Endovascular Management of Bleeding Aortoenteric Fistula May be Feasible as a Definitive Repair.

Aorto-enteric fistula (AEF) is a complication with devastating sequelae and significant morbidity. Although open surgery remains primary treatment endovascular approach may be used as a temporary bridge but rarely as a definitive therapy. We present a case of a patient who presented with a secondary AEF, due to hemodynamic instability we chose to treat the fistula with an aortic endograft. The patient underwent bowel resection due to bowel obstruction with omental patch over the aortic rent, 6 weeks of antibiotics. Patient is now at 8-year follow-up without evidence of infection. Although there is scarce literature on this topic, endovascular treatment of bleeding AEF may be feasible as a definitive option. Due to high risk of graft infection we recommend close observation and suppressive antibiotics.

Catheter-Directed Therapy is Safe and Effective for the Management of Acute Inferior Vena Cava Thrombosis.

BACKGROUND: The management of acute thrombosis of inferior vena cava (AT-IVC) has evolved to catheter-based therapies, the results of which remain uncertain. We report our institution's experience treating AT-IVC using endovascular methods. METHODS: A 10-year retrospective review of patients presenting with symptomatic IVC thrombosis between the years 2005 and 2014 was performed. Demographic data, treatment modalities, and outcomes were reviewed. RESULTS: Twenty-five patients (44% men) underwent treatment for acute (<2 weeks) symptomatic IVC thrombosis. Presenting symptoms included pain and limb swelling in 23 (92%), motor dysfunction in 16 (64%), sensory loss in 14 (56%), and pulmonary embolism (PE) in 2 (8%) patients. Phlegmasia cerulea dolens was present in 5 patients, a history of malignancy was identified in 7 patients, and 21 patients had an IVC filter at presentation (Trapease 12, G2X 3, Option 2, Eclipse 2, Meridian 2). Four patients had a documented hypercoagulable state, 21 patients underwent venous angioplasty, and 7 (28%) patients underwent venous stenting of the IVC or iliofemoral veins. Significant (>50% luminal gain) angiographic resolution of venous thrombus was achieved in all 25 patients. Twenty-one (84%) patients reported moderate-to-complete symptomatic improvement immediately after completion of the procedures. Two patients had a clinically symptomatic PE and 1 patient underwent an above-knee amputation secondary to venous gangrene. Other complications included 6 minor bleeding complications (2 local hematoma, 4 hematuria) all of which resolved spontaneously. There were 2 major bleeding complications (1 disseminated intravascular coagulation, 1 retroperitoneal hematoma). CONCLUSIONS: Endovascular treatment of AT-IVC, regardless of etiology, is safe and effective with excellent short-term clinical results. An aggressive endovascular approach to treatment of AT-IVC is warranted even in the presence of a thrombosed vena cava filter.

Development and implementation of an introductory endovascular training course for medical students.

BACKGROUND: Endovascular simulation has been promoted as an educational tool for trainees to practice procedures in a safe environment and improve basic technical skills. We sought to determine whether an established endovascular training course for medical students could increase technical proficiency, enhance interest in vascular surgery, and be implemented at another academic institution. METHODS: At Center A, medical students participated in an eight-week elective course with a structured curriculum comprised of weekly mentored simulator sessions and didactic teachings. A similar course was developed at Center B to train a similar cohort of students using the same high-fidelity simulator. Demographics and survey data, including interest in vascular surgery, were obtained, and pre- and postcourse graded simulator sessions on renal stent or iliac/superficial femoral artery stent modules were conducted. Performance was assessed by expert observers using a standardized global endovascular rating scale and objective procedural metrics collected from the simulator. RESULTS: Seventy-seven medical students (41 at Center A and 36 at Center B; 56 men and 21 women) completed the course from 2007 to 2009. Parameters measured on the standardized global endovascular rating scale, including angiography skills, wire handling, and interventional criteria as well as simulator-generated metrics, significantly improved from pre- to postcourse values for both groups of medical students at the two institutions (p < 0.05). More than 94% of the students agreed or strongly agreed that the simulation course increased their interest in vascular surgery. CONCLUSION: A simulation-based endovascular course provides an educational tool that improves basic technical performance and increases interest in vascular surgery among medical students. This simple educational module appears to be transferable and adaptable at another institution with minimal modification to produce similar results.

Determining criteria for predicting stenosis with ultrasound duplex after endovascular intervention in infrainguinal lesions.

