Transarterial Embolisation of Abdominal Aortic Type II Endoleaks Accessed via the Deep Circumflex Iliac Artery: A Case Series and Literature Review.

We report our technique and experience treating 3 patients with native abdominal aortic aneurysm (AAA) sac expansion following EVAR, who were managed with transarterial embolisation via the deep circumflex iliac artery (DCIA). In this case series, we demonstrate that transarterial embolisation via the DCIA is a feasible and safe treatment option. The DCIA should be routinely interrogated with angiography as not only a cause of possible Type II endoleak, but also to identify a potential access route to the abdominal aortic sac for interventional treatment.

Is There a Role for Heli-FX Endoanchors in Treating Type 1B Common Iliac Artery Endoleaks?

OBJECTIVES: The management of type 1B endoleaks following endovascular aortic aneurysm repair (EVAR) can be challenging. The Heli-FX Endoanchor system effectively treats proximal type 1A endoleaks but has not been used for type 1B common iliac artery endoleaks. This study demonstrates that it is both safe and effective in being used in the common iliac artery (CIA) limb of an EVAR. METHODS: A retrospective review of patients identified through coding and medical records was performed to extract information on demographics, aneurysmal features, operative features, and postoperative outcomes. This was then collated and analysed thoroughly and compared to existing research. RESULTS: Four patients with six type 1B CIA endoleaks were treated with Heli-FX Endoanchors in the CIA limbs of EVAR grafts. There was 100% technical success rate with complete exclusion of the endoleaks at 6 months. With mean follow up of 714 days, there were no Endoanchor-specific complications. One patient required explantation of the aortic endograft due to contralateral limb fracture, where it was found that an Endoanchor had penetrated the common iliac vein, requiring primary closure. CONCLUSIONS: Heli-FX Endoanchors were effective within this cohort of patients, though key risks were identified. Adjacent anatomy to the CIA must be considered, which also have nearly half the arterial thickness compared to the aorta. Pre-operative planning is essential given the theoretical risk of placing Endoanchors.

AFX unibody stent graft: Effective and safe for the treatment of severe aorto-iliac occlusive disease.

OBJECTIVES: The primary objective of this study was to determine the primary, assisted primary and secondary patency rates of the Endologix AFX stent-graft in patients considered high risk for open surgery with complex aorto-iliac occlusive disease. The secondary objective was to determine 30-day major adverse cardiovascular and cerebrovascular events. METHODS: A retrospective review was undertaken of clinical records of 38 patients who underwent AFX stent-graft placement for aorto-iliac occlusive disease from 2016 to 2019. Patient data was de-identified and entered into a REDcap secure database. Descriptive statistical analysis (means and standard deviations) and Kaplan-Meier survival curves were created to determine the duration of patency of the AFX stent-graft system. RESULTS: Primary patency rates at 6, 12 and 24 months were 92%, 92% and 84%, respectively. Assisted primary patency rates at these times were 100%, 100% and 93% with secondary patency of 100% maintained throughout. The incidence of 30-day major adverse cardiovascular and cerebrovascular events was 8% and major adverse limb events was 3%. One death unrelated to the AFX device occurred during the study period though outside of the 30-day peri-operative period. CONCLUSIONS: Primary, assisted primary and secondary patency rates of AFX stent-grafts, when used to treat aorto-iliac occlusive disease, are high. This study supports the use of the AFX stent-graft for the endovascular treatment of complex aorto-iliac occlusive disease as an alternative to other endovascular options as well as a safe alternative to open aorto-iliac or aorto-femoral bypass in patients who are at high risk for open procedures.

Editor's Choice - Optimal Timing of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis.

OBJECTIVE: Type B aortic dissections (TBAD) have a high mortality rate and are challenging to both classify and manage. There is significant evidence supporting the use of early intervention in complicated TBAD with thoracic endovascular aortic repair (TEVAR). Currently, there is equipoise regarding the optimal timing for TEVAR in TBAD. This systematic review answers whether early TEVAR in the hyperacute or acute phase of the disease has improved aorta related events in the one year follow up period with no change in mortality rate when compared with TEVAR in the subacute or chronic phase. DATA SOURCES: A systematic review and meta-analysis was performed with Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search guidelines for MEDLINE, Embase, and Cochrane Reviews until 12 April 2021. Inclusion and exclusion criteria targeting the review objective and high quality research were employed by separate authors. REVIEW METHODS: These studies were then reviewed for suitability, risk of bias, and heterogeneity using the ROBINS-I tool. Results were extracted for the meta-analysis with RevMan using odds ratios with 95% confidence intervals with I2 used to assess heterogeneity. RESULTS: Twenty articles were included. A meta-analysis showed no significant difference between acute phase TEVAR (excluding the hyperacute phase) and subacute or chronic phase TEVAR for the all cause 30 day and one year mortality rates. Aorta related events in the 30 day post-operative period were unaffected by the timing of intervention but had significant improvement in aorta related events in the one year follow up favouring TEVAR in the acute phase compared with subacute or chronic phase. Risk of confounding was high but with low heterogeneity. CONCLUSION: Without prospective randomised controlled studies, it is evident that there is improved aortic remodelling in long term follow up with intervention in the acute setting from three to 14 days after symptom onset. This suggests that TEVAR in the acute period of TBAD is both safe and beneficial, and can be considered for early stent grafting based on clinical, anatomical and patient factors.

