B-cell lymphoma related iliac vein occlusion treated by endovenous stent placement.

Unilateral leg swelling is most often caused by deep vein thrombosis but other conditions may mimic this disorder. We describe the case of a patient with symptoms of unilateral lower extremity swelling caused by external compression of the iliac vein by a mass originating from the iliopsoas muscle. Initially this mass was diagnosed as an iliopsoas hematoma in a patient using anticoagulants. However, it proved to be B-cell non-Hodgkin lymphoma. Compression was relieved by placement of an endovenous stent in the left common iliac vein. Endovenous stenting is a relatively new treatment modality that is used to treat post-thrombotic venous occlusions and chronic venous insufficiency. Only a few case series have been described of stenting of compressed pelvic veins by adjacent structures such as gynecological malignancies. Although stent patency lasted only four weeks in this patient, venous stent placement quickly reliefs symptoms and should therefore be considered as an option to bridge time to allow development of sufficient venous collaterals.

Accuracy of FDG-PET-CT in the diagnostic work-up of vascular prosthetic graft infection.

OBJECTIVES: To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET-CT in diagnosing vascular prosthetic graft infection. DESIGN: Prospective cohort study with retrospective analysis. MATERIALS: Twenty five patients with clinically suspected vascular prosthetic infection underwent CT and FDG-PET scanning. METHODS: Two nuclear medicine physicians assessed the FDG-PET scans; all CT scans were assessed by two radiologists. Fused FDG-PET/CT were judged by the radiologist and the nuclear medicine physician. The concordance between CT and FDG-PET and the inter-observer agreement between the different readers were investigated. RESULTS: Fifteen patients had a proven infection by culture. Single FDG-PET had the best results (sensitivity 93%, specificity 70%, positive predictive value 82% and negative predictive value 88%). For CT, these values were 56%, 57%, 60% and 58%, respectively. Fused CT and FDG-PET imaging also showed high sensitivity and specificity rates and high positive and negative values. Inter-observer agreement for FDG-PET analysis was excellent (kappa = 1.00) and moderate for CT and fused FDG-PET-CT analysis (0.63 and 0.66, respectively). CONCLUSION: FDG-PET scanning showed a better diagnostic accuracy than CT for the detection of vascular prosthetic infection. This study suggests that FDG-PET provides a useful tool in the work-up for diagnosis of vascular prosthetic graft infection.

Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience.

OBJECTIVES: To present an 8-year clinical experience in the endovascular treatment of short-necked and juxtarenal abdominal aortic aneurysm (AAA) with fenestrated stent grafts. METHODS: At our tertiary referral centre, all patients treated with fenestrated and branched stent grafts have been enrolled in an investigational device protocol database. Patients with short-necked or juxtarenal AAA managed with fenestrated endovascular aneurysm repair (F-EVAR) between November 2001 and April 2009 were retrospectively reviewed. Patients treated at other hospitals under the supervision of the main author were excluded from the study. Patients treated for suprarenal or thoraco-abdominal aneurysms were also excluded. All stent grafts used were customised based on the Zenith system. Indications for repair, operative and postoperative mortality and morbidity were evaluated. Differences between groups were determined using analysis of variance with P < 0.05 considered significant. RESULTS: One hundred patients (87 males/13 females) with a median age of 73 years (range, 50-91 years) were treated during the study period; this included 16 patients after previous open surgery or EVAR. Thirty-day mortality was 1%. Intra-operative conversion to open repair was needed in one patient. Operative visceral vessel perfusion rate was 98.9% (272/275). Median follow-up was 24 months (range, 1-87 months). Twenty-two patients died during follow-up, all aneurysm unrelated. No aneurysm ruptured. Estimated survival rates at 1, 2 and 5 years were 90.3 +/- 3.1%, 84.4 +/- 4.0% and 58.5 +/- 8.1%, respectively. Cumulative visceral branch patency was 93.3 +/- 1.9% at 5 years. Visceral artery stent occlusions all occurred within the first 2 postoperative years. Four renal artery stent fractures were observed, of which three were associated with occlusion. Twenty-five patients had an increase of serum creatinine of more than 30%; two of them required dialysis. In general, mean aneurysm sac size decreased significantly during follow-up (P < 0.05). CONCLUSIONS: Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm appears safe and effective on the longer term. Renal function deterioration, however, is a major concern.

