Outcomes of Chimney Thoracic Endovascular Aortic Repair for an Aortic Arch Aneurysm.

BACKGROUND: Chimney thoracic endovascular aneurysm repair (TEVAR) has advantages that include no requirements for special devices; however, problems have been identified such as gutter leaks. The aim of this study is to evaluate the short- and mid-term results of TEVAR with chimney technique including the safety, efficacy, and risk factors for occurrence of gutter endoleak in this technique. METHODS: A retrospective single-center study was conducted on 55 consecutive patients who underwent first-time chimney TEVAR for arch aneurysms in the past 7 years. This consisted of 33 cases of single-chimney (SC) TEVAR and 22 cases of double-chimney (DC) TEVAR. The outcomes of these 55 cases of SC-TEVAR and DC-TEVAR were retrospectively examined. Risk factors for endoleaks in chimney TEVAR were also examined. RESULTS: Operative mortalities of 3.0% and 4.5% were observed in SC-TEVAR and DC-TEVAR, respectively. Incidences of stroke were 12.1% in the SC-TEVAR and 4.5% in the DC-TEVAR, resulting in endoleaks in 16 patients (48.5%) in SC-TEVAR and 6 patients (27.3%) in DC-TEVAR. Only 1 of the 77 chimney grafts was occluded, with a patency rate of 98.7%. SC-TEVAR and small distance from the common carotid artery were the risk factors of type I endoleaks. Overall survival rates over a period of 1, 3, and 5 years were 82.3%, 78.0%, and 57.7%, respectively, in the SC-TEVAR group and 95.2%, 89.3%, and 76.5%, respectively, in the DC-TEVAR group. Freedom from aneurysm-related death over 1, 3, and 5 years was 82.3%, 69.0%, and 57.7%, respectively, in the SC-TEVAR group and 95.2%, 89.3%, and 89.3% in the DC-TEVAR group. Freedom from secondary intervention over 1, 3, and 5 years was 80.2%, 64.7%, and 47.2%, respectively, in the SC-TEVAR group and 95.0%, 74.0%, and 74.0%, respectively, in the DC-TEVAR group. CONCLUSIONS: The short- and mid-term results of chimney TEVAR were worse than expectation. Especially, the results of SC-TEVAR were not acceptable because of extremely high incidence of type I endoleak and high incidence of stroke.

Result of Thoracic Endovascular Aortic Repair for Patients with Esophageal Cancer.

BACKGROUND: Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer. Thoracic endovascular aortic repair (TEVAR) was recently applied for aortic invasion by esophageal cancer. However, only a few case reports have been published. This study was performed to clarify the effectiveness and safety of TEVAR for patients with advanced esophageal cancer. METHODS: We retrospectively reviewed 18 patients who underwent TEVAR for esophageal cancer. We also performed a literature search and reviewed 21 similar cases. RESULTS: From 2007 to 2016, 10 patients were treated on an emergent basis for aortic hemorrhage (salvage group) and 8 patients underwent urgent prophylactic surgery (prophylactic group). Hemostasis was achieved in all cases. One (10%) patient in the salvage group died of aspiration pneumonia on postoperative day 1, while all patients in the prophylactic group survived for >1 month. The median survival period in the salvage and prophylactic group was 3.25 and 11.10 months, respectively. The longest survivor was still alive 9 years after TEVAR and chemoradiotherapy. No fatal adverse events or negative impacts on subsequent treatment for esophageal cancer occurred. CONCLUSIONS: TEVAR is feasible, safe, and effective in preventing fatal aortic hemorrhage secondary to esophageal cancer invasion, although it is palliative in most cases. Because the outcomes of emergent TEVAR after bleeding tended to be worse in the salvage than in prophylactic group, prophylactic TEVAR may be considered a viable treatment option for patients with aortic invasion by advanced esophageal cancer.

Metastasis to the skin at the drain site after complete resection of the lower bile duct cancer: report of a case.

There are extremely few reports of metastases from a lower cholangiocarcinoma to the skin except for metastatic seeding in a percutaneous transhepatic biliary drainage catheter tract. This report presents a rare case of metastases to the skin after the removal of a drain following curative pancreaticoduodenectomy for lower bile duct cancer (LBDC). A 73-year-old female had undergone subtotal stomach-preserving pancreaticoduodenectomy. Skin metastasis was noted at the site where the drain from the lower border at pancreaticojejunostomy had been removed 22 weeks postoperatively, and it was en bloc resected with the abdominal wall without exposing the carcinoma. Multiple nodules were confirmed in the axilla and chest wall 40 weeks after the initial operation. Careful discussion is necessary to avoid this mode of metastasis. The surgical field should not be exposed to pancreatic juice, even with LBDC. Nevertheless, this case is rare. Therefore, the risks and benefits of using such drains must be considered.

Primary aortoduodenal fistula in testicular cancer: A fatal complication associated with retroperitoneal lymph node metastasis.

