Breast cancer screening in BRCA1/2 pathogenic sequence variant carriers during pregnancy and lactation.

OBJECTIVES: Women harboring germline BRCA1/BRCA2 pathogenic sequence variants (PSVs) are at an increased risk for breast cancer. There are no established guidelines for screening during pregnancy and lactation in BRCA carriers. The aim of this study was to evaluate the utility of whole-breast ultrasound (US) screening in pregnant and lactating BRCA PSV carriers. METHODS: Data were retrospectively collected from medical records of BRCA PSV carriers between 2014 and 2020, with follow-up until 2021. Associations between imaging intervals, number of examinations performed and pregnancy-associated breast cancers (PABCs) were examined. PABCs and cancers diagnosed at follow-up were evaluated and characteristics were compared between the two groups. RESULTS: Overall 212 BRCA PSV carriers were included. Mean age was 33.6 years (SD 3.93, range 25-43 years). During 274 screening periods at pregnancy and lactation, eight (2.9 %) PABCs were diagnosed. An additional eight cancers were diagnosed at follow-up. Three out of eight (37.5 %) PABCs were diagnosed by US, whereas clinical breast examination (n = 3), mammography (n = 1) and MRI (n = 1) accounted for the other PACB diagnoses. One PABC was missed by US. The interval from negative imaging to cancer diagnosis was significantly shorter for PABCs compared with cancers diagnosed at follow-up (3.96 ± 2.14 vs. 11.2 ± 4.46 months, P = 0.002). CONCLUSION: In conclusion, pregnant BRCA PSV carriers should not delay screening despite challenges like altered breast tissue and hesitancy towards mammography. If no alternatives exist, whole-breast ultrasound can be used. For lactating and postpartum women, a regular screening routine alternating between mammography and MRI is recommended.

Lumbar Tubular Decompression: Barriers and Limitations Hampering the Technique's Dissemination Across Latin America.

OBJECTIVES: We sought to explore the barriers and limitations preventing the widespread use of tubular lumbar spine decompressions in Latin America. METHODS: A cross-sectional study was performed using a survey designed specifically by the authors. This survey was mailed to all spine surgeons who are members of AO Spine Latin America. Eighty-seven surgeons spanning 15 Latin American countries answered the survey. RESULTS: Thirty-one percent of participating surgeons claimed they needed to adapt their technique to perform minimally invasive tubular surgeries. Meanwhile, though 70.5% answered they do not consider tubular surgery expensive, 32.8% lacked access to standard equipment like a complete set of retractors or curved high-speed drill. CONCLUSIONS: Several barriers limit the development of tubular spine surgery in Latin America. The most important discrepancies between surgeons' preferred equipment and their availability for such operations are high-speed drills, bayoneted instruments, and hemostatic agents.

Findings on emergent magnetic resonance imaging in pregnant patients with suspected appendicitis: A single center perspective.

This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

Revascularization of multiple tibial arteries is not associated with improved limb salvage.

OBJECTIVE: We sought to determine the benefit of performing multiple tibial artery revascularization compared with single vessel revascularization for patients with chronic limb-threatening ischemia (CLTI). METHODS: We performed a single-center, retrospective cohort study of all patients with CLTI treated with below-the-knee endovascular intervention from 2012 to 2019. Group 1 included patients who had undergone single tibial artery revascularization. Group 2 included patients who had undergone multiple (two or more) tibial artery revascularization. More proximal disease, if present, was treated, in addition to the tibial disease. The primary endpoint was freedom from amputation. The secondary endpoints included the reintervention rates and all-cause mortality. RESULTS: A total of 527 limbs in 470 patients with CLTI (nonhealing ulcers, 62%; gangrene, 33%; and ischemic rest pain, 5%) were included in the present study. Of the 527 limbs, 245 (46%) had undergone single vessel revascularization and 282 (54%) had undergone multiple vessel revascularization. The mean follow-up was 19 ± 18 months. No difference was found in freedom from amputation between the two groups (68% vs 63%; P = .109). On multivariable analysis, the factors associated with amputation included dialysis (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16-2.45), dyslipidemia (OR, 1.37; 95% CI, 0.96-1.94), and gangrene (OR, 2.08; 95% CI, 1.50-2.98). No differences were found in the reintervention rates between the two groups (21.2% vs 16.7%; P = .13). The overall survival rate was 73% in both study groups. CONCLUSIONS: The results from the present large, single-center study have demonstrated that multiple below-the-knee vessel revascularization is not associated with improved limb salvage compared with single vessel revascularization.

