Relapse rate and predictors of relapse after cessation of glucocorticoid maintenance therapy in type 1 autoimmune pancreatitis: a multicenter retrospective study.

BACKGROUND: Type 1 autoimmune pancreatitis responds well to glucocorticoid therapy with a high remission rate. Moreover, glucocorticoid maintenance therapy can help prevent relapse. However, the relapse rate following cessation of long-term glucocorticoid therapy is unknown. The aim of this study was to clarify the relapse rate and predictors of relapse following long-term glucocorticoid therapy cessation. METHODS: We analyzed 94 patients who achieved remission after undergoing glucocorticoid therapy, discontinued treatment after at least 6 months of maintenance therapy, and were subsequently followed up for at least 6 months. The patients were divided into three groups based on treatment duration (< 18, 18-36, and ≥ 36 months), and their relapse rates were compared. Univariate and multivariate analyses of clinical factors were conducted to identify relapse predictors. RESULTS: After discontinuing glucocorticoid therapy, relapse was observed in 43 (45.7%) patients, with cumulative relapse rates of 28.2% at 1 year, 42.1% at 3 years, 47.0% at 5 years, and a plateau of 77.6% at 9 years. Of the 43 patients who relapsed, 25 (58.1%) relapsed within 1 year after after cessation of glucocorticoid therapy. Relapse and cumulative relapse rates did not differ significantly according to treatment duration. In the multivariate analysis, an elevated serum IgG4 level at the time of glucocorticoid cessation was found to be an independent predictor of relapse (hazard ratio, 4.511; p < 0.001). CONCLUSIONS: A high relapse rate occurred after cessation of glucocorticoid maintenance therapy, regardless of the duration of maintenance therapy, especially within the first year after cessation. However, the normalization of long-term serum IgG4 levels may be a factor in considering cessation.

Excessive EP4 Signaling in Smooth Muscle Cells Induces Abdominal Aortic Aneurysm by Amplifying Inflammation.

OBJECTIVE: Excessive prostaglandin E2 production is a hallmark of abdominal aortic aneurysm (AAA). Enhanced expression of prostaglandin E2 receptor EP4 (prostaglandin E receptor 4) in vascular smooth muscle cells (VSMCs) has been demonstrated in human AAAs. Although moderate expression of EP4 contributes to vascular homeostasis, the roles of excessive EP4 in vascular pathology remain uncertain. We aimed to investigate whether EP4 overexpression in VSMCs exacerbates AAAs. Approach and Results: We constructed mice with EP4 overexpressed selectively in VSMCs under an SM22α promoter (EP4-Tg). Most EP4-Tg mice died within 2 weeks of Ang II (angiotensin II) infusion due to AAA, while nontransgenic mice given Ang II displayed no overt phenotype. EP4-Tg developed much larger AAAs than nontransgenic mice after periaortic CaCl2 application. In contrast, EP4fl/+;SM22-Cre;ApoE-/- and EP4fl/+;SM22-Cre mice, which are EP4 heterozygous knockout in VSMCs, rarely exhibited AAA after Ang II or CaCl2 treatment, respectively. In Ang II-infused EP4-Tg aorta, Ly6Chi inflammatory monocyte/macrophage infiltration and MMP-9 (matrix metalloprotease-9) activation were enhanced. An unbiased analysis revealed that EP4 stimulation positively regulated the genes binding cytokine receptors in VSMCs, in which IL (interleukin)-6 was the most strongly upregulated. In VSMCs of EP4-Tg and human AAAs, EP4 stimulation caused marked IL-6 production via TAK1 (transforming growth factor-ß-activated kinase 1), NF-κB (nuclear factor-kappa B), JNK (c-Jun N-terminal kinase), and p38. Inhibition of IL-6 prevented Ang II-induced AAA formation in EP4-Tg. In addition, EP4 stimulation decreased elastin/collagen cross-linking protein LOX (lysyl oxidase) in both human and mouse VSMCs. CONCLUSIONS: Dysregulated EP4 overexpression in VSMCs promotes inflammatory monocyte/macrophage infiltration and attenuates elastin/collagen fiber formation, leading to AAA exacerbation.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Coil embolization of intercostal arteries accessed by surgical exposure for type II endoleak after thoracic endovascular aortic repair.

Many patients with type II endoleak after thoracic endovascular aortic repair (TEVAR) are closely observed without secondary intervention. Herein, we report a new technique of coil embolization for type II endoleak from intercostal arteries after TEVAR for ruptured acute type B aortic dissection. A hybrid procedure of exposing intercostal arteries via subcostal incision in the prone position and transcatheter technique enables embolization of intercostal arteries at their origin from the aorta. This technique could avoid lung injury and be applicable in multiple intercostal arteries. This technique may be a useful secondary intervention for type II endoleak after TEVAR caused by intercostal arteries.