A primary aortoduodenal fistula (PADF) has rarely been reported as a complication of testicular cancer. A 48-year-old Japanese male with relapsed retroperitoneal lymph node metastases received four courses of paclitaxel, ifosfamide, and cisplatin (TIP). On day 19 of the fourth cycle of TIP, he developed hematochezia and hypovolemic shock. Angiography confirmed the presence of a PADF, and we then deployed an endovascular stent graft in the aorta. Although the bleeding improved, the patient died of re-bleeding that developed 18 days later. It is important to recognize this severe complication in order to achieve its early diagnosis and optimal surgical intervention.

A new option using adjunctive microsheath angiography to increase the safety during percutaneous endovascular aortic aneurysm repair.

BACKGROUND: Percutaneous endovascular aortic repair (PEVAR) is widespread for the treatment of abdominal aortic aneurysm (AAA). The purpose of this study was to present outcomes of PEVAR using simultaneous angiography via microsheath. METHODS: There were 100 punctures in 50 patients undergoing PEVAR for AAA. All cases used the ProGlide closure device (Abbot Vascular, Santa Clara, CA, USA) for PEVAR, and another puncture with microsheath placed on the common femoral artery for a second insertion point of the ProGlide. Basically, a single ProGlide was used for each puncture in the PEVAR. Hemostasis, stenosis, dissection, and distal embolization were confirmed in angiography via the adjunctive microsheath after removal of the delivery system. Since the PEVAR for AAA requires at least two punctures, this procedure was applied to both sites. Primary outcome was technical success and occurrence rates of access-related complications in PEVAR. Technical success was defined as complete hemostasis without surgical intervention and the need for conversion to general anesthesia. RESULTS: Technical success was achieved in 98% (98/100) of the cases. Access-related complications on perioperative periods were identified in two cases. One case involved a tip of the microsheath being transected by the ProGlide that led to a distal embolization, which is why a cut down was required to retrieve the tip of the sheath. Another case required a cut down due to persistent hemorrhage from the puncture site of the microsheath. Although persistent hemorrhage was identified in five punctures (5.0%) via the adjunctive microsheath angiography, additional manual compression or ProGlide achieved complete hemostasis. Both stenosis and dissection following PEVAR were not identified in any case. CONCLUSIONS: A supporting angiography via microsheath in confirming the absence of hemorrhage, stenosis, dissection, and distal embolization may be worthwhile to selectively use for cases of PEVAR.

Case of inflammatory fibroid polyp of the esophagogastric junction.

Upper gastrointestinal endoscopy of a 25-year-old man with heartburn revealed an elevated lesion in the esophagogastric junction (EGJ). Piecemeal endoscopic mucosal resection (EMR) followed by histopathological examination led to a diagnosis of inflammatory fibroid polyp (IFP). After EMR, the heartburn persisted despite giving a proton pump inhibitor (PPI), and the residual lesion gradually enlarged and a transverse mucosal break developed on the esophageal side of it. However, the combined administration of the PPI and an H2 receptor antagonist reduced the heartburn, and led to endoscopic regression of the lesion and disappearance of the transverse mucosal break. IFP of the esophagogastric junction is extremely rare, and this case is interesting in that potent inhibition of gastric acid secretion resulted in the regression of the lesion.

Early and midterm outcomes of endovascular treatment for chronic aneurysmal aortic dissection: a retrospective study.

BACKGROUND: The aim of this study was to evaluate endovascular treatment for enlarged Stanford type B chronic aneurysmal aortic dissection (CAAD). The conventional treatment for CAAD is open repair; however, the operative mortality is high in extensive prosthetic graft replacements. METHODS: A retrospective single-center study was conducted on 74 consecutive patients who underwent endovascular treatment for CAAD in the past 8.5 years. In the partial exclusion (PE) group, entry sites in close proximity to the maximum diameter of CAAD were closed using a stent graft and reentry sites were left without closure. In the complete exclusion (CE) group, we attempted to close all entry and reentry sites. RESULTS: A total of 43 patients (PE group) and 31 patients (CE group) were included with mean ages of 59 and 63 years, respectively. Operative mortalities of 2.3% and 0% were observed in the PE and CE groups, respectively. Complete tear closure was successful in 17 of 31 patients (54.8%) in the CE group. In the PE group, complete thrombosis of the false lumen was achieved in only one case (2.3%). Freedom rates from reentry closure were 90.2%, 86.9%, and 78.2% at 1, 3, and 5 years, respectively. The diameter of the true lumen/aorta changed from 16.9/62.9 mm to 30.2/53.6 mm and from 13.7/55.1 mm to 25.8/51.0 mm in the aortic arch and descending thoracic aorta, respectively. The freedom rates from secondary intervention in successful and unsuccessful CE cases were 92.9% and 69.1%, respectively, at 1 year and 92.9% and 53.7%, respectively, at 3 years. CONCLUSION: Endovascular treatment for CAAD had favorable early and midterm outcomes.