Long-term outcome after nonsurgical management of Paget-Schroetter syndrome.

OBJECTIVE: Paget-Schroetter syndrome (PSS) is an uncommon disease with potentially debilitating long-term effects. The optimal therapy for PSS is unclear, and the role of surgical decompression of the thoracic outlet is still being questioned. In this study, we present long-term results of patients treated with catheter-directed thrombolysis (CDT) and anticoagulation without surgical management. METHODS: This is a retrospective case series of all patients who previously underwent treatment of PSS in our institution between the years 2007 and 2019. Patients were evaluated for clinical signs of post-thrombotic syndrome (PTS) using a modified Villalta scoring scale, including measurements of the circumference of the treated and untreated arms. Duplex ultrasound examination of the treated vein was performed, and quality of life was evaluated using the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Eighteen consecutive patients previously treated for PSS with CDT and anticoagulation compose the cohort of this study. None underwent surgical thoracic outlet decompression. All were contacted and invited for clinical and ultrasound evaluation. Follow-up was available for all patients. Mean age at diagnosis was 29 years (range, 16-46 years), and 15 (79%) were male. Mean time from the index event to the follow-up clinic visit was 109 months (range, 37-176 months). Patients were treated with anticoagulation for a mean period of 26 months (range, 6-120 months). Seventeen patients (94%) had a Villalta score of 0 to 3, consistent with nonexistence of PTS. Fourteen patients (78%) were completely asymptomatic. Seven patients (39%) had no difference in arm circumference. A difference in arm circumference between the treated arm and the healthy arm of 1 cm and 2 cm was seen in nine (50%) and two (11%) patients, respectively. Based on the shortened Disabilities of the Arm, Shoulder, and Hand score, none of the patients suffered from impaired quality of life. Duplex ultrasound scanning of the affected veins was performed on 16 of the 18 patients (89%). The vein appeared patent in all examined patients. In three patients, the wall of the examined vein was thickened and irregular. CONCLUSIONS: This study suggests that PSS patients can be treated with anticoagulation and CDT alone, without the need for surgical thoracic outlet decompression. This is based on long-term follow-up of these patients objectively evaluated by means of valid scoring systems. These findings suggest that symptoms or signs of PTS rarely develop, the patients do not suffer from impaired quality of life, and patency of the diseased vein is commonly maintained.

Inguinal lymphadenopathy as a predicting factor for ipsilateral primary limb amputation after a successful endovascular treatment.

PURPOSE: To assess the correlation between inguinal lymph node characteristics and ipsilateral limb amputation rates in patients with ischemic foot ulcers after a successful endovascular treatment. METHOD: A retrospective review of patients who were endovascularly treated for ischemic foot ulcers between January 2015 and May 2017. Technical success was defined as arterial recanalization with stenosis less than 30 % and ankle brachial index improvement by > 0.2 after 24 h. Unilateral lymph node size, contrast enhancement, necrosis, and perinodular fat stranding were assessed on pre-procedural CTA. Primary endpoints were amputation and sepsis within 12 months following treatment. The relationship between lymph node characteristics and limb amputation and septic shock were examined. RESULTS: Endovascular treatment of 202 limbs in 202 patients (135 males; median age 72.8 years [42.2-93.7]) was technically successful. Forty-two (20.8 %) patients underwent amputation, six (3 %) patients had septic shock. There was a significant difference in lymph node sizes between the amputated and the non-amputated limbs (P = 0.000). Lymph node characteristics (size, enhancement, necrosis, and perinodular fat stranding) were significantly related to amputation (P < 0.001). Patients with perinodular fat stranding or increased node size were 5.940 and 1.109 times more likely to undergo limb amputation, respectively. Lymph node characteristics were also significantly related to septic shock (P < 0.05). CONCLUSIONS: Certain lymph node characteristics are associated with amputation in patients with ischemic foot ulcers, after a technically successful endovascular treatment of the limb. Large lymph node size and perinodular fat stranding are predictive of limb amputation.

