTA. RESULTS: A total of 300 patients (mean age, 74 ± 8.5 years; 83.7% male) underwent EVAR. Ninety-nine patients had preemptive embolization of the IMA and/or LA. Mean follow-up of the cohort was 59.3 ± 30.5 months. Thirty-six patients (12%) demonstrated sac growth on follow-up; 12 of these (33.3%) had preemptive embolization. The median time until detection of sac growth was 28.8 months (interquartile range, 15.2-46.5 months), with a mean growth of 10.1 ± 6.4 mm. Sac growth was significantly associated with presence of EL-2: 27 of 36 (75%) with EL-2 vs 9 of 36 (25%) without EL-2 (P < .001). Patients with sac growth had a higher mean total number (2.6 ± 1.5) of patent lower LAs (L3, L4) compared with those without (2.0 ± 1.4; P = .03). Patency of L1, L2, and L3 LAs were not associated with sac growth. However, patency of at least one L4 LA was significantly associated with sac growth (14.8% vs 7.7%; P = .04). The highest incidence of sac growth (17.6%) was seen when both IMA and L4 LA were patent; significantly different from the lowest incidence (5.3%) when both were occluded preoperatively (P = .018). Preemptive coiling of the IMA and/or LA significantly reduced the need for post-EVAR secondary intervention for sac growth. Freedom from post-EVAR secondary intervention was achieved in 92 of 99 (92.9%) pre-EVAR coiled patients vs 163 of 201 (81.5%) patients who did not undergo pre-EVAR coiling (P = .009). CONCLUSIONS: Preemptive coil embolization of the IMA and LAs, especially L4 LA, reduces the need for secondary interventions for sac growth, potentially improving the long-term durability of EVAR.

Surgical Management of a Retained Appendicolith Following Laparoscopic Appendectomy.

Appendicitis is one of the most common surgical emergencies, and surgical intervention remains the gold standard for curative treatment. Although laparoscopic appendectomy is associated with less pain, shorter hospital stays, and earlier mobilization, it is also more frequently complicated by postoperative abscesses. Retained appendicoliths are a rare complication that can serve as a nidus for repeated infections. Laparoscopic removal of the stone can provide definitive source control and reduce repeated hospital admissions. There are many surgical approaches for retrieval and this case, in particular, describes a laparoscopic hand-assisted approach while simultaneously using an interventional radiologic drain to assist with localization.

Cecal Volvulus Through an Internal Hernia Created by an Elongated Fallopian Tube.

Internal hernias result from abdominal viscera protruding through a congenital or acquired defect in the peritoneum or the mesentery of the abdominal cavity. They are less common than external hernias, and the overall incidence is rare. Internal hernias carry a high mortality rate if there is no immediate surgical intervention and can lead to complications such as bowel perforation, ischemia, and necrosis. There are multiple classifications, and a rare subtype identified in only a select few cases involves the fallopian tube. This case documents the development of a cecal volvulus due to the cecum herniating through an aperture created by a normal-appearing fallopian tube attaching to the retroperitoneum.  A 78-year-old female with multiple comorbidities was admitted for abdominal pain lasting 3-4 days, nausea, emesis, and poor oral tolerance. Computerized tomography imaging revealed a complete large bowel obstruction secondary to a cecal volvulus, and she was taken emergently for an exploratory laparotomy. Intra-operatively, a distended cecum was noted, herniated through a loop created by the right fallopian tube tethering its free end to the left pelvis. Upon decompression of the bowel, the fallopian tube released itself from the retroperitoneum. The cecum and right fallopian tube were noted to be ischemic and resected with an ileo-transverse anastomosis. Internal hernias that involve the fallopian tubes are a rare variation of an already uncommon condition. However, they should be included in the differential diagnosis when evaluating a female patient for intestinal obstruction since it can develop into a life-threatening condition that requires prompt surgical attention.