Evaluating the Effectiveness and Clinical Outcomes of Endovascular Aneurysm Repair-First Approach for Ruptured Abdominal Aortic Aneurysm in Japan.

PURPOSE: To verify the validity of an endovascular aneurysm repair (EVAR)-first strategy for treating patients with ruptured abdominal aortic aneurysm (rAAA) in Japan. MATERIALS AND METHODS: This study was conducted on 2 groups of patients with rAAA who underwent surgical treatment at 3 hospitals in the Kanagawa Prefecture, Japan, between January 2007 and September 2016. The open surgical treatment group comprised patients with rAAA who underwent open surgical treatment before January 2012; their data were retrospectively collected from their medical records. The EVAR-first strategy group comprised patients with rAAA who underwent treatment based on the Shonan rAAA protocol (SRAP; the standard protocol-based EVAR-first strategy) in or after February 2012; their data were collected prospectively. The short- and long-term treatment outcomes of both groups were compared. In addition, a risk score-based sensitivity analysis (one-to-one matching) was conducted on both groups using a caliper with 0.2 standard deviations of the score. RESULTS: Of the 163 patients with rAAA, the open surgical and EVAR-first strategy groups comprised 53 and 110 patients, respectively (EVAR: 91.8%, open repair: 8.2%). The 30-day postoperative mortality rate differed significantly, being 42% for the open surgery group and 25% for the EVAR-first strategy group (odds ratio: 0.44, 95% confidence interval: 0.20-0.97). The postoperative survival rates at 6 months, 1 year, and 3 years were 66%, 48%, and 58% for the EVAR-first group, respectively, and 51%, 66%, and 48% for the open surgery group, respectively (p=0.072). In a matched cohort analysis (n=50), the 30-day postoperative mortality rate was 22% for the EVAR-first group and 44% for the open surgery group (odds ratio: 0.35, 95% confidence interval: 0.14-0.90). The postoperative survival rates at 6 months, 1 year, and 3 years were 76%, 76%, and 63% for the EVAR-first group, respectively, and 48%, 45%, and 45% for the open surgery group, respectively (p=0.003). CONCLUSION: The SRAP-based EVAR-first strategy for rAAA yielded significantly better treatment outcomes than the open surgical strategy. These findings suggest that EVAR should be considered the primary treatment option for rAAA, given its potential to reduce early mortality rates. CLINICAL IMPACT: Multicenter retrospective analysis of prospectively collected registry data was done to compare treatment outcomes of two groups of ruptured abdominal aortic aneurysm patients open surgery and endovascular-aneurysm-repair (EVAR)-first strategy (Shonan ruptured abdominal aortic aneurysm protocol). EVAR-first group showed better outcomes: lower 30-day mortality (25% vs. 42%), higher survival rates at 6 months, 1 year, and 3 years. Take home Message: The study supports the use of the EVAR-first strategy with the Shonan Protocol for treating ruptured abdominal aortic aneurysms in Japan, showing improved outcomes, reduced 30-day postoperative mortality, and better long-term survival rates compared to the conventional approach.

Long-Term Outcomes of a Japanese Prospective Multicenter Registry Using a Heparin-Bonded Expanded Polytetrafluoroethylene Graft for Above-the-Knee Femoropopliteal Bypasses.

BACKGROUND: Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN®use for above-knee femoropopliteal bypass (AKFPB).Methods and Results: After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36-88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively. CONCLUSIONS: This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN®constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.

Midterm Results of a Japanese Prospective Multicenter Registry of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Above-the-Knee Femoropopliteal Bypass.

BACKGROUND: This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1-36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency. CONCLUSIONS: AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.

Hemodynamic comparison of CoreValve and SAPIEN-XT TAVI valves in Japanese patients.