Successful endovascular exclusion of Mycobacterium bovis mycotic aneurysm following intravesical bacille Calmette-Guerin therapy.

Bacille Calmette-Guerin (BCG) is a live-attenuated strain of Mycobacterium bovis. It is routinely used in the treatment of early-stage transitional cell carcinoma. The development of mycotic aneurysm in the context of prior intra-vesical BCG treatment has not been reported. This case demonstrates a rare but potentially catastrophic vascular complication of BCG. A high index of suspicion is required for any patient presenting with new aneurysmal disease in the context of previous BCG therapy. The value of endovascular surgery as a bridge to definitive surgical repair and diagnostic considerations is discussed.

A Novel Approach to a Patient with both Aortoiliac and Venous Occlusive Disease.

Radiation-induced arteritis is a well-recognized complication of radiotherapy; however, radiation-induced venous stenosis is very rare (Zhou W, Bush RL, Lin PH, et al. Radiation-associated venous stenosis: endovascular treatment options. J Vasc Surg 2004;40:179-182). We describe a case of mixed aortoiliac arterial occlusive disease and iliac venous outflow obstruction secondary to radiation-induced vascular disease. Several endovascular procedures were undertaken to treat aortoiliac occlusive disease, which was followed by stenting for venous occlusive disease.

Grafts for mesenterico-portal vein resections can be avoided during pancreatoduodenectomy.

BACKGROUND: The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD+VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR). STUDY DESIGN: Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed. RESULTS: One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD+VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD+VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n = 101) required VR. A significantly higher rate of positive resection margins (p < 0.001) was noted in the PD+VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin. CONCLUSIONS: Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR.

One hundred and seventy-eight consecutive pancreatoduodenectomies without mortality: role of the multidisciplinary approach.

BACKGROUND: Pancreatoduodenectomy offers the only chance of cure for patients with periampullary cancers. This, however, is a major undertaking in most patients and is associated with a significant morbidity and mortality. A multidisciplinary approach to the workup and follow-up of patients undergoing pancreatoduodenectomy was initiated at our institution to improve the diagnosis, resection rate, mortality and morbidity. We undertook the study to assess the effect of this approach on diagnosis, resection rates and short-term outcomes such as morbidity and mortality. METHODS: A prospective database of patients presenting with periampullary cancers to a single surgeon between April 2004 and April 2010 was reviewed. All cases were discussed at a multidisciplinary meeting comprising surgeons, gastroenterologists, radiologists, oncologists, radiation oncologists, pathologists and nursing staff. A standardized investigation and management algorithm was followed. Complications were graded according to the Clavien-Dindo classification. RESULTS: A total of 295 patients with a periampullary lesion were discussed and 178 underwent pancreatoduodenectomy (resection rate 60%). Sixty-one patients (34%) required either a vascular or an additional organ resection. Eighty-nine patients experienced complications, of which the commonest was blood transfusion (12%). Thirty-four patients (19%) had major complications, i.e. grade 3 or above. There was no in-hospital, 30-day or 60-day mortality. CONCLUSIONS: Pancreatoduodenectomy can safely be performed in high-volume centers with very low mortality. The surgeon's role should be careful patient selection, intensive preoperative investigations, use of a team approach, and an unbiased discussion at a multidisciplinary meeting to optimize the outcome in these patients.

Pattern of equestrian injuries presenting to a Sydney teaching hospital.

BACKGROUND: Equestrian activities are associated with a high rate of injury. Attempts to reduce the incidence and severity of injury require accurate characterization of risk factors and pattern of injury. The present study was performed to analyse the injuries seen at an Australian centre where a large number of equestrian injuries present. METHODS: Data were collected prospectively over a 3 year period on all equestrian injuries presenting to the Prince of Wales -Hospital complex. These data were compared against and combined with retrospectively collected data over the preceding 3 years at the same centre. RESULTS: Two hundred and twenty-one injured equestrians presented (181 consented) in the prospective period of the study, and 208 presented in the retrospective period. Overall, 81% of riders were wearing a helmet at the time of their injury. Helmet use was associated with a significantly lower admission rate (27% vs 55%; P < 0.0001, from combined data). Recreational equestrians had a higher admission rate than professional equestrians, and had a significantly higher head and spine injury rate than the professional group. Rate of helmet use increased from 72% in the retrospective group to 91% in the more recent prospective group, and total admissions decreased from 43% to 14%. CONCLUSION: Significant and serious injuries are associated with equestrian activities, with the higher risk group being recreational equestrians, and riders not using a helmet. The pattern of injury favours head and spine in recreational and non-helmeted riders, and extremities for professional and helmeted riders. Helmet use is still not universal among riders, although an increase in its use may be contributing to an overall reduction in admission rate. Facial and spinal injuries still occurred in helmeted patients.