Analysis of risk factors and classification of aortic fistula after esophagectomy.

BACKGROUND: Aortic fistula after esophagectomy is a rare and serious complication. The aims of this study were to describe the causes of and classify the fistulas. MATERIALS AND METHODS: Between January 2008 and December 2017, a total of 1018 patients underwent esophageal resection, mainly for esophageal cancer; aortic fistula after esophagectomy was diagnosed in four patients. We perform a literature review through a database search for similar cases. Aortic fistulas may be classified into two types based on the site at which they occur in relation to the alimentary tract and area of anastomosis. Type 1 fistula occurs within the area of anastomosis, whereas type 2 fistula occurs above or below the anastomosis. The risk factors and clinical features associated with aortic fistulas are described, and comparison between the two types is made. RESULTS: Through a literature search, 39 cases were identified, of which 26 cases were classified as type 1, and 13 cases were classified as type 2. Of 13 patients (33.3%) who underwent emergent intervention, seven patients survived. Approximately 76.9% of aortic fistula were related to anastomotic fistula, which was more prevalent in type 1 aortic fistula than in type 2 (92% versus 50%, P = 0.005). There was no statistically significant difference in age, gender, side of thoracotomy, type of anastomosis, the postoperative day the hemorrhage occurred, warning hemorrhage, chest pain, or the outcome between the two types of fistula. CONCLUSIONS: Anastomotic fistula is the primary cause of type 1 aortic fistula after esophagectomy, and early diagnosis and intervention of aortic fistula can improve prognosis. This classification may be a useful guide in determining the approach for second-stage alimentary tract reconstruction.

Management and classification of type II congenital portosystemic shunts.

BACKGROUND: Congenital portosystemic shunts (PSS) with preserved intrahepatic portal flow (type II) present with a range of clinical signs. The indications for and benefits of repair of PSS remain incompletely understood. A more comprehensive classification may also benefit comparative analyses from different institutions. METHODS: All children treated at our institution for type II congenital PSS from 1999 through 2009 were reviewed for presentation, treatment, and outcome. RESULTS: Ten children (7 boys) with type II PSS were identified at a median age of 5.5 years. Hyperammonemia with varying degrees of neurocognitive dysfunction occurred in 80%. The shunt arose from a branch of the portal vein (type IIa; n = 2), from the main portal vein (type IIb; n = 7), or from a splenic or mesenteric vein (type IIc; n = 1). Management included operative ligation (n = 6), endovascular occlusion (n = 3), or a combined approach (n = 1). Shunt occlusion was successful in all cases. Serum ammonia decreased from 130 ± 115 µmol/L preoperatively to 31 ± 15 µmol/L postoperatively (P = .03). Additional benefits included resolution of neurocognitive dysfunction (n = 3), liver nodules (n = 1), and vaginal bleeding (n = 1). CONCLUSION: Correction of type II PSS relieves a wide array of symptoms. Surgery is indicated for patients with clinically significant shunting. A refined classification system will permit future comparison of patients with similar physiology.

Treatment of slow-flow (type I) perimedullary spinal arteriovenous fistulas with special reference to embolization.

Embolization of type I perimedullary spinal arteriovenous fistulas (AVFs) can be difficult, because of tortuosity and the small diameter of the feeder and distal location of the fistula site. The 1.5F flow-directed catheter in conjunction with a hydrophilic guidewire has been used in fistula embolization with cyanoacrylate glue for spinal vascular malformations at our institution. This combination has improved our success rate in achieving superselective catheterization of the fistula. Thus, 4 of 5 patients with type I perimedullary AVFs could be cured with this technique. Like type II and type III perimedullary AVFs, the endovascular approach may also be the first line of treatment in type I perimedullary spinal AVF.

[Macroscopic intrahepatic portosystemic venous shunt: review of the literature and reclassification]. / Shunts veineux portosystemiques intrahepatiques macroscopiques: revue de la litterature et reclassification.

Macroscopic intrahepatic portosystemic venous shunts (IHPSS) are defined as communications between the portal and the systemic venous circulation, measuring more than 1mm in diameter, and at least partially located inside the liver. Four different types can be identified based on anatomical, clinical, and pathophysiological criteria. Type I includes patent paraumbilical veins, located in the liver, and commonly encountered in portal hypertension. Types II, III, and IV are much less common and have been reported in only 47 publications in the entire French and English literature. They include shunts, unique or multiple, between a portal branch and a hepatic vein, located either in two adjacent liver segments (type II) or in non-adjacent liver segments (type III). Type IV corresponds to any tubular communication developed between the right portal branch and the inferior vena cava. The exceptional patent ductus venosus or a patent umbilical vein should not be considered as IHPSS since their course is strictly extrahepatic.