Aorto-cutaneous fistula of the ascending aorta-case report and a literature review of endovascular management.

Aorto-cutaneous fistulas are an unusual and life-threatening complication after aortic surgery. We present the case of an endovascular intervention for an aorto-cutaneous fistula of the ascending aorta that was intended to be a bridge to definitive surgical treatment and report a literature review. A 56-year-old woman had a previous Bentall's procedure and mitral valve annuloplasty in 2016. Four years later she re-presented with an infective pseudoaneurysm of the distal anastomosis of the ascending aortic graft, with aorto-cutaneous fistulation. She was at high risk for a revision operation and required optimization before a major open surgery. A thoracic endovascular aortic repair stent graft (Valiant Navion; Medtronic Inc) was implanted to exclude the distal anastomotic pseudoaneurysm. Two months later she re-presented with a new infected pseudoaneurysm at the proximal end of the previously implanted stent graft, and a further thoracic endovascular aortic repair was undertaken.

Clinical utility of technetium-99m-labelled leukocyte scan in diagnosis of vascular infections.

INTRODUCTION: The diagnosis of vascular graft infections and infected aneurysms via conventional methods such as computed tomography (CT) and ultrasound (US) can often be challenging. Nuclear medicine imaging techniques can detect infection in these difficult cases. We aim to evaluate the diagnostic value of technetium-99m-labelled leukocyte scans in diagnosing vascular graft infections in our centre. METHODS: There were 164 patient-scans identified over a 16-year period. The electronic clinical records, laboratory findings and radiology of these patients were reviewed. An adapted case definition of infection was defined using the criteria proposed by the Management of Aortic Graft Infection Collaboration. There were 43 patients identified to have vascular indications and had sufficient information to be divided into infected and non-infected groups. Imaging and reports of the leucocyte scans in these patients were analysed to calculate specificity and sensitivity. RESULTS: Overall sensitivity of leucocyte scans to detect vascular infection was 78.1% and specificity of 81.8% with a positive likelihood ratio of 4.30 and negative likelihood ratio of 0.27. Two false positives in patients with aortic grafts; one patient possibly had concurrent gastrointestinal infection and continued antibiotic treatment. The other patient had persistent uptake around an endoleak and was treated with lifelong antibiotics for aortic vascular graft infection on the basis of the leucocyte scan; no other clinical or laboratory evidence was found to fulfil the case definition of the vascular graft infection. CONCLUSION: Technetium-99m-labelled leukocyte scan can be a useful adjuvant test in diagnosing suspected vascular infections in this uncommon presentation.

Management of transjugular intrahepatic portosystemic shunt (TIPS)-associated refractory hepatic encephalopathy by shunt reduction using the parallel technique: outcomes of a retrospective case series.

PURPOSE: To investigate the reproducibility and technical and clinical success of the parallel technique of transjugular intrahepatic portosystemic shunt (TIPS) reduction in the management of refractory hepatic encephalopathy (HE). MATERIALS AND METHODS: A 10-mm-diameter self-expanding stent graft and a 5-6-mm-diameter balloon-expandable stent were placed in parallel inside the existing TIPS in 8 patients via a dual unilateral transjugular approach. Changes in portosystemic pressure gradient and HE grade were used as primary end points. RESULTS: TIPS reduction was technically successful in all patients. Mean ± standard deviation portosystemic pressure gradient before and after shunt reduction was 4.9 ± 3.6 mmHg (range, 0-12 mmHg) and 10.5 ± 3.9 mmHg (range, 6-18 mmHg). Duration of follow-up was 137 ± 117.8 days (range, 18-326 days). Clinical improvement of HE occurred in 5 patients (62.5%) with resolution of HE in 4 patients (50%). Single episodes of recurrent gastrointestinal hemorrhage occurred in 3 patients (37.5%). These were self-limiting in 2 cases and successfully managed in 1 case by correction of coagulopathy and blood transfusion. Two of these patients (25%) died, one each of renal failure and hepatorenal failure. CONCLUSION: The parallel technique of TIPS reduction is reproducible and has a high technical success rate. A dual unilateral transjugular approach is advantageous when performing this procedure. The parallel technique allows repeat bidirectional TIPS adjustment and may be of significant clinical benefit in the management of refractory HE.