Transcatheter aortic valve implantation (TAVI) is a viable treatment option for high-risk patients with severe aortic stenosis. In Japan, TAVI can be performed using first-generation self-expandable Medtronic CoreValve or balloon-expandable Edwards SAPIEN-XT from 2012. Since the durability and hemodynamic outcomes after transcatheter heart valve (THV) implantation in Japanese patients have not been clearly elucidated, we assessed serial changes in post-TAVI THV performances over a-3-year period by transthoracic echocardiography (TTE). From January 2012 to September 2014, among 83 patients with severe aortic stenosis, 26 underwent TAVI with CoreValve and 57 underwent TAVI with SAPIEN-XT. We assessed the serial changes in first post-implant (FPI) and 3-year post procedure THV hemodynamics by TTE. Valve performance was evaluated by serial assessment of aortic valve mean pressure gradient (PG) and aortic valve area (AVA) assessments. Three-year clinical outcomes were compared between the patients with CoreValve and those with SAPIEN-XT. Seventeen patients with CoreValve and 34 patients with SAPIEN-XT had FPI and 3-year TTEs. The AVA decreased significantly from FPI to 3-year follow-up among patients with SAPIEN-XT, but not among patients with CoreValve. The mean aortic PG decreased significantly from FPI to the 3-year follow-up point among patients with CoreValve; however, it was not significantly different from those with SAPIEN-XT. The absolute change in mean PG from FPI to the 3-year follow-up point decreased significantly among those with CoreValve compared to those with SAPIEN-XT. Clinical outcomes after TAVI were similar for both devices at 3-years after TAVI. In this study, long-term clinical outcomes for CoreValve and SAPIEN XT were similar. The 3-year THV performance of both devices was maintained after TAVI. Serial change in mean aortic PGs for CoreValve decreases significantly from FPI to the 3-year follow-up point compared to that for SAPIEN-XT.

Retroperitoneal hematoma volume is a good predictor of perioperative mortality after endovascular aneurysm repair for ruptured abdominal aortic aneurysm.

OBJECTIVE: The objective of this study was to validate the usefulness of retroperitoneal hematoma volume as a predictor of perioperative mortality after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). METHODS: We retrospectively reviewed consecutive patients with rAAA who underwent the unified EVAR first protocol between 2012 and 2016 at any one of three participating institutions in Japan and were prospectively registered in a dedicated database. Only patients with preoperative computed tomography scans adequate for three-dimensional volumetric analysis were included. Volumetry was used to measure the retroperitoneal hematoma volume. To adjust for body size differences between patients, the retroperitoneal hematoma volume was divided by the abdominal cavity volume, and the predictive power of this ratio was validated using appropriate statistical methods. RESULTS: Of 114 patients with rAAA managed during the study period, 101 (88.6%) underwent EVAR, 9 (7.9%) underwent open surgical repair, and 4 (3.5%) did not undergo any repair. Finally, 82 of 101 patients treated with EVAR were included in the analysis. Within 30 days after EVAR, the mortality rates for the 82 patients included in the analysis and the 19 excluded patients were 24.4% and 31.6%, respectively, without statistically significant differences (P = .518). The retroperitoneal hematoma volume ratio was 3.59% ± 2.46% and 7.63% ± 3.45% in survivors and nonsurvivors, respectively (P < .001). Univariate analysis of other preoperative demographic and anatomic factors revealed that a Glasgow Aneurysm Score >85, systolic blood pressure <90 mm Hg, loss of consciousness, and mean minimum right external iliac artery diameter were statistically significant. Receiver operating characteristic curve analysis for the prediction of perioperative mortality revealed that retroperitoneal hematoma volume ratio was the best predictor of perioperative mortality in patients with rAAA of type >III in the Fitzgerald classification (area under the curve: retroperitoneal hematoma volume ratio, 0.880; Glasgow Aneurysm Score, 0.587; P < .001). Based on the Youden index, the optimal cutoff for the retroperitoneal hematoma volume ratio was 6.97%, providing a sensitivity of 0.833 and specificity of 0.860. CONCLUSIONS: Our study suggests that retroperitoneal hematoma volume may be a good predictor of perioperative mortality after EVAR for rAAA, especially for patients with Fitzgerald classification >III and a best cutoff value of 6.97%.

Lumbar Arterial Bleeding Treated with Endovascular Aneurysm Repair: A Report of 4 Patients.

BACKGROUND: Lumbar arterial bleeding is a severe condition. Surgical exploration is not indicated because of its rich collateral flow. Transarterial embolization (TAE) is reportedly effective, but there have been cases of failure. It may be a time-consuming procedure for patients with multiple bleeding sources or those with poor vital signs. In this case series, we used endovascular aneurysm repair (EVAR) instead of TAE. METHOD: In this case series, we described 4 male patients (2 with traumatic injury, 1 with iatrogenic injury, and 1 with drug-induced hypocoagulability) with lumbar arterial bleeding. The reasons we chose EVAR are because 2 patients had poor vital signs, one patient was a technically difficult case for selective cannulation, and one patient had accompanying aortic dissection. RESULT: In all patients, EVAR was performed successfully, and hemostasis was obtained although one patient died of pneumonia on postoperative day 23. CONCLUSIONS: EVAR is an effective alternative for lumbar arterial bleeding although TAE is a first choice of treatment.

Stomach resection with intraoperative fluoroscopy in laparoscopic distal gastrectomy for early gastric cancer.

BACKGROUND: In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG. PATIENTS AND METHODS:: A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures. RESULTS: No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13-60) mm. CONCLUSION: Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

[Successful Treatment of Empyema with Bronchial Fistulas by Filling under Thoracoscopic Observation; Report of a Case].

Empyema with fistula usually resists conservative treatment such as thoracic cavity drainage and administration of antibacterial agents, thus it often requires surgeries such as fenestration, omental/muscle filling, and thoracoplasty. However, due to advanced age and poor condition, conducting invasive surgeries is often difficult in elderly patients. We report a case with the improvement of empyema by bronchial filling with endobronchial Watanabe spigot (EWS) under thoracoscopic observation for an 89-year-old patient who had developed chronic empyema with a bronchial fistulas. After filling EWS, air-leakage from bronchial fistula disappeared and the patient could discharged from the hospital successfully.

[Early diagnosis of capecitabine-induced acute leukoencephalopathy by using diffusion-weighted MRI].

A 63-year-old woman with colon cancer who was treated with capecitabine as adjuvant chemotherapy presented with vertigo on day 5, and dysarthria and dysphagia on day 7 of the treatment. Diffusion-weighted magnetic resonance imaging of the brain revealed high signal intensity in the corpus callosum and corona radiata. The patient was diagnosed with acute leukoencephalopathy, and the capecitabine treatment was discontinued. Her symptoms recovered immediately. On the basis of these findings, it can be concluded that diffusion-weighted imaging is useful for the early detection and diagnosis of acute leukoencephalopathy.

Duodenal Ulcer Perforation Causing Acute Cholecystitis.

Acute cholecystitis is an inflammatory condition of the gallbladder, characterized by infection, ulceration, and neutrophilic infiltration of the gallbladder wall. Approximately 90% of cases are caused by gallstones. In contrast, acalculous cholecystitis is defined as the inflammation of the gallbladder in the absence of gallstones during diagnosis. The causes of acalculous cholecystitis include impaired blood flow to the gallbladder, chemical injury, bacterial or parasitic infections, and collagen vascular diseases. However, in this case, it was caused by an extremely rare condition: a duodenal ulcer penetration. Physical examination, blood tests, and ultrasound suggested a diagnosis of acute cholecystitis. However, contrast-enhanced CT showed no gallstones and revealed a partial mucosal defect in the first portion of the anterior duodenum. There was also wall thickening and increased density of the surrounding fat tissue, particularly around the gallbladder wall adjacent to the first portion of the anterior duodenum. Based on these findings, secondary cholecystitis due to perforation of a duodenal ulcer was diagnosed, and laparoscopic cholecystectomy with omental patching was performed. Although rare, a duodenal ulcer should be considered as a cause of acalculous cholecystitis.

A Case of Profunda Femoris Artery Pseudoaneurysm Treated With Catheterization and Surgical Hematoma Removal.

A pseudoaneurysm of the profunda femoris artery (PFA) is a rare disease induced by femoral trauma, proximal femoral fracture, or iatrogenic causes associated with orthopaedic surgery. Recently, transcatheter arterial embolism was reported as an effective treatment for profunda femoris artery pseudoaneurysm. This report presents the case of an 85-year-old male who underwent artificial head replacement for a left femoral neck fracture and was hospitalized with a peri-stem fracture four years later. Conservative treatment was conducted with a brace, though the swelling and pain in his left thigh increased one week after his hospital admission. Contrast-enhanced computed tomography (CT) led to a diagnosis of a left profunda femoris artery pseudoaneurysm, and the patient underwent emergency transcatheter arterial embolism and surgical hematoma removal. Since the emergency surgery, the patient's course has been good, and he has been undergoing rehabilitation.

Subacute hemorrhagic pericardial tamponade after COVID-19 infection mimicking carcinomatous pericarditis: a case report.