The Jailed Coiling Technique for the Treatment of Penetrating Ulcers and Saccular Aneurysms of the Aortic Arch.

OBJECTIVE: To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique. METHODS: A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter. RESULTS: All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention. CONCLUSION: PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.

Chimney Endovascular Repair of Primary Mycotic Aneurysms Involving the Paravisceral Aorta.

BACKGROUND: Primary mycotic aneurysm of the aorta (MAA) is a rare and potentially life-threatening disease. Endovascular aneurysm repair (EVAR) of MAAs involving the paravisceral aorta has been rarely reported. The purpose of this study is to report our experience with chimney EVAR (CHEVAR) in patients with MAAs involving the paravisceral aorta. METHODS: We performed a retrospective review of all patients treated with EVAR at our institution during the years 2009-2019. Of those, we identified the patients who were treated with CHEVAR for MAAs. Diagnosis of MAAs was based on clinical presentation, abnormal laboratory results, and a computed tomography scan suggestive of a MAA. The data collected included patient demographics, clinical presentation, the antibiotic regimen before and after the surgery, preoperative imaging, surgical details, and perioperative and long-term morbidity and mortality. RESULTS: During the study period, we performed 54 cases of CHEVARs for aortic aneurysms. Of those, 8 (15%) were performed for mycotic aneurysms involving the visceral segment. Six (75%) were men, and the mean age was 68 years (range: 59-76). All patients were symptomatic at the time of diagnosis, presenting with either back or abdominal pain. A total of 16 visceral vessels (celiac trunk, 2; superior mesenteric artery, 7; right renal artery, 4; and left renal artery, 3) were revascularized with parallel grafts (PGs). Six patients required 2 PGs, 1 patient required 3 PGs, and 1 patient had a single PG inserted. Fifteen (94%) PGs were upward-pointing chimney stent grafts, and 1 was placed in a downward-pointing "periscope" configuration. Eight visceral arteries in 6 patients were sacrificed, either by preoperative occlusion or intentional coverage with the endograft during the procedure. The vessels sacrificed included 4 celiac trunks and 4 renal arteries (3 main branches and 1 accessory renal artery). Technical success was achieved in all patients. One patient expired in the perioperative period. One patient developed an infection-related complication. One patient experienced worsening of his renal function and eventually required dialysis. Of the 4 patients who underwent intentional sacrifice of a kidney, all experienced a moderate decrease in renal function from the baseline ( mean preoperative and postoperative serum creatinine 0.76 mg/dL and 1.2 mg/dL, respectively, increase of 43%). The mean follow-up was 8 months (range: 3-28 months). During this period, 2 patients expired, 1 from an aneurysm-related cause. No stent occlusion of the PGs occurred and no reintervention due to endoleaks was required. No patient required explanation of the stent grafts or conversion to an open repair. CONCLUSIONS: CHEVAR is a feasible and safe treatment modality for MAAs involving the visceral segment. Occasionally, intentional occlusion of the selected visceral arteries may be required to minimize the risk of gutter endoleaks in this urgent setting. Further follow-up is needed to accurately assess the durability of this repair.

Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms.