Fenestrated stent-grafting after previous endovascular abdominal aortic aneurysm repair.

AIM: The aim of this study was to present their experience and highlight the technical difficulties associated with the use of fenestrated stent-grafts to treat juxta and pararenal abdominal aortic aneurysms (AAA) in patients having undergone a previous infrarenal endovascular aneurysm repair (EVAR). METHODS: A prospectively held database maintained at the University Medical Center of Groningen including 162 patients who have undergone branched and fenestrated stent-grafting for AAA, was queried for patients treated with this technology after previous EVAR. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality and morbidity were evaluated. RESULTS: A total of 9 patients underwent repair with a fenestrated endograft after previous EVAR. All patients had aneurysmal degeneration of the juxta- and pararenal aorta not suitable to standard endovascular techniques. We encountered various intraoperative complications including iliac and renal artery access problems, intraoperative previous graft migration, and dislocation of previous graft limb. In one patient, immediate conversion was needed because a twisted graft limb prevented retrieval of the top cap of the fenestrated graft. The remaining eight patients were successfully treated by endovascular means. For these patients, target vessel success rate was 100% (20/20) and mean hospital stay 6.0 days (range 3-12 days). Thirty-day and one-year mortality were 0%. Mean follow up was 31 months (range 1-76 months). No aneurysm related death occurred during follow-up. CONCLUSION: Fenestrated endovascular stent-grafts can be used to repair juxta- and pararenal AAA after previous EVAR. However, several technical challenges have to be overcome due to the presence of a previous stent-graft.

Results of endovascular abdominal aortic aneurysm repair with selective use of the Gore Excluder.

AIM: To evaluate single center results with selective use of the Gore Excluder stent-graft for elective abdominal aortic aneurysm repair. METHODS: Retrospective analysis of a prospective data base. Primary endpoints were technical success, all-cause and aneurysm-related mortality and aneurysm rupture. Secondary endpoints were late complications including migration, endoleak, aneurysm growth, limb occlusion, and re-intervention. RESULTS: The Gore Excluder stent-graft was used in 92 elective cases, mainly in cases with difficult iliac anatomy. There were 81 (88%) male patients. Mean age was 70.4+/-7.5 (range, 53-87). Primary assisted technical success rate was 98.9% (91/92 patients). Thirty-day mortality was 0%. Median follow-up was 35.7 months (range, 2-99). Overall survival was 95.2+/-2.4% at 1 year, 89.2+/-3.7% at 2 years, 83.9+/-4.5% at 3 years and 70.2+/-6.8% at 5 years. During follow-up there were 3 (3.3%) Type I endoleaks and 20 (21.7%) Type II endoleaks. Proximal migration of more than 5 mm without endoleak occurred in two patients. In total 13 re-interventions were performed in 12 (13%) patients. No graft limb occlusion occurred. No aneurysm ruptured during follow-up. CONCLUSIONS: Selective use of the Gore Excluder demonstrates excellent short- and long-term results. Despite being used in challenging iliac anatomy no graft limbs occluded.

The role of branched endografts in preserving internal iliac arteries.

AIM: The aim of this study was to report our treatment algorithm and early results with the use of an iliac branched device (IBD) to preserve the internal iliac artery (IIA) in the treatment of aortoiliac and solitary common iliac artery (CIA) aneurysms. METHODS: From September 2004 on, all patients with aorto-iliac aneurysms with a suitable proximal neck or CIA aneurysms were evaluated. Selection for treatment with an IBD was done based on activity level of the patient and anatomical criteria of the aneurysm. Absolute exclusion criteria included aneurysmal IIA, severe atherosclerosis of the IIA, and small residual CIA lumen. Patients who were at risk of losing one out of two patent IIA were only considered for IBD if they were physically active. Follow-up was performed with computed tomography scanning at six weeks and one year, and thereafter yearly. RESULTS: Fifty-nine patients (39 aorto-iliac, 20 CIA) were evaluated for treatment with an IBD. Seven patients were not considered for IBD for low activity level. Twenty-five patients were not suitable because of adverse anatomy. In total, 27 patients (20 aorto-iliac, 7 CIA) were treated with 30 IBDs. Technical success was achieved in 96.3% of patients. There was no 30-day mortality. Mean follow-up period was 16+/-14 months. In three patients the IIA side branch occluded, resulting in buttock claudication in only one patient. No external iliac artery occlusion or device component disconnection was observed. CONCLUSIONS: An IBD provides a totally endovascular option to preserve the IIA in selected aortoiliac and isolated CIA aneurysms. Anatomical application rate for the use of an IBD was 52.5% in our series. Further studies are needed to determine the indications for use of this device.

