Endovascular treatment of aneurysms using fenestrated-branched endografts with distal inverted iliac limbs.

BACKGROUND/OBJECTIVE: Open aortoiliac grafts have typically been constructed with a short aortic bifurcation sewn near or to the visceral vessels to avoid limb kinking. Similarly, the majority of endovascular bifurcated stent grafts have short aortic main body ranging from 3 to 5 cm. In these patients, endovascular salvage with fenestrated stent grafts is technically challenging because of the short distance between the renal arteries and the flow divider of the graft. Custom fenestrated stent grafts can be extended into the prior open surgical graft or stent graft using a short distal bifurcated stent graft with inverted iliac limb for the contralateral gate. The aim of this study was to evaluate outcomes of patients treated with fenestrated stent grafts coupled with inverted iliac limbs for salvage of failed open surgical and endovascular stent grafts. METHODS: The clinical data of three U.S. aortic centers that use fenestrated stent grafts was entered into prospectively maintained databases from 2011 to 2014. All patients received customized distal bifurcated devices constructed with a main body less than 70 mm and an inverted iliac limb to dock the contralateral gate. End points were technical success, 30-day mortality, type I or III endoleak, limb occlusion, and secondary reintervention. The Institutional Review Board of each institution approved the use of the modified graft, and each patient provided informed consent. RESULTS: There were 56 patients (41 male), with mean age of 75 years treated by fenestrated stent grafts using distal bifurcated devices with inverted iliac limbs. Forty-seven patients had a previous aortic repair with a short main body device, and nine had short distances between the native renal artery and aortic bifurcation requiring inverted limbs. A total of 184 visceral arteries were targeted by fenestrations. Technical success was 96.4% with no 30-day deaths. At a mean follow-up of 11 months, seven patients developed endoleaks, with one device migration, no occlusions, or other complications associated with the inverted limb. On the inverted iliac limb side, there were four complications. Two patients developed type Ib endoleaks treated by limb extension and angioplasty, and one patient developed distal limb ischemia secondary to embolization treated by thrombectomy. One additional patient developed a component separation of the inverted limb discovered with follow-up imaging treated with aortouni-iliac repair. CONCLUSIONS: Patients with a short distance between the renal arteries and the aortic bifurcation can be challenging for endovascular treatment using currently available devices. The use of inverted limb custom devices avoids the need for aortouni-iliac repair with femoral-femoral bypass preserving antegrade perfusion. In the short term, rates of complication are similar to what has been reported for universal bifurcated devices with noninverted iliac limbs.

Coil embolization of an aortic pseudoaneurysm after open repair of type A aortic dissection.

Anastomotic pseudoaneurysms represent an uncommon and challenging complication of open aortic repair with prosthetic graft. First characterized by Clayton et al. in 1956, they affect approximately 1.4-4% of arterial anastomoses. These pseudoaneurysms are the result of many factors, foremost of which are infection, integrity of the host tissue, surgical technique, and location of the anastomosis. Pseudoaneurysms were traditionally treated with open resection of the pseudoaneurysm and revision of the anastomosis. This case presents a novel approach to the treatment of pseudoaneurysms in a difficult location. The patient was a 77-year-old man status after repair of a type A aortic dissection with a Dacron tube graft. Follow-up imaging 18 months postoperatively showed a 1.6 cm×1.7 cm pseudoaneurysm off of the posteromedial proximal suture line. Through a right brachial artery approach, a diagnostic angiogram was performed demonstrating a bilobed pseudoaneurysm. A Judkins left 3.5 catheter and 0.035″-angled Glidewire was used to engage the orifice of the pseudoaneurysm. Two 4 mm×6 cm Boston Scientific Interlock coils were then deployed into the pseudoaneurysm sac. Completion angiogram demonstrated complete exclusion of the pseudoaneurysm. The patient did well and was discharged the following day. Follow-up computed tomography scan at 3 months showed regression and complete thrombosis of the pseudoaneurysm. Traditional operative repair of anastomotic pseudoaneurysms can lead to long operations, high blood loss, and increased morbidity and mortality as a result of their reoperative nature. Coil embolization is a safe and effective approach for the treatment of anastomotic pseudoaneurysms in difficult locations.

Congenital absence of the left external iliac vein with anomalous venous connection in a pediatric patient.

We report an interesting case of a 2-year-old boy with congenital absence of the left external iliac vein and an anomalous lower extremity venous connection. Magnetic resonance imaging was used to identify aplasia of the vessel and aid in the diagnostic algorithm. In the present report, we have discussed the relevant literature associated with congenital venous anomalies and their clinical presentations and treatment options. Our patient did not undergo surgical intervention for his vascular malformation.

Management of acute type B aortic dissections.

INTRODUCTION: For the last several decades, initial management of Stanford type B aortic dissections (DeBakey IIIa or IIIb) has involved medical therapy aimed at reducing blood pressure and impulse stress (Dp/dT). This concept has been indoctrinated into the medical field but is now being challenged with advancements in endovascular therapies and devices. Although there have been advances in the medical management and intensive care unit care, medical modalities alone may still pose a 25 -50% complication rate to the patients, resulting in some physicians seeking alternative approaches to reduce this risk in certain subsets of these patients. AREAS COVERED: This review will detail the etiology, classification, diagnosis and evolution in treatment of acute type B dissections. We will also review data from recent trials on thoracic endovascular aortic repair and its role in the management of type B aortic dissections to help determine which patients may benefit from placement of a stent graft. Expert commentary: As we see new technologies develop and obtain long-term results with TEVAR, the paradigm of management may shift toward a more aggressive operative approach to improve on the longterm mortality of patients with type B aortic dissections.

Sentinel lymph node detection using laser-assisted indocyanine green dye lymphangiography in patients with melanoma.

INTRODUCTION: Sentinel lymph node (SLN) biopsy is a vital component of staging and management of multiple cancers. The current gold standard utilizes technetium 99 (tech99) and a blue dye to detect regional nodes. While the success rate is typically over 90%, these two methods can be inconclusive or inconvenient for both patient and surgeon. We evaluated a new technique using laser-assisted ICG dye lymphangiography to identify SLN. METHODS: In this retrospective analysis, we identified patients with melanoma who were candidates for SLN biopsy. In addition to tech99 and methylene blue, patients received a dermal injection of indocyanine green (ICG). The infrared signal was detected with the SPY machine (Novadaq), and nodes positive by any method were excised. RESULTS: A total of 15 patients were evaluated, with 40 SLNs removed. Four patients were found to have nodal metastases on final pathology. 100% of these 4 nodes were identified by ICG, while only 75% (3/4) were positive for tech99 and/or methylene blue. Furthermore, none of the nodes missed by ICG (4/40) had malignant cells. CONCLUSION: ICG dye lymphangiography is a reasonable alternative for locating SLNs in patients with melanoma. Prospective studies are needed to better ascertain the full functionality of this technique.

A case of laparoscopic mesenteric cyst excision.

The objective of this study is to discuss the presentation, diagnosis, and surgical management of a young, healthy patient with a symptomatic mesenteric cyst. He had a 5-month history of abdominal pain from this disorder, and the case is presented to illustrate the clinical picture and operative management of this rare disorder.