Proteomic analysis of aortic smooth muscle cell secretions reveals an association of myosin heavy chain 11 with abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a life-threatening disease, and no disease-specific circulating biomarkers for AAA screening are currently available. We have identified a smooth muscle cell (SMC)-specific biomarker for AAA. We cultured aneurysmal tunica media that were collected from eight patients undergoing elective open-repair surgeries. Secreted proteins in culture medium were subjected to liquid chromatography/tandem mass spectrometry. Myosin heavy chain 11 (myosin-11) was identified as a SMC-specific protein in the tunica media-derived secretions of all patients. We then examined myosin-11 protein concentrations by ELISA in plasma samples from patients with AAA ( n = 35) and age-matched healthy control subjects ( n = 34). Circulating myosin-11 levels were significantly higher in patients with AAA than control subjects. The area under the receiver-operating characteristic curve (AUC) of myosin-11 was 0.77, with a specificity of 65% at a sensitivity of 91%. Multivariate logistic regression analysis showed a significant association between the myosin-11 level and presence of AAA. When the myosin-11 level was combined with hypertension, it improved the prediction of AAA (AUC 0.88) more than hypertension per se. We then investigated the correlation between aortic diameter and circulating myosin-11 levels using AAA serum samples from patients undergoing endovascular aneurysm repair ( n = 20). Circulating myosin-11 levels were significantly correlated with maximum aortic diameter. Furthermore, changes in myosin-11 concentrations from the baseline 12 mo after endovascular aneurysm repair were associated with those in aortic diameter. These data suggest that circulating levels of myosin-11, which is a SMC-specific myosin isoform, may be useful as a biomarker for AAA. NEW & NOTEWORTHY Extensive studies have revealed that inflammation- or proteolysis-related proteins are proposed as biomarkers for abdominal aortic aneurysm (AAA). Changes in these protein concentrations are not specific for smooth muscle, which is a major part of AAA pathologies. Hence, no disease-specific circulating markers for AAA are currently available. We found, using secretome-based proteomic analysis on human AAA tunica media, that myosin heavy chain 11 was associated with AAA. Circulating myosin heavy chain 11 may be a new tissue-specific AAA marker.

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients.

PURPOSE: To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves. METHODS: Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups. RESULTS: The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p = 0.02), with significantly shorter aortic cross-clamp (ACC) time (p < 0.01), cardiopulmonary bypass (CPB) time (p < 0.01), intensive care unit stay (p < 0.01), intubation time (p < 0.01), and overall hospital stay (p = 0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p = 0.01). CONCLUSIONS: The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

Impact of comorbidities on the postoperative outcomes of acute cholecystitis following early cholecystectomy.

PURPOSES: The purpose of this study was to evaluate the influence of comorbidities on the surgical outcomes of early cholecystectomy for acute cholecystitis. METHODS: Data were retrospectively collected for patients with acute cholecystitis who underwent early cholecystectomy. Patients were separated into three groups based on the cholecystitis severity grade, and the surgical outcomes of early cholecystectomy were analyzed. Patients with mild and moderate cholecystitis were subdivided into a comorbidity group (n = 10) and a non-comorbidity group (n = 83). RESULTS: There were 57 (55.3%) patients with mild cholecystitis, 36 (35.0%) with moderate cholecystitis, and 10 (9.7%) with severe cholecystitis. The surgical outcomes were significantly worse for patients with severe cholecystitis than for patients with mild or moderate cholecystitis. There were no postoperative deaths after cholecystectomy. There were no significant differences in the complication rate (P = 0.629), conversion rate (P = 0.114), or intraoperative blood loss (P = 0.147) between the comorbidity and non-comorbidity groups. CONCLUSION: Our findings suggest that early cholecystectomy can be performed safely for patients with mild and moderate cholecystitis even if comorbidities are present. Early cholecystectomy may be an alternative treatment strategy for patients with severe cholecystitis who are candidates for anesthesia and surgery.

Evaluation and Influence of Brachiocephalic Branch Re-entry in Patients With Type A Acute Aortic Dissection.

BACKGROUND: Stanford type A acute aortic dissection (A-AAD) extends to the brachiocephalic branches in some patients. After ascending aortic replacement, a remaining re-entry tear in the distal brachiocephalic branches may act as an entry and result in a patent false lumen in the aortic arch. However, the effect of brachiocephalic branch re-entry concomitant with A-AAD remains unknown.Methods and Results:Eighty-five patients with A-AAD who underwent ascending aortic replacement in which both preoperative and postoperative multiple-detector computed tomography (MDCT) scans could be evaluated were retrospectively studied. The presence of a patent false lumen in at least one of the brachiocephalic branches on preoperative MDCT was defined as brachiocephalic branch re-entry, and 41 patients (48%) had this. Postoperatively, 47 of 85 (55%) patients had a patent false lumen in the aortic arch. False lumen remained patent after operation in 34 out of the 41 (83%) patients with brachiocephalic branch re-entry, as compared to that in 13 of the 44 (30%) patients without such re-entry (P<0.001). Brachiocephalic branch re-entry was a significant risk factor for a late increase in the aortic arch diameter greater than 10 mm (P=0.047). CONCLUSIONS: Brachiocephalic branch re-entry in patients with A-AAD is related to a patent false lumen in the aortic arch early after ascending aortic replacement and is a risk factor for late aortic arch enlargement.

A case report on metastatic pancreatic tumor from pulmonary adenocarcinoma that difficult to differentiate from primary pancreatic ductal carcinoma.

A woman was admitted to our department for lung adenocarcinoma and she was treated with left upper lobectomy. The carcinoembryonic antigen level had increased. Enhanced computed tomography showed a hypovascular tumor in the pancreatic tail and in the extension of the distal main pancreatic duct. Endoscopic ultrasonography (EUS) clearly showed a low echoic lesion, and histological examination revealed adenocarcinoma. On immunostaining, the lesion was diagnosed as metastatic adenocarcinoma of the lungs. The patient was treated with chemotherapy for lung cancer and survived for 4 years after diagnosis. Differentiating a metastatic lesion to the pancreas from pancreatic ductal adenocarcinoma is very important. Accurate diagnosis enables administration of appropriate treatment. In this case, EUS was especially useful for assessing the tumor in the pancreas. When patients with a history of extra-pancreatic cancer present with a pancreatic lesion, pancreatic metastases should be considered, regardless of the time elapsed since occurrence of the primary cancer. EUS-fine needle aspiration (FNA) with histological examination is the best method for definitive diagnosis of pancreatic disease in this group of patients. This approach has very high sensitivity and accuracy for the diagnosis of pancreatic metastases.

Evaluation of antibiotic use to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis.

BACKