Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection.

BACKGROUND: Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. METHODS: A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. RESULTS: A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17). CONCLUSIONS: Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Ethnic & Sex Disparities in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair: An International Perspective.

BACKGROUND: There has been a revolution in the management of type B aortic dissection (TBAD) over the last 2 decades due to the increasing development of endovascular techniques, with the prime example being thoracic endovascular aortic repair (TEVAR). However, many controversies concerning the use of TEVAR in TBAD exist. For instance, there is little available evidence suggesting any differences in demographics, disease characteristics, intervention technicalities, and clinical outcomes between males and females as well as different ethnicities when undergoing TEVAR for TBAD, both in the short and long term. Also, there is no risk prediction model/tool available. The objective of this international study is to describe and delineate the disparities between male and female patients of different ethnicities in terms of demographics, disease and interventional characteristics, and clinical outcomes. METHODS: Over 17 years a total of 58 TBAD patients were admitted to 2 tertiary vascular centres and treated using TEVAR. Mortality, postoperative complications and reintervention data were recorded for the first 30 days after the procedure as well as during follow-up. Follow-up for all patients lasted until the study endpoint or until a patient's death. Data were analysed retrospectively using IBM SPSS statistical package 26 for Windows. RESULTS: The mean age was similar between the 2 groups, with the majority of patients in both being Caucasian. More than half of the males had complicated TBAD, while the majority of females were classed as having uncomplicated disease. The most commonly utilized proximal and distal landing zone for the TEVAR stent graft was zone 2 and zone 4, respectively. The mean proximal stent diameter was significantly larger in males compared to females (P = 0.004). The difference in mean distal diameter between the 2 groups was insignificant (P = 0.721). The mean total stent coverage of the thoracic aorta was 251.3 mm in male patients compared to 291.2 mm in females (P = 0.203). A total of 32 patients underwent adjunctive procedures. Seven (17%) of the males had one or more postoperative complications compared to 2 (12%) females. Nine (22%) males underwent a reintervention procedure post TEVAR compared to only 1 (6%) female (P = 0.136). Overall, males had a mortality rate of 24% (n = 10) compared to 41% of females (n = 7) (P = 0.201). Estimated survival of males and females post TEVAR was 80.4 ± 9.6 months and 69.7 ± 14.4 months (P = 0.428). For the total population, the number of stent grafts was inversely correlated with mortality. CONCLUSIONS: Despite the favourable clinical outcomes achieved by TEVAR in TBAD, there remains a grey area concerning its management. Thus, it is important to perform risk stratification of individual patients using their demographics and comorbidities, particularly scrutinizing patient sex and ethnic origin, when considering intervention for TBAD to achieve optimum results.

Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review.

BACKGROUND: Adrenal hemorrhage (AH) is a rare condition that can result in a life-threatening medical emergency. This medical condition could be caused by several underlying factors, one of which is the use of anticoagulants. As far as we are aware, direct oral anticoagulant (DOAC) agents are a rare but possible cause of AH. CASE PRESENTATION: Herein, we described two cases of AH due to DOACs. The first case was a 35-year-old Iranian woman with a past medical history of Hashimoto thyroiditis who was being treated with apixaban due to the previous thrombosis. Her first symptoms of AH (November 2021) were strangely similar to symptoms of autoimmune Addison disease (AAD) which led to a confirmed diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). An abdominal MRI revealed an oval shape well-encapsulated cystic mass with a diameter of 20 × 14 mm with a thick and low signal intensity rim in the left adrenal gland, highly suggestive of sub-acute left-sided AH. Our second case was an 89-year-old Iranian woman who had been admitted to the hospital (August 2021) with low blood pressure and disorientation. At the beginning of her admission, the evaluation showed hyponatremia, and further evaluations confirmed adrenal insufficiency (AI). The patient reported rivaroxaban usage for deep vein thrombosis prophylaxis after femur fixation surgery. Her abdominal CT scans showed bilateral adrenal masses highly suggestive of AH. Her follow-up examination showed persistent AI after three months. CONCLUSION: Given the history of our cases, physicians should be aware of AH in patients receiving DOACs, particularly in elderly patients who are at high risk of bleeding. It is also worth noting that AH can occur in any patient with any medical history and history of DOAC use, which is why patients must be closely monitored.

Spontaneous Resolution of Symptomatic Thoracic Spine Calcified Disc Herniation: A Case Report and Literature Review.

Calcification of intervertebral disc (IVD) is an uncommon but well-defined clinical syndrome in children. Despite its benign nature, occasionally, calcified nucleus pulposus can herniate into the spinal canal. We report an interesting case of calcified disc herniation in the thoracic spine. Although it resulted in cord compression and syrinx formation, it well responded to conservative management. An 8-year-old girl presented with back pain and lower limbs hyperreflexia. The spinal imaging revealed that calcification within IVD, associated with huge calcified disc herniation on the T5/6, resulted in cord compression and syrinx formation within the spinal cord from T4/5 through T9/10. Despite cord compression and syrinx formation, the patient underwent conservative management. After a 6-month follow-up, the control imaging showed complete resolution of the calcified disc herniation and decreased syrinx size. In the patients with a calcified herniated IVD, in the absence of motor neurological deficit, conservative management consisting of bed rest, lifestyle adjustment, weight loss, and brace or collar wearing combined with a close follow-up can result in spontaneous regression of calcification, improvement of symptoms, and partial to complete resolution of the underlying pathology.

Concomitant occurrence of appendiceal mucocele and ulcerative colitis: Case reports.

Background: Appendiceal mucocele (AM) is a rare disease, manifested by accumulation of mucus in appendiceal lumen. The role of ulcerative colitis (UC) in the occurrence of appendiceal mucocele is not known. However, it is suggested that AM may be a presentation of colorectal cancer in IBD patients. Case Presentation: Here, we presented 3 cases of concomitant AM and ulcerative colitis. The first patient was a 55-year-old woman with 2-year history of left sided UC; the second person was a 52-year-old woman with 12-year history of pan-UC; and the third patient was a 60-year-old man with 11-year history of pan-colitis. They were all referred due to indolent right lower quadrant abdominal pain. Imaging evaluations suggested the presence of appendiceal mucocele and therefore, they all went under operation. Pathologic evaluation reported AM of mucinous cyst adenoma type; low-grade appendiceal mucinous neoplasm of appendix with intact serosa; and cyst-adenoma type AM for the three above-mentioned patients, respectively. Conclusion: Although concomitant occurrence of AM and ulcerative colitis is rare, regarding the potential of neoplastic changes in AM, physicians must keep in mind the diagnosis of AM in UC patients with non-specific abdominal RLQ pain or bulged appendiceal orifice during colonoscopy.

Multiple congenital visceral abnormalities as a rare cause of pulmonary arterial hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a rare, progressive disorder. PAH is caused by a wide spectrum of pathologies but the cause remains undetermined on many occasions and patients are classified in the idiopathic group. CASE PRESENTATION: Here we report a young woman with rare congenital visceral abnormalities presenting with severe pulmonary hypertension. CONCLUSIONS: Pulmonary hypertension is a complex disorder. Search for uncommon conditions that lead to pulmonary hypertension is necessary to determine the best management options.