Superior Vena Cava Syndrome and Wallstent: A Systematic Review.

Purpose: To elucidate the indication, presentation, demographics, Stanford classification, technical efficacy, morbidity, mortality and long term patency of Wallstent for superior vena cava (SVC) syndrome. Materials and Methods: A systematic review of literature in Pubmed and Embase, CINAHL and Cochrane Library in accordance to PRIMSA was conducted. Retrieval and extraction was performed by two independent reviewers with inter-rater reliability test. The hierarchy of the evidence was assessed through the National Institute for Health and Care Excellence Checklist. Data was subjected to pooled prevalence analysis, Cox regression, Kaplan-Meir survival and test of probability using log rank analytics. This review is registered with International prospective register of systematic review: CRD42021271009. Results: A total of n=701 individuals with n=930 stents with median age of 60 (interquartile range (IQR): 26-89) years and male predominance 3.5 : 1 were identified in n=30 articles. The most common venographic classification was Stanford type II (n=344, 50%) and complete symptomatic resolution was achieved in 48 h. The 30-day morbidity was (n=62, 8%) and mortality was (n=21, 3%). Female gender was associated with higher 30-day morbidity (p<0.03). The cumulative median patency of Wallstent for non-malignant aetiology was [550 days (IQR: 14-1080) vs. 120 days (IQR: 0-925)] for malignancy (p<0.03). Conclusion: The use of Wallstent for resolution of malignancy induced SVC syndrome as a first line therapy is feasible and associated with low mortality. Their use for non-malignant aetiology demands a more in depth review and advocates further investigation.

Total endoluminal repair of aorto-oesophageal fistula.

A woman in her 50s presented to the Emergency Department, following massive haematemesis, having swallowed a single tooth denture 3 years previously. Endoscopy initially revealed profuse bleeding at 20cm from the incisors, initially treated with an oesophageal covered stent. Following ongoing haematemesis, a thoracic and abdominal CT angiogram demonstrated an aorto-oesophageal fistula, which was successfully treated with a thoracic endograft and left tube thoracostomy. The patient remains well to 1 year. This is the first case to demonstrate successful use of covered stents in both the aorta to stop exsanguination, as well as the oesophagus to prevent mediastinitis and avoid the need for thoracotomy and hypothermic circulatory arrest in a critically ill patient.

Outcomes after Transverse-Incision 'Mini' Carotid Endarterectomy and Patch-Plasty.

PURPOSE: Traditional exposure for carotid endarterectomy (CEA) involves making a longitudinal incision parallel to the anterior border of the sternocleidomastoid. Such incisions can be painful, aesthetically displeasing, and associated with a high incidence of cranial nerve injury (CNI). This study describes the outcomes of CEA performed through small (<5 cm long), transversely oriented incisions located directly over the carotid bifurcation, as identified by color-enhanced Duplex ultrasound. MATERIALS AND METHODS: Patient demographics and operative data were collected retrospectively from an in-house database of consecutive vascular patients undergoing CEA with a small transversely oriented incision for both symptomatic and asymptomatic carotid artery stenoses. RESULTS: A total of 52 consecutive patients underwent CEA between 2012 and 2016 (median age, 73.5 years; interquartile range, 67-80.3; male/female ratio, 40:12). CEA was performed under regional/local anesthesia (LA) in 48 (92.3%) patients, with 4 (7.7%) being performed under general anesthesia. One patient under LA experienced neurological dysfunction intraoperatively (manifesting as an inability to count out loud) that resolved with insertion of shunt. One patient experienced a transient neurological event (expressive dysphasia) within the immediate postoperative period, which resolved within 6 hours. No in-hospital death or perioperative major adverse cardiovascular events were noted. No persistent CNIs nor bleeding complications necessitating re-exploration were reported. Follow-up data were available for a median period of 3.1 years and for all patients. Three patients experienced strokes following discharge (2 strokes contralateral to and 1 transient ischemic attack ipsilateral to the operated side). CONCLUSION: Small, transversely orientated incisions, hidden within a neck skin crease can be safely performed in the majority of patients undergoing CEA.