Results of endovascular abdominal aortic aneurysm repair with the Zenith stent-graft.

OBJECTIVE: To evaluate single center results of the Zenith stent-graft for elective abdominal aortic aneurysm repair. METHODS: Data from all patients treated with a Zenith graft between March 1999 and December 2006 were retrospectively analyzed from a prospective database. Outcome measures were technical success, all-cause and aneurysm related mortality, late complications, and re-interventions. RESULTS: A total of 234 patients were included, of which 216 were male. Mean age was 72.1+/-6.9 years. Mean diameter of the aneurysm was 60.9+/-10mm. Technical success rate was 98.3%. Thirty day mortality was 1.7%. Median follow-up was 26.9 months (range, 1-104). Overall survival was 92.2+/-1.8% at 1 year, 87.2+/-2.3% at 2 years, and 69.9+/-4.6% at 5 years. During follow-up, one aneurysm ruptured due to limb disconnection, which was treated by bridging stent-grafting. Re-interventions were performed in 9.2% of the patients, with 79% by endovascular means. There was no mortality related to re-intervention. CONCLUSIONS: Endovascular abdominal aortic aneurysm repair with the Zenith device provides excellent results with a low risk for aneurysm-related death and rupture, and a low re-intervention rate in the mid-term.

Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?

AIM: Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort. METHODS: Between June 1998 and February 2007, 73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel. RESULTS: Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016). CONCLUSION: Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.

The Cook Zenith endovascular graft.

From its early release in 1994, the Zenith endovascular graft presented with a more complex but very controlled deployment mechanism. It was loaded into small and flexible introduction systems. The main difference with most early grafts was the intended suprarenal fixation with a bare stent including hooks and barbs. This suprarenal fixation proved to be both safe and efficient. Several improvements were made over the years, resulting in the Zenith Tri-Fab stent-graft. Major advantages of the Tri-Fab include availability of stock products and the versatility with regard to distal diameter and lengths. Finally, the Zenith graft acted as the platform in the development of fenestrated and branched grafts.

Fenestrated and branched stent-grafting: a 5-years experience.

Fenestrated stent-grafts aim at treating short-necked aneurysms. As a result of customized fenestrations, patency of vital side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft over these aortic side branches. Over the years, the technique has been refined. Results in a few experienced centers are good, with excellent patency rates of targeted side branches. Suprarenal and thoraco-abdominal aneurysms can only be treated by endovascular means with branched grafts. This can be achieved with fenestrated grafts, but with the use of covered stents through the fenestrations, or by fully branched grafts. Both options are feasible and present with specific advantages and disadvantages. This report gives an overview of our 5-years experience with fenestrated and branched grafts, and discusses the following aspects of the technique: indications, technical principles, results, and limitations.

Fenestrated and branched endovascular techniques for thoraco-abdominal aneurysm repair.

Since 1991, endovascular aortic aneurysm repair (EVAR) has been established as an alternative for open surgical repair of aortic aneurysms. One of the main limitations for EVAR is the need for a sufficient sealing zone below or above vital aortic side branches. Recently, efforts have been made to overcome these limitations by incorporating fenestrations or branches in customized stent-grafts. This paper reviews the technical and clinical possibilities, as well as the results with fenestrated and branched stent-grafts. All these techniques can be classified into 6 groups, including abdominal fenestrated, abdominal branched, thoraco-abdominal fenestrated, thoraco-abdominal branched, thoracic fenestrated, and thoracic branched stent-grafting. The only well-elaborated technique at this moment is abdominal fenestrated stent-grafting. Currently, branched stent-grafting must be regarded as experimental, but advancements are taking place rapidly. It is anticipated that wider adoption will take place in the near future. New developments include the further use of reinforced fenestrations, indwelling catheters and flexor sheaths, as well as the use of new type branches.