Background: Coronavirus disease (COVID-19)-associated acute pericarditis has recently received much attention owing to its high frequency associated with pericardial tamponade (PT), showing unfavorable prognosis. However, early diagnosis and treatment remain challenging in cases of non-specific signs and symptoms. Case presentation: A 64-year-old man was admitted to our hospital for acute osteomyelitis of the toes and was properly treated with antimicrobial agents. Three days after admission, the patient developed mild COVID-19 without pneumonia, for which early anti-COVID-19 agents were initiated. Nevertheless, the patient developed hemorrhagic PT due to acute pericarditis 2 weeks later, which was confirmed by cardiac magnetic resonance, requiring an urgent pericardiocentesis. Although cytological analysis of the hemorrhagic pericardial fluid strongly suggested adenocarcinoma, the atypical cells were eventually proven to be mesothelial cells with reactive atypia. Furthermore, lymph nodes swelling with abnormal 2-[18F]-fluoro-2-deoxy-D-glucose accumulation on imaging were suggestive of malignancy. However, biopsy examination revealed multiple non-caseating granulomas in the lymph node, unlikely due to malignancy. Eventually, the temporal association of the preceding COVID-19 with the occurrence of subacute PT without other identifiable cause led to a final diagnosis of COVID-19-associated acute pericarditis. With anti-inflammatory and corticosteroids treatment, the patient's symptoms involving the pericardial structure and function were completely resolved along with improvements in size of the affected lymphadenopathies. Conclusions: We encountered a unique case of COVID-19-associated acute pericarditis exhibiting hemorrhagic PT. This case underscores the residual risk of delayed pericardial involvement even in patients with mild COVID-19 who receive early treatment, and the recognition that COVID-19 may cause various cytomorphological and histological features. Additionally, the importance of considering this rare entity as a cause of hemorrhagic pericardial effusions should be highlighted.

Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study.

BACKGROUND: Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis. MATERIALS AND METHODS: In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors. RESULTS: Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10. CONCLUSION: This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.

[Two-staged hybrid surgery for an extended thoracic aortic aneurysm with Komerell's diverticulum].

We have successfully performed 2 staged hybrid operation for an extended thoracic aortic aneurysm with Komerell diverticulum, which lessened surgical stress of the patient with avoidance of postoperative complications. An 82-year-old man who had been under observation for thoracic aortic aneurysm was admitted to the hospital with continuous chest discomfort. The patient initially underwent graft replacement for an ascending and arch aneurysm by using the elephant trunk technique. Thirty-five days later, he underwent endovascular repair for the residual descending thoracic aneurysm. The postoperative course was uneventful, and postoperative computed tomography (CT) revealed no stent migration and just a little type II endoleak. This 2 staged hybrid approach might be less invasive than the conventional approach, and be a potential therapeutic option for high risk patients with an extended thoracic aortic aneurysm.

Negative-pressure wound therapy to treat thoracic empyema with COVID-19-related persistent air leaks: A case report.

The novel coronavirus disease (COVID-19) has resulted in a global pandemic. Recently, COVID-19-related pneumothorax has gained attention because of the associated prolonged hospital stay and high mortality. While most cases of pneumothorax respond well to conservative and supportive care, some cases of refractory pneumothorax with persistent air leaks (PALs) do not respond to conventional therapies. There is a lack of evidence-based management strategies to this regard. We describe the case of a 73-year-old man with COVID-19-related acute respiratory distress syndrome (ARDS) who developed delayed tension pneumothorax with PALs caused by alveolopleural fistulas. Despite chest tube drainage, autologous blood pleurodesis, and endoscopic procedures, the PALs could not be closed, and were complicated by thoracic empyema. Subsequent minimally invasive open-window thoracostomy (OWT) with vacuum-assisted closure (VAC) therapy helped successfully control the refractory PALs. Serial chest computed tomography monitoring was useful for the early detection of the pneumothorax and understanding of its temporal relationship with air-filled lung cysts. Our case provides a new perspective to the underlying cause of refractory pneumothorax with PALs, secondary to COVID-19-related ARDS, and underscores the potential of OWT with VAC therapy as a therapeutic alternative in such cases.

Decisive diagnostic clue for infectious abdominal aortic aneurysm caused by Arthrobacter russicus in a diabetic elderly woman with renal dysfunction: A case report and literature review.

Infectious aortic aneurysm (IAA) can be a rare but potentially fatal sequela of infectious inflammatory disease of the aortic wall with a high incidence of rupture. The definitive diagnosis is based on vascular imaging of the aneurysm using contrast-enhanced computed tomography (CE-CT) and identification of the causative microorganism from positive blood cultures (BCs). However, IAA remains extremely difficult to diagnose and treat in patients with prior antimicrobial treatment or with renal dysfunction. Here we describe a case of an 85-year-old woman with IAA caused by Arthrobacter russicus presenting with abdominal pain and fever that was initially diagnosed as a presumptive urinary tract infection and treated with empiric antimicrobial therapy. However, persistent abdominal pain with increased serological inflammation necessitated further evaluation. Unenhanced multimodality imaging considering the renal dysfunction revealed infectious aortitis of the infrarenal abdominal aorta, together with the initial culture results, leading to the tentative diagnosis of Klebsiella pneumoniae aortitis. Thereafter, serial monitoring with unenhanced magnetic resonance angiography (MRA) using thin-slab maximum intensity projection (TS-MIP) revealed acute aortic expansion strongly suggestive of a pseudoaneurysm that was successfully treated with early surgical repair under adequate infection control. Despite negative Gram staining and tissue culture results for the excised aortic wall, a definitive diagnosis of IAA secondary to A. russicus rather than K. pneumoniae was finally made by confirming the histologic findings consistent with IAA and the identification of A. russicus 16S rRNA on the resected aortic wall. The patient also developed a vascular graft infection during the postoperative course that required long-term systemic antimicrobial therapy. This case highlights the value of unenhanced MRA in the early detection of IAA in patients with renal dysfunction and the importance of a molecular diagnosis for identifying the causative microorganism in cases of culture- or tissue-negative IAA.

