Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy.

OBJECTIVE: To evaluate and compare the outcome after endovascular abdominal aortic aneurysm repair (EVAR) with the newly released Endurant endograft system in patients with different aortoiliac anatomic characteristics. METHODS: We conducted a prospective observational study assigning patients with infrarenal abdominal aortic aneurysm (AAA) treated with the Endurant endoprosthesis from February 2009 to March 2010. Two groups were studied, according to the presence of a friendly (group I [GI] = 43) or hostile (group II [GII] = 34) infrarenal aortoiliac anatomy. Hostile profile was defined as any (or combination) of the following measurements: 5 mm ≤ proximal neck length (Lpr) ≤ 12 mm, 60° < proximal neck angle (A°pr) ≤ 90° and 60° < any iliac axis angle (A°iliac) ≤ 90°. Primary end points included technical and clinical success, freedom from early or late secondary interventions, any type of endoleak, and aneurysm-related death. All outcome measures were calculated using the Kaplan-Meier method and the log rank test was applied for comparisons between the groups. RESULTS: The mean comorbid severity scoring was higher in GII (P = .018). The mean follow-up period in GI and GII was 12.9 ± 3.9 months (± SD, range: 6.4-19.8) and 12.4 ± 4 months (range: 4.2-19.6), respectively. Two unplanned conversions to aortouniiliac configurations were required in GI. The technical success rate in GI and GII was 95.4% and 100%, respectively. The requirement for intentional occlusion of the internal iliac artery, the requirement for cross-limb technique, the necessity of troubleshooting techniques, the procedure and radiation times, the frequency of postimplantation syndrome, and mean hospital stay were significantly higher in GII (P = .028, P = .013, P = .005, P = .037, P < .001, P = .032, P = .021, respectively). Two patients of GI died in the early postoperative period (one aneurysm but not device-related death), whereas no deaths in GII were recorded, yielding an overall 30-day mortality rate of 2.3%. No type I/III endoleaks were recorded up to the end of the study. Freedom from any type of endoleak, early or late secondary interventions, and aneurysm-related death at 12 months were found in 93.2%, 87.1%, and 93.3% of GI patients; respective values for GII were 86% (P = .21), 93.4% (P = .066), and 93.4%. The clinical success rate was 82.1% and 100% at 12 months for GI and GII, respectively. CONCLUSIONS: Early (12 months) results suggest similar clinical performance of the Endurant stent graft system in endovascular treatment of AAAs with friendly and hostile anatomies, however, demonstrating more intra- and perioperative adversities for the last group. Larger prospective studies or even randomized trials comparing different new generation graft models are required to evaluate the comparable long-term results and possible expansion of EVAR indications for this specific endograft in adverse anatomies.

Giant extra gastrointestinal stromal tumor of lesser omentum obscuring the diagnosis of a choloperitoneum.

INTRODUCTION: Herein we present an extremely rare case of a giant extra gastrointestinal stromal tumor (EGIST) of the lesser omentum obscuring the diagnosis of a choloperitoneum. PRESENTATION OF CASE: A 79 years old female was admitted to our hospital with symptoms of vomiting and epigastric pain. Abdominal computer tomography revealed a sizable formation that was diagnosed as a tumor of the pancreas. In laparotomy, a choloperitoneum was diagnosed as the cause of patient's symptoms. A tumor adherent firmly to the lesser curvature of stomach was also discovered. Cholecystectomy and subtotal gastrectomy were performed. Histologically, the tumor was diagnosed as a EGIST of the lesser omentum. The patient did not receive any adjuvant therapy and after two years of follow up she is without any recurrence. DISCUSSION: Omental EGISTs may remain clinically silent despite the large tumor's size. It is difficult to differentiate a EGIST in the lesser omentum from a GIST of the lesser curvature of the stomach, despite the use of advanced radiological imaging techniques. Our case of a giant EGIST of lesser omentum obscuring the diagnosis of acute choloperitoneum is the only one reported in literature. CONCLUSION: EGISTs that arise from the omentum are very rare and complete surgical resection is the only effective treatment approach. Adjuvant therapy following resection of localized disease has become standard of care in high risk cases.

