Endovascular rescue of failed physician-modified multibranched endografts with fabric tear, using Gore thoracoabdominal multibranched endoprosthesis.

The thoracoabdominal multibranch endoprosthesis is a commercially available off-the-shelf four-vessel inner branched endograft for complex abdominal and thoracoabdominal aortic aneurysms. Type IIIb endoleak owing to fabric tear of fenestrated branched endovascular repair (FBEVAR) can be challenging, often requiring relining FBEVAR. Here, we present a case where thoracoabdominal multibranch endoprosthesis was used to reline the previous physician modified FBEVAR in a patient with a 10-cm extent IV thoracoabdominal aortic aneurysm distal to the previous open extent I thoracoabdominal aortic aneurysm repair.

Hybrid approach to achieve secure distal seal zones during endovascular aortic repair in a patient with Marfan syndrome.

This report details a hybrid approach for treatment of abdominal aortic aneurysm in a patient with Marfan syndrome (MFS). A 34-year-old patient with MFS and prior open thoracoabdominal aortic aneurysm repair underwent bilateral common iliac artery interposition graft repair and endovascular aortic repair. The bifurcated stent graft was implanted into the previous thoracoabdominal graft proximally and iliac interposition grafts distally. Postoperatively, the patient recovered uneventfully with sac regression to 4.5 cm through 2-year follow-up, without seal zone degeneration. This hybrid approach aimed to eliminate landing zone degeneration in patients with MFS undergoing endovascular repair.

Three-year outcomes of off-the-shelf Gore thoracoabdominal multibranch endoprosthesis and physician-modified endografts for complex abdominal and thoracoabdominal aortic aneurysms.

OBJECTIVE: Fenestrated-branched endovascular aortic repair (FB-EVAR) has shown favorable outcomes for repair of complex aneurysms and thoracoabdominal aortic aneurysms. Physician-modified endografting (PMEG) and the Gore thoracoabdominal multibranch endoprosthesis (TAMBE) provide custom and off-the-shelf devices for FB-EVAR, respectively. This study compares the outcomes of TAMBE and PMEG at a single institution. METHODS: A retrospective review of patients who underwent TAMBE as part of the multicenter pivotal trial or PMEG as part of a prospective physician-sponsored investigational device exemption at a single institution between 2020 and 2022 were completed. Patient demographics, characteristics, and perioperative and midterm outcomes were compared. RESULTS: A total of 68 patients were included, with 12 in the TAMBE group and 56 in the PMEG group. Baseline characteristics were comparable between groups. Aneurysm type was most often thoracoabdominal aortic aneurysm in both groups (58% TAMBE and 52% PMEG). TAMBE had a higher rate of upper extremity access (100% vs 63%; P = .013) and longer mean procedure time (247 ± 36 minutes vs 189 ± 49 minutes; P < .001). Other intraoperative metrics were similar between groups. Technical success was 100% in TAMBE and 95% in PMEG (P = .412). There was no 30-day mortality in either group. No major adverse events occurred with TAMBE, whereas in PMEG cases, 2% had respiratory failure, 2% required dialysis, and 4% experienced spinal cord ischemia. Although the overall endoleak rates were similar (50% of TAMBE vs 41% of PMEG; P = .57), type II endoleaks accounted for all of the endoleaks in the TAMBE group, whereas type I or III endoleaks were seen in 11% of PMEG patients. At a median follow-up of 26.7 months for the TAMBE group and 21.2 months for the PMEG group, target vessel instability was seen in 10.4% of TAMBE, and 6.9% of PMEG targeted branches (P = .401). Reintervention was required in 33% of TAMBE patients and 27% of PMEG patients (P = .646). Estimated freedom from reintervention rates at 3 years were similar (56% TAMBE vs 62% PMEG, log-rank P = .910). Freedom from visceral renal target vessel instability at 3 years was 89% for both groups (log-rank P = .459). The Kaplan-Meier 3-year estimated survival was 100% for patients in the TAMBE group and 77% for patients in the PMEG group (log-rank P = .157). CONCLUSIONS: At experienced centers, FB-EVAR can be completed with PMEG or TAMBE with comparable, excellent perioperative and midterm outcomes. Reinterventions are frequently needed for both TAMBE and PMEG.