Endovascular aortic repair for abdominal aortic injury complicated with bowel injury due to blunt abdominal trauma: A case report.

INTRODUCTION AND IMPORTANCE: Blunt abdominal aortic injury (BAAI) resulting from blunt abdominal trauma is rare; therefore, there are no standard guidelines for its treatment. Herein, we report the successful treatment of BAAI via endovascular aortic repair (EVAR) performed immediately after emergency laparotomy to repair a bowel injury. CASE PRESENTATION: A 78-year-old man was injured after being caught between a shovel car and the bumper of his own car for approximately 15 s. Upon arrival at the hospital, the patient was conscious and had stable vital signs, abdominal and low back pain, and numbness in the right lower limb. Computed tomography revealed contrast medium leakage into the mesentery, as well as aortic dissection and rupture. Hemostasis and intestinal resection were completed, and EVAR was performed immediately after abdominal closure. The patient was discharged from the hospital at 35 days after surgery. CLINICAL DISCUSSION: In this case, there existed a risk of artificial blood vessel infection if reconstruction was simultaneously performed with intestinal resection. Symptoms of lower limb ischemia that were observed prior to surgery resolved. After open surgery, bleeding was controlled, and the patient's vital signs were stable. EVAR was performed as treatment for aortic injury, thereby reducing the risk of direct implant infection and enabling minimally invasive treatment. CONCLUSION: EVAR may be useful for the treatment of BAAI in the presence of intestinal injuries, reduce the risk of implant infection, and allow for a one-time, minimally invasive treatment.

Ruptured Emphysematous Prostatic Abscess Caused by K1-ST23 Hypervirulent Klebsiella pneumoniae Presenting as Brain Abscesses: A Case Report and Literature Review.

Emphysematous prostatic abscess (EPA) is an extremely rare but potentially fatal urinary tract infection (UTI). Here, we describe a case (a 69-year-old male with prediabetes) of ruptured EPA caused by a hypervirulent Klebsiella pneumoniae (hvKp) K1-ST23 strain, presenting as motor aphasia. Our patient presented with ruptured EPA concurrent with various severe systemic pyogenic complications (e.g., urethro-prostatic fistula, ascending UTIs, epididymal and scrotal abscesses, and liver, lung, and brain abscesses). Whole-body computed tomography (CT) and next-generation sequencing (NGS) were useful for the detection of ruptured EPA and its systemic complications, and for identification of K1-ST23 hvKp strains, respectively. Subsequently, the infections were successfully treated with aggressive antimicrobial therapy and multiple surgical procedures. This case highlights the significance of awareness of this rare entity, the clinical importance of CT for the early diagnosis of EPA and the detection of its systemic complications in view of hvKp being an important causative organism of severe community-acquired UTI, and the usefulness of NGS to identify hvKp strains.

Descending aortic banding for re-rupture of retrograde aortic dissection after emergency thoracic endovascular aortic repair.

Conversion to open repair after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection is rare, but inevitable. We present a case of an 86-year-old man with ruptured type B aortic dissection after TEVAR. He received a successful stent-graft implantation of the descending aorta without any type of endoleak. After the patient was transferred to the intensive care unit, he went into a shock state. Contrast-enhanced CT revealed a re-rupture of acute retrograde type B aortic dissection. The false lumen was patent and perforated to the left thorax. Left thoracotomy and descending aortic banding was performed. Descending aorta was encircled with a woven Dacron graft at the distal part of the rupture site to compress the patent false lumen. The bleeding was stopped, and the follow-up CT showed false lumen thrombosis. Descending aortic banding is one of the quick and effective open conversion techniques.

Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding.

AIM: Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites. METHODS: This retrospective study analyzed contrast-enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3-5 mL indocyanine green was injected through the microcatheter. The green-stained segment of the small bowel was resected. RESULTS: Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred. CONCLUSIONS: Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.