Endovascular therapy for penetrating ulcers of the infrarenal aorta.

BACKGROUND: We sought to investigate the short- and mid-term results of the endovascular repair of infrarenal abdominal penetrating aortic ulcers (aPAUs). METHODS: Patients with infrarenal aPAUs treated by endovascular means between March 2004 and June 2012 were recruited. Pre-interventional imaging included computed tomography (CT) or CT angiography. Endoprostheses were chosen and deployed according to standard elective endovascular aneurysm repair anatomical requirements. Endpoints included 30-day survival, in-hospital mortality, 1-year PAU-related mortality, 1-year all-cause mortality, freedom from death and freedom from cumulative complication and interventions. Statistically, the Kaplan-Meier method was applied. RESULTS: Nineteen patients (18 men, median age 70 years (interquartile range, IQR = 59-75)) suffering aPAUs (n = 29, infrarenal = 25) were detected. The median co-morbid severity scoring was 1.0 (IQR = 0.4-1.4). The median follow-up period was 33 months (IQR = 8-51.5). Furthermore, 94.7% of patients had hypertension. Fourteen patients (73.7%) had symptoms, including four of them admitted with shock from large-contained PAU rupture. Endoluminal stent grafting was successfully delivered in all patients. In-hospital mortality was 10.5%. Two patients required secondary interventions (10.5%). The 30-day survival, 1-year PAU-related mortality and 1-year all-cause mortality were 94.7%, 89.5% and 89.5%, respectively. Freedom from death and freedom from cumulative complications and interventions was 86.4% and 86.4%, 78.9% and 78.9%, and 67.9% and 71.2% at 12, 24 and 36 months, respectively. CONCLUSIONS: Urgent and elective endovascular repair of aPAUs can be achieved with high technical success. The significant co-morbid status of the treated patients is illustrated in the considerable in-hospital mortality and underlines the advantage of such treatment over open surgical repair.

Desmoid tumor of the abdominal wall: a case report.

INTRODUCTION: Desmoid tumors are rare lesions without any metastatic potential but a strong tendency to invade locally and to recur. These tumors are associated with women of fertile age, especially during and after pregnancy. CASE PRESENTATION: The case of a desmoid tumor of the anterior abdominal wall in a 40-year-old Caucasian man with no relevant family history is presented, describing its appearance on computed tomography and ultrasonography. The patient, who presented with a painless mass in the left anterolateral abdomen, had a history of previous urgent abdominal surgery after a shotgun injury two years earlier. Radical resection of the affected abdominal wall musculature was performed, and the defect was reconstructed with polypropylene mesh. CONCLUSION: The diagnosis of desmoid tumor should be strongly considered even in male patients with an abdominal mass and a history of previous abdominal surgery. The goal of its treatment is complete tumor excision and avoidance of the development of complications such as hernia.

Benign multicystic peritoneal mesothelioma: a case report.

INTRODUCTION: We report the case of a patient with a benign multicystic peritoneal mesothelioma and describe its appearance on computed tomography scans and ultrasonography, in correlation with gross clinical and pathological findings. CASE PRESENTATION: A 72-year-old Caucasian woman presented to our emergency department with acute abdomen signs and symptoms. A clinical examination revealed a painful palpable mass in her left abdomen. Abdominal ultrasonography and computed tomography demonstrated the presence of a large cystic mass in her left upper abdomen, adjacent to her left hemidiaphragm. The lower border of the mass extended to the upper margin of her pelvis. A complete resection of the lesion was performed. Pathological analysis showed a benign multicystic peritoneal mesothelioma. CONCLUSIONS: Benign multicystic peritoneal mesothelioma is a rare lesion with a non-specific appearance on imaging. Its diagnosis always requires pathological analysis.