Transfusion and Anemia in Patients Undergoing Vascular Surgery.

This cohort study examines the association between blood transfusion and major adverse cardiovascular events and mortality among people undergoing elective open vascular operations.

Incorporation of internal iliac arteries as target vessels during physician-modified fenestrated branched endovascular repair of pararenal abdominal aortic aneurysm with concomitant bilateral short common iliac artery aneurysms.

This report describes an alternative endovascular approach to iliac branch devices for treatment of an abdominal aortic aneurysm with concomitant bilateral short common iliac aneurysms. The short distance between the renal arteries and internal iliac artery origins made the addition of distal iliac branch devices to the proximal fenestrated stent graft challenging. We elected to perform physician-modified fenestrated branched endovascular repair, using four fenestrations for the visceral and renal arteries and an additional two directional branches for the bilateral internal iliac arteries. The patient recovered uneventfully, and the 24-month follow-up imaging shows successful aneurysm exclusion with patent internal iliac artery branches.

Hodgkin lymphoma masquerading as perforated gallbladder adenocarcinoma: A case report.

BACKGROUND: There are several case reports of acute cholecystitis as the initial presentation of lymphoma of the gallbladder; all reports describe non-Hodgkin lymphoma or its subtypes on histopathology of the gallbladder tissue itself. Interestingly, there is no description in the literature of Hodgkin lymphoma causing hilar lymphadenopathy, inevitably presenting as ruptured cholecystitis with imaging mimicking gallbladder adenocarcinoma. CASE SUMMARY: A 48-year-old man with a past medical history of diabetes mellitus presented with progressive abdominal pain, jaundice, night sweats, weakness, and unintended weight loss for one month. Work-up revealed a mass in the region of the porta hepatis causing obstructions of the cystic and common hepatic ducts, gallbladder rupture, as well as retroperitoneal lymphadenopathy. The clinical picture and imaging findings were suspicious for locally advanced gallbladder adenocarcinoma causing ruptured cholecystitis and cholangitis, with metastases to retroperitoneal lymph nodes. Minimally invasive techniques, including endoscopic duct brushings and percutaneous lymph node biopsy, were inadequate for tissue diagnosis. Therefore, this case required exploratory laparotomy, open cholecystectomy, and periaortic lymph node dissection for histopathological assessment and definitive diagnosis. Hodgkin lymphoma was present in the lymph nodes while the gallbladder specimen had no evidence of malignancy. CONCLUSION: This clinical scenario highlights the importance of histopathological assessment in diagnosing gallbladder malignancy in a patient with gallbladder perforation and a grossly positive positron emission tomography/computed tomography scan. For both gallbladder adenocarcinoma and Hodgkin lymphoma, medical and surgical therapies must be tailored to the specific disease entity in order to achieve optimal long-term survival rates.

Atypical presentation of necrotising autoimmune myopathy.

Necrotising autoimmune myopathy (NAM) is characterised by a common phenotype of profound symmetrical proximal muscle weakness, elevated creatine kinase levels, irritable myopathy on electromyography and histological findings of myocyte necrosis and regeneration without remarkable inflammation. NAM is associated with autoimmune antibodies including anti-3-hydroxy-3-methylglutaryl-coenzyme receptor, which is strongly associated with statin use. We report a case of statin-associated NAM with an atypical presentation of severe oropharyngeal dysphagia and no remarkable proximal muscle weakness at initial presentation but with rapid progression to severe quadriparesis in weeks. This case expands the spectrum of presentation patterns of this rare disease and highlights the need for a high index of suspicion in patients with a remote history of statin use.