BACKGROUND: Studies examining duplex surveillance of lower extremity bypass grafts have defined a role for guiding graft re-intervention. The goal of this study is to determine the utility of duplex scanning to detect angiographic restenosis after endovascular therapy in patients with infrainguinal arterial disease. METHODS: A prospective registry including all patients treated for lower extremity atherosclerotic disease between February 2004 and September 2008 was established. Patients were followed up with duplex ultrasound at 1, 3, 6, 12 months, and then annually. Patients receiving repeat angiograms were identified and angiogram and duplex data were abstracted. Velocity ratios (Vr) were calculated for each lesion by dividing the peak velocity within the lesion by the peak velocity proximal to the lesion. Logarithmic regression and receiver operator characteristic (ROC) curve analyses were used. RESULTS: Repeat angiograms were performed on 345 lesions in 143 patients, and 254 lesions in 103 patients had a corresponding duplex ultrasound. Indications for the initial intervention were claudication (n = 62, 43.4%), rest pain (n = 23, 16.1%), and tissue loss (n = 58, 40.5%). A total of 178 superficial femoral artery (SFA) lesions, 59 popliteal lesions, and 17 tibial lesions were identified by surveillance duplex in 103 patients. In all, 70.5% of the intervened vessels that were studied were nonstented and the remaining 29.5% were stented. A total of 65% of the patients had diabetes. On determining correlations for peak systolic velocity (PSV) as measured by duplex ultrasound with degree of angiographic stenosis, strong correlation coefficients for SFA disease (R² = 0.84) and popliteal disease (R² = 0.88) were found. However, poor correlation was found in patients with tibial disease. When analyzing the lesions on the basis of Vr < 2.0, 11 of 86 (12.8%) had >70% angiographic stenosis. In lesions with ratios from 2 to 2.5, 12 of 13 (92.3%) had >70% angiographic stenosis and in lesions with ratios >2.5, 69 of 75 (92.0%) had >70% angiographic stenosis. ROC curve analysis showed that to detect ≥ 70% stenosis in the SFA, a PSV ≥ 204 cm/sec had a sensitivity of 97.6% and specificity of 94.7%. To detect ≥ 70% stenosis in the overall femoropopliteal region, a PSV ≥ 223 cm/sec had a sensitivity of 94.1% and specificity of 95.2%. CONCLUSIONS: Duplex ultrasound surveillance correlates to the degree of angiographic stenosis on the basis of PSV in the SFA and popliteal region. Correlation in the tibial vessels is poor. Vr > 2.0 appear to correlate to angiographic stenosis of > 70%. ROC analysis shows that PSV can have sufficiently high sensitivity and specificity to predict angiographic stenosis in the femoropopliteal region.

Closed-cell stents present with higher velocities on duplex ultrasound compared with open-cell stents after carotid intervention: short- and mid-term results.

BACKGROUND: The purpose of this study was to evaluate the effect of carotid cell design on duplex ultrasound velocity readings in the immediate postoperative period and over time. METHODS: A prospective database encompassing all patients treated with carotid artery stents between 2003 and 2008 was established and analyzed for stent type (closed-cell vs. open-cell), indications, and comorbidities. Patients were followed up clinically and with duplex ultrasound immediately after surgery, and every 6 months thereafter. Peak systolic velocities (PSV), end diastolic velocities (EDV), and internal carotid artery (ICA) to common carotid artery (CCA) ratios of PSV were recorded. RESULTS: A total of 214 interventions with 157 (73.3%) open-cell and 57 (26.7%) closed-cell types of carotid stents were performed in 205 patients. Two groups were similar regarding demographics, comorbidities, lesions characteristics, and stent length and diameter. The only difference was a significantly higher mean age (74.4 ± 10.1 vs. 70.9 ± 9.7 years; p = 0.027) and a history of myocardial infarction (34.5% vs. 15.6%; p = 0.004) in the closed-cell group versus open-cell group. Immediately after surgery PSV (115.9 ± 66.1 vs. 93.1 ± 38.7 cm/s; p = 0.003) and ICA/CCA ratio (2.08 ± 1.66 vs. 1.45 ± 0.52; p = 0.001) were significantly higher in closed-cell compared with open-cell group. This difference persisted during the follow-up period of 20.2 +/- 16.4 months; PSV (147.2 ± 108.8 vs. 110.0 ± 51.9; p = 0.003) and ICA/CCA ratio (2.61 ± 2.31 vs. 1.76 ± 0.81; p = 0.001). Patients with diabetes and calcified lesions had higher PSV and ICA/CCA ratio immediately after surgery (p > 0.05 and p < 0.05 for those with diabetes and calcified lesions, respectively) and over time. The number of readings showing significant restenosis (PSV >300 cm/s) over time were significantly higher in closed-cell 5 (8.7%) versus open-cell 1 (0.06%). EDV was not statistically different in the two groups (p > 0.05). CONCLUSION: Our study suggests that duplex criteria to screen for poststent restenosis may require modification according to stent-type. However, long-term effect of stent design on restenosis is still to be established.

Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors.

This questionnaire-based study assessed the attitudes of the general public to the symptoms of a transient ischaemic attack (TIA) and determined the current level of knowledge about the management of TIA among doctors. The public chose to wait for symptom recurrence before seeking medical advice for amaurosis (41%) and upper limb (UL) monoparesis (51%), sensory loss (68%), or paraesthesia (95%). However, medical advice would be sought most often for slurred speech alone (89%) or combined with UL monoparesis (99%). Most physicians confirmed that these symptoms could represent a 'carotid TIA' but many considered diverse symptoms as relevant. While most general practitioners would prescribe anti-platelet therapy, 22-40% would not refer first-time TIA patients, depending upon the presenting symptom. In conclusion, the general public does not recognise the importance of TIA symptoms and the need for rapid assessment. This is compounded by deficiencies in the medical management of TIA. Stroke guidelines will remain ineffective without public awareness campaigns and physician education.

Papillary adenoma of the distal common bile duct associated with a synchronous carcinoma of the peri-ampullary duodenum.

CONTEXT: Benign tumours of the biliary tract are an extremely rare group of neoplasms. The diagnosis of these rare tumours is established on histopathological analysis following resection. Coincidence of a biliary adenoma of the distal common bile duct and a synchronous adenocarcinoma of the peri-ampullary duodenum has never been reported in the literature. CASE REPORT: We report a case of a papillary adenoma in the common bile duct in a 75-year-old female, who had synchronous invasive adenocarcinoma of the peri-ampullary duodenum. CONCLUSION: Isolated papillary adenoma of the bile duct is extremely rare, and in this unusual case it coincided with a peri-ampullary duodenal adenocarcinoma. However, this is a rare instance of an incidental finding within the distal bile duct following pancreaticoduodenectomy for curative treatment of a peri-ampullary adenocarcinoma.