OBJECTIVE: The use of fenestrated and branched endografts for the treatment of complex aortic aneurysms is increasing. Despite the low morbidity and mortality associated with these repairs, reintervention rates in the midterm and long term remain a concern. The purpose of this study was to investigate our experience with reinterventions after fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: We performed a retrospective analysis of all patients treated with F/BEVAR at our institution during the years 2009 to 2019. Among them, we identified those who required reinterventions during the period of follow-up. Data collected included patients' demographics, type of treated aneurysm, indications for reintervention, and methods of repair. RESULTS: During the study period, 47 patients underwent F/BEVAR. A total of 160 branches were placed. Of those, 12 patients (25%) underwent 15 secondary interventions for late-occurring complications. Among those requiring reinterventions, mean age was 70 years (range, 59-80 years), and 10 (83%) were male. The majority of those requiring reinterventions were treated for thoracoabdominal aortic aneurysms. Mean time to reintervention was 14 months (range, 2-32 months). Indications for reinterventions included separation of side branches from fenestrations (nine), separation of side branches (three), type IA endoleak (one), type II endoleak (one), and limb occlusion (one). All endoleaks were detected on routine follow-up imaging. All reinterventions were performed using endovascular techniques. Mean follow-up after reinvention was 22 months (range, 1-53 months). During this period, no patient required open conversion. Follow-up imaging revealed successful obliteration of the endoleak, and none experienced continued growth of the sac. CONCLUSIONS: Reinterventions after F/BEVAR are not uncommon. The majority of reinterventions are performed for endoleaks that are due to failure at the level of the fenestrations or component separation. These endoleaks can be treated successfully with endovascular methods and do not require open conversion. Because of the possibility of development of late endoleaks, continual monitoring of these patients is required after the primary procedure.

Morbidity and Mortality Following Endovascular Repair of Abdominal Aortic Aneurysms in the Elderly.

BACKGROUND: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is associated with decreased perioperative morbidity and mortality. OBJECTIVES: To report the outcomes of EVAR among patients older than 80 years of age. METHODS: In this retrospective study, we reviewed patients older than 80 years of age who underwent elective EVAR at our institution between 2007 and 2017. The demographics, perioperative morbidity and mortality, and long-term results are reported. RESULTS: During the study period, 444 patients underwent elective EVAR for AAAs. Among them 128 patients (29%) were > 80 years of age. Mean age was 84 ± 3.4 (range 80-96) years, and 110 patients (86%) were male. The EVAR was technically successful in 127 patients (99%) and there were intraoperative mortalities. Within 30 days of the surgery, nine patients (7%) died. Major and minor adverse events occurred in 26 (20%) and 59 (46%) patients, respectively. Factors associated with increased risk of perioperative morbidity and mortality included chronic kidney disease, peripheral artery disease, and the existence of three or more co-morbidities. CONCLUSIONS: EVAR in the elderly can be performed with a high rate of success; however, it is associated with a substantial rate of morbidity and mortality, particularly when patients present with multiple co-morbidities. When performing EVAR in this population group, the risk of rupture must be considered opposed to the life expectancy of these patients and the risk of perioperative morbidity and mortality.

Parallel stent grafts for the treatment of complex aortic aneurysms: A single center study.

Background "Chimney" techniques with parallel grafts used in order to extend the landing zones in endovascular aneurysm repair (ch-EVAR) are increasingly being reported. Conflicting data has been reported regarding the success and durability of the repair. We report a single center experience using ch-EVAR in treating complex aortic pathologies. Methods We performed a retrospective review of all patients treated with ch-EVAR in our institution between 2013 and 2017. Data collected included patients demographics, indications for surgery, configuration of parallel grafts, technical success, and perioperative morbidity and mortality. Follow-up data included aortic sac size, reintervention rate, and overall mortality. Results Thirty-five patients underwent treatment of their aneurysms with parallel grafts. Sixty parallel grafts were placed. Mean age was 75 years (range 59-93) and 30 (85%) were male. Technical success was achieved in 32 (91%) patients. Mean follow up was 12 months. Sac size decreased in diameter or remained unchanged in 26 of the 30 (86.6%) patients. Four patients were found to have enlarging aneurysms due to gutter endoleaks. All were treated successfully with endovascular methods. The estimated primary patency was 95% at 12 months. Probability of freedom from intervention was 75% at 12 months. No late aneurysm related mortality occurred. Conclusion The use of ch-EVAR in treating complex aortic aneurysms is technically feasible and safe. Gutter endoleaks are encountered only in a minority of the cases, and can be treated with minimally invasive techniques. Longer term follow up is required to evaluate the patency of these parallel grafts and the durability of the aneurysm exclusion.