Safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions.

BACKGROUND: We investigated the safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions. METHODS: A total of 42 consecutive patients (mean age 67.2 ± 12.7 years; 32 men) with aortic arch lesions were treated by physician-modified thoracic endovascular aortic repair using a low-profile device (Zenith Alpha Thoracic Endovascular Graft) with four scallops or 13 fenestrations for the common carotid artery and 38 fenestrations or 30 branches for the left subclavian artery. The aortic repair indications were acute type B aortic dissection (n = 17, 40.5%), degenerative aneurysm (n = 14, 33.3%), chronic dissection aneurysmal degeneration (n = 4, 9.5%), and ulcer-like projection (n = 2, 4.8%). The mean iliac artery diameter was 7.6 ± 1.1 mm. RESULTS: There were no branches covered unintentionally or patients who died and suffered from severe spinal cord ischemia perioperatively. One patient (2.4%) experienced a postoperative minor stroke with full neurological recovery. The mean follow-up time was 18 ± 11 months, with 28 patients (66.7%) having at least 12 months. One access-related complication (2.4%) occurred. Two residual Ia (4.8%) and three residual IIIa (7.1%) endoleaks were treated by reintervention. There were no open repair conversions, ruptures, or other aortic complications. CONCLUSION: Physician-modified thoracic endovascular aortic repair using the low-profile device may be a safe, feasible, and time-saving method for preserving the cervical artery and has high reproducibility and anatomical reconstruction. However, its durability requires long-term follow-up.

Full PETTICOAT in acute type B aortic dissection with patent false lumen may offer positive remodeling for the distal aorta.

OBJECTIVE: The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. METHODS: In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1 year after surgery. RESULTS: Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. CONCLUSIONS: This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

Outflow of N-butyl-2-cyanoacrylate into the Pancreatic Duct: Transcatheter Arterial Embolization for Hemosuccus Pancreaticus.

A 54-year-old Japanese woman, hospitalized for recurrent chronic alcoholic pancreatitis, manifested bloody stools. An esophagogastroduodenoscopy revealed active bleeding from the papilla of Vater. Contrast-enhanced computed tomography (CECT) revealed a pseudoaneurysm in the pancreatic pseudocyst (hemosuccus pancreaticus). Angiography demonstrated pseudoaneurysm of the dorsal pancreatic artery branch. We selected N-butyl-2-cyanoacrylate (NBCA) as an embolus material because of the existing coagulopathy and difficulty in selecting the arterial branch. The administered NBCA outflowed into the pancreatic duct over the pseudoaneurysm. However, transcatheter arterial embolization (TAE) was successful, and no complication or rebleeding was observed after TAE. CECT showed NBCA cast in the pancreatic duct; however, the chronic pancreatitis improved. NBCA may be used to regulate hemosuccus pancreaticus in emergency settings; however, interventional radiologists must carefully consider the complications caused by NBCA.

Transcatheter arterial embolization for initial hemostasis in a hemodynamically unstable patient with mesenteric hemorrhage: A case report.

Surgical treatment of mesenteric injuries is necessary to control hemorrhage, manage bowel injuries, and evaluate bowel perfusion. It has recently been suggested that some patients can be managed with transcatheter arterial embolization (TAE) for initial hemostasis. We present a hemodynamically unstable patient who was initially managed by TAE for traumatic mesenteric hemorrhage. A 60-year-old man was injured in a motor vehicle accident and transported to our facility. On arrival, the patient was hemodynamically stable, and had abdominal pain. Physical examination revealed a seatbelt sign on the lower abdomen. A contrast-enhanced computed tomography (CT) scan showed intra-abdominal hemorrhage, mesenteric hematoma, and a giant-pseudoaneurysm, but no intra-abdominal free air or changes in the appearance of the bowel wall. After the CT scan, his vital signs deteriorated and surgical intervention was considered, but TAE was performed to control the hemorrhage. After TAE, the patient was hemodynamically stable and had no abdominal tenderness. A follow-up CT scan was performed 2 days later which showed partial necrosis of the transverse colon and some free air. Resection of the injured transverse colon with primary anastomosis was performed. The patient improved and was discharged 35 days after injury. TAE can be effective as the initial hemostatic procedure in patients with traumatic mesenteric hemorrhage.

Necrotizing enterocolitis associated with Clostridium butyricum in a Japanese man.

Case: Necrotizing enterocolitis (NEC) caused by Clostridium butyricum is common in neonates; however, a case of NEC in adults has not been previously reported. An 84-year-old Japanese man developed C. butyricum-related NEC during hospitalization for treatment of stab wounds to the left side of the neck and lower abdomen, without organ damage, and concomitant pneumonia. Outcome: The patient developed acute onset of emesis accompanied by shock during his admission; partial resection of the small intestine was carried out due to necrosis. Pathologic findings showed mucosal necrosis and extensive vacuolation with gram-positive rods in the necrotic small intestine. Blood culture tests revealed C. butyricum infection. The patient's condition improved after the surgery. He was moved to a rehabilitation hospital on day 66. Conclusion: This study suggests that hospitalized adult patients who receive antibiotic treatment are at risk for NEC.

Loss of gray-white matter discrimination as an early CT sign of brain ischemia/hypoxia in victims of asphyxial cardiac arrest.

Brain CT obtained from cardiac arrest (CA) victims immediately after resuscitation may be useful in predicting their outcomes. Most data have been derived from CA victims of cardiac etiology, however, CT signs of brain ischemia/hypoxia have rarely been studied in victims of asphyxial CA. Loss of gray-white matter discrimination (GWMD) at the basal ganglia seems to be the most reliable early CT sign of brain ischemia/hypoxia; a retrospective study was conducted to clarify its incidence, prognostic significance, and temporal profile in resuscitated victims of CA by food asphyxiation. Brain CT scans of each victim were interpreted by two blinded observers. During a 5-year period, 39 resuscitated victims of CA by food asphyxiation underwent brain CT. Thirty-one (79%) showed loss of GWMD, none of whom survived to discharge. Among the other eight victims with seemingly intact brain CT, five (63%) survived to discharge. Loss of GWMD predicted fatality with sensitivity of 100% and specificity of 63%. The interobserver concordance was 82% with kappa coefficient of 0.56. Loss of GWMD developed almost invariably when the asphyxiation-return of spontaneous circulation (ROSC) interval exceeded 10 min. There were five victims with asphyxiation-ROSC interval ≤ 10 min, all of whom survived to discharge. In contrast, none of the 34 victims with the interval >10 min survived to discharge. Loss of GWMD may develop in a relatively time-dependent manner and may be a reliable radiographic indicator of poor outcome in resuscitated victims of asphyxial CA.

Megacolon in an adult case of hypoganglionosis, a pseudo-Hirschsprung's disease: an autopsy study.

We report an autopsied 20-year-old man case of intestinal necrosis associated with megacolon from hypoganglionosis, a pseudo-Hirschsprung's disease. The patient had suffered from severe constipation since two years of age, and presented abdominal distention from age ten. Autopsy revealed marked dilatation and necrosis of the entire large intestine. Although ganglion cells in the intestinal plexus were found throughout the large intestine, their number was reduced to 12-20% of that in the normal control. In pseudo-Hirschsprung's disease, there are occasional cases where an acute abdomen first presents itself in adulthood after running its course as chronic constipation.