Venography of the lower limbs. Pitfalls of the diagnostic standard. The ETTT Trial Investigators.

RATIONALE AND OBJECTIVES: Phlebography is considered the diagnostic standard for suspected deep venous thrombosis. The authors studied the inter-observer variability of phlebogram interpretation in the setting of a multicenter therapeutic trial of the thrombolytic agent alteplase. METHODS: The interpretation of 31 pairs of venograms (before and after thrombolytic therapy) was studied by comparing the quantitative Marder's scores which were computed by three experts and the qualitative assessment of phlebographic changes induced by thrombolysis by the panel of experts and by the investigators. RESULTS: Although the scores of the three experts correlated fairly well (r = .67-.82; P < .001), they differed significantly from each other (P < .0001). Substantial differences also were found between local (by investigators) qualitative evaluation of the venographic changes induced by the treatment and central evaluation by the panel of experts (coefficient of agreement kappa = 0.19), local assessment being significantly more optimistic (P = .002) than central judgment. CONCLUSION: Significant differences were observed between assessment of changes in venographic scores after thrombolytic treatment both among three expert radiologists, and between the panel of experts and the local investigators of the multicenter trial. This observation points to the need for an a priori definition of well-characterized decision criteria to allow a valid interpretation of the effects of the therapeutic intervention.

Arteriography and portal venography on routine follow-up after orthotopic liver transplantation.

RATIONALE AND OBJECTIVES: To describe the findings of routinely performed angiographic examinations in patients at discharge 2 months after orthotopic liver transplantation (OLT) and at follow-up 1 year later. METHODS: The findings of 315 angiographic examinations performed in 190 patients 2 months and 1 year after OLT were reviewed, and the changes at the anastomotic site of the hepatic artery and portal vein were analyzed. RESULTS: Routine angiography 2 months and 1 year after OLT demonstrated a normal anastomosis or low-grade stenosis in 82% and 84% of the patients (hepatic artery) and in 88% and 84% (portal vein), respectively. High-grade stenosis occurred in 9% and 5% of the patients (hepatic artery) and in 3% and 5% (portal vein). Hepatic artery occlusion and portal vein occlusion were observed in two and seven patients and in one and three patients, respectively. In 76% of patients, the anastomotic site of the hepatic artery did not change significantly. In eight patients, a normal anastomosis or a low- or medium-grade stenosis developed into high-grade stenosis or occlusion. Conversely, in nine patients, medium- or high-grade stenosis developed into a normal anastomosis or a low-grade stenosis. In all eight patients who initially had a high-grade stenosis, the hepatic artery proved to be patent at 1 year. In 98% of patients, the anastomotic site of the portal vein did not change significantly. In one patient who initially had a normal anastomosis, occlusion was found at I year. CONCLUSIONS: In most patients, routine angiography 2 months and 1 year after OLT demonstrated normal findings or a low-grade stenotic anastomosis of the hepatic artery and portal vein. Significant changes occurred mainly at the anastomotic site of the hepatic artery and could not be predicted by previous angiograms.

[Massive haemoptysis: primary care, diagnosis and treatment]. / Massale hemoptoë: eerste opvang, diagnostiek en behandeling.

Massive haemoptysis is life-threatening because of asphyxiation from flooding of the central airways with blood. The first step in treatment includes airway protection, usually managed by intubation. Imaging may be inconclusive, and bronchoscopy--rigid or flexible--is essential to establish the site and cause of the bleeding. Bronchoscopy may be therapeutic in that a balloon catheter may be inserted in the bleeding airway in order to tamponade the source of bleeding. Embolisation of pathological bronchial arterial vessels is the treatment of choice in most cases; surgery is limited to causes that cannot be managed by the endovascular treatment modality, or to cases that fail to respond to embolisation.

Iliac branched device implantation in tortuous iliac anatomy after previous open ruptured aortic aneurysm repair.

The aim of this paper was to present iliac branched device (IBD) implantation in a fit 67-year-old man with tortuous iliac anatomy after previous emergent open abdominal aortic aneurysm (AAA) repair. The patient underwent open treatment for a ruptured abdominal aortic aneurysm in another hospital. The procedure was complicated by extreme blood loss which prevented concommitant treatment of two large iliac aneurysms. Later, the patient underwent stent-grafting of a right common iliac artery aneurysm (CIAA) with coil embolization of the internal iliac artery (IIA). He was then refferred to our institute for treatment of the left CIAA with preservation of the left IIA. An IBD was used to this purpose. The introduction system was inserted over a through-and-through wire, and the bridging stent-graft via a left axillary approach. An Excluder leg was used to mate the IBD with the surgical graft limb. Additional self-expanding stents were needed to keep the limbs of the surgical graft open. One year later the patient is doing well, without buttock claudication, and the aneurysm is well excluded. With challenging anatomy, endovascular repair with an IBD may require additional technical tricks but also back-up materials to achieve success.

A new interventional technique for percutaneous treatment of drainage-resistant liver abscess.

The objective of this case report is to describe a device that can be used as a minimally invasive alternative for the treatment of drainage-resistant liver abscess. The device uses pulse lavage to fragment and evacuate the semi-solid contents of a liver abscess. The treatment of liver abscesses consists of percutaneous drainage, antibiotics and treatment of the underlying cause. This approach can be ineffective if the contents of the abscess cavity are not liquid, and in those cases open surgery is often needed. Here, we describe for the first time a new minimally invasive technique for treating persistent liver abscesses. A patient developed a liver abscess after a hepatico-jejunostomy performed as a palliative treatment for an unresectable pancreatic head carcinoma. Simple drainage by a percutaneously placed pig-tail catheter was insufficient because of inadequate removal of the contents of the abscess cavity. After dilatation of the drain tract the persistent semi-solid necrotic contents were fragmented by a pulsed lavage device, after which the abscess healed uneventfully. The application of pulsed lavage for debridement of drainage-resistant liver abscesses proved to be an effective and minimally invasive alternative to open surgery.

Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery.

OBJECTIVE: To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak. METHODS: Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n=4), suprarenal aneurysm after open AAA (n=4), distal type I endoleak after endovascular TAA (n=1), proximal anastomotic aneurysm after open AAA (n=1), and an aborted open AAA repair due to bleeding around a short infrarenal neck. RESULTS: The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period. CONCLUSIONS: Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.

Local anesthesia for endovascular abdominal aortic aneurysm repair.

OBJECTIVES: This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications. METHODS: All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation). RESULTS: A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001). CONCLUSIONS: A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.

Endovascular treatment of acute abdominal aortic aneurysm with a bifurcated stentgraft.

OBJECTIVES: To analyse the results of emergency endovascular aneurysm repair (eEVAR) for acute abdominal aortic aneurysms (AAA), in comparison to open repair, and to evaluate suitability and application rate. PATIENTS AND METHODS: All patients treated for an acute AAA between January 1998 and August 2004 were included. The primary outcome measure was in-hospital mortality. Secondary outcome measures were procedure time, intra-operative blood loss, transfusion requirement, intensive care unit, and hospital length of stay. Suitability and application rate for eEVAR were assessed in a subgroup of patients, from January 2003. RESULTS: A total of 253 patients were treated. eEVAR was performed in 40 patients, 5 (13%) died in-hospital. Open repair was performed in 213 patients, 64 (30%) died in-hospital. Secondary outcome measures were all significantly improved in the eEVAR subgroup. From January 2003, 56 patients were treated. Of the 44 (79%) patients who were evaluated for eEVAR, 16 (36%) patients were anatomically suitable. Eventually, 15 out of the 56 (27%) patients were treated by eEVAR. CONCLUSION: The results of eEVAR in a selected group of patients are promising, but suitability and application rate were low.

Metachromatic leukodystrophy and coincidental finding of papillomatosis of the gallbladder. A case report.

In this case report we describe the coincidental finding of polyps in the gallbladder by ultrasound investigation in a six-year-old girl, known to have metachromatic leukodystrophy. The investigation was carried out because of suspicion of abdominal trauma after falling down the stairs and finding elevated serum amylase.