The Use of Re-entry Devices in Aortoiliac Occlusive Disease.

Endovascular approach is the first-choice treatment in patients suffering from aortoiliac occlusions. Nevertheless, standard endoluminal revascularization fails in treating occlusions in about 20% (1) of cases. Thus, subintimal revascularization can be a solution, but it fails in 25% (2) of cases as well. In the last decades, different devices have been created, in order to ease the cross back into the true lumen, when standard subintimal revascularization does not work or risks to occlude important collateral vessels. Herein, we revise the currently available re-entry devices and their application in the aortoiliac occlusive pathology.

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue.

OBJECTIVES: To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. METHODS: Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. RESULTS: In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient. CONCLUSIONS: Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Failed stapled rectal resection in a constipated patient with rectal aganglionosis.

A rare case of a severely constipated patient with rectal aganglionosis is herein reported. The patient, who had no megacolon/megarectum, underwent a STARR, i.e., stapled transanal rectal resection, for obstructed defecation, but her symptoms were not relieved. She started suffering from severe chronic proctalgia possibly due to peri-retained staples fibrosis. Intestinal transit times were normal and no megarectum/megacolon was found at barium enema. A diverting sigmoidostomy was then carried out, which was complicated by an early parastomal hernia, which affected stoma emptying. She also had a severe diverting proctitis, causing rectal bleeding, and still complained of both proctalgia and tenesmus. A deep rectal biopsy under anesthesia showed no ganglia in the rectum, whereas ganglia were present and normal in the sigmoid at the stoma site. As she refused a Duhamel procedure, an intersphincteric rectal resection and a refashioning of the stoma was scheduled. This case report shows that a complete assessment of the potential causes of constipation should be carried out prior to any surgical procedure.