A Simple Target Will Save the Day and the Kidney: This Is How We Perform Our Endovascular Fenestrated Graft Procedure.

With the advent of state-of-the-art imaging modalities, increasing population age, and advanced preventive medical treatments, medical device design attempts to keep up with procedural demand. An abdominal aortic aneurysm (AAA) is a recognized, potentially fatal disease process where strides have been made in screening, detection, and treatment since its discovery. With the introduction of percutaneous endograft procedures in 1991, open surgical treatment is nearly a lost art. Endovascular aortic repair is now the gold standard. However, short landing zone necks, hostile angulation, and markedly dilated seal zones present challenges for one size fits all endovascular aortic devices. Suprarenal and juxtarenal fenestrated aortic grafts are the most advanced individually customized grafts invented to date. Subsequently, proper placement of these complex devices still presents challenges. We present a method for preoperative renal stent placement for target purposes. This article includes a pictorial guide and describes the tips and pitfalls for easy proper AAA exclusion with a fenestrated aortic graft. We were successful in the deployment of the fenestrated graft device and the exclusion of an aortic aneurysm while preserving the patency of the renal arteries. The patient had no postoperative complications. During 18-month postoperative surveillance, imaging demonstrated proper graft positioning without evidence of an endoleak. In fenestrated endovascular aortic repair, preoperative renal stenting is paramount for targeting purposes. This allows for the precise and timely deployment of the renal limbs through the fenestrations while minimizing the risk of postoperative complications, including renal artery occlusion.

Portal Vein Tumor Thrombus: No Longer a Death Sentence.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and a leading cause of cancer mortality worldwide. HCC commonly results from longstanding liver cirrhosis, which presents a host of complications and a severely diminished quality of life. Despite advancements in diagnosis, molecular pathogenesis, and management of the complications associated with irreversible liver diseases, HCC remains an aggressive malignancy with high mortality. HCC is often invasive to adjacent vasculature, including the inferior vena cava (IVC) and portal veins, which present with rapid morbidity and patient decline. This article describes a patient with cirrhosis and HCC previously treated with cryoablation now presenting with multiple new foci and invasion of the left medial portal vein. These lesions were synchronously cryoablated. Cryoablation is typically reserved for solid tumor masses within the soft tissue or specific organs. This report illustrates a technique of directly cryoablating tumors within vessels. We achieved adequate cryoablation of the intravascular HCC portal vein tumor thrombus in the left medial portal vein. A one-month follow-up CT scan demonstrated significant portal vein macrovascular invasion (MVI) regression from 22.8 mm to 7.7 mm. Portal vein invasion by HCC presents unique challenges and traditionally precludes percutaneous or surgical therapy. Our technique shows successful cryoablation of MVI as a viable adjunct to treatment in select patients.

Expanding the Frontiers of Treatment: Cryoablation of an Ovarian Mass.

The ovaries are a common site of metastasis from a variety of solid organ malignancies. These tumors most commonly originate from the gastrointestinal tract. Neuroendocrine tumors of the small bowel are unrelenting in their tendency to exhibit this type of distant spread, which poses a challenge for curative treatment. Whether metastatic disease to the ovary or primary ovarian malignancy, this is a major cause of morbidity and mortality for women of various ages. Currently, a mainstay of palliative treatment for advanced-stage disease resides in surgical debulking and chemotherapy. At times, these patients may not be surgical candidates due to various reasons which may include a large disease burden. Computed tomography-guided percutaneous cryoablation is a minimally invasive technique that has shown promise in treating solid organ metastatic lesions by exposing them to lethal temperatures. We describe a novel technique of palliative cryoablation of a primary small bowel carcinoid tumor that metastasized to the ovary. Hydrodissection was utilized to create a window for safe percutaneous treatment. At the end of freeze cycles, intraoperative CT was performed, demonstrating greater than 90% incorporation of the ovarian tumor within the margins of the lethal ice zone. Our team decided that this was a maximum percentage of freeze due to neighboring vessels and bowel. The patient tolerated this treatment well, and there were no reported post-operative complications. The procedure was clinically successful at shrinking the tumor as demonstrated on a nine-month follow-up CT. Percutaneous cryoablation is already a widely utilized method for treating tumors in various locations including the kidneys and liver. The application of cryoablation can be expanded as an effective and safe palliative technique for treating ovarian tumors. This may be especially useful in patients that are not surgical candidates.

Covered or Not, Here I Come: Stanford Type B Aortic Dissection Repair With a Covered and Uncovered Stent Hybrid Technique.

The complications resulting from aortic dissections are often devastating. Historically, when a Stanford B aortic dissection extended into the visceral abdominal aorta, only surgical management was considered to limit visceral organ malperfusion. Complications of surgical management for Stanford B aortic dissections are as high as 50%. The inherently high complication and mortality rate for any acute aortic dissection, in addition to the complication rates resulting from surgical management, have demonstrated poor outcomes. This is especially true when aortic dissections involve the visceral segment, where thoracic endovascular aortic repair (TEVAR) becomes limited or contraindicated. In the last two decades, various approaches for TEVAR have improved in both endograft design and interventional technique. The current literature demonstrates improved outcomes for patients that receive TEVAR for Stanford B aortic dissections, including those that involve the visceral segment. Despite favorable prognostic advancement in TEVAR, the proven management complexity of Stanford B aortic dissections continue to reflect the pitfalls of the endovascular devices that are currently available. We describe a covered and uncovered stent hybrid technique in patients with complicated Stanford B aortic dissections involving the visceral segment, considering these deficiencies. Hundred percent technical success was demonstrated in the short and mid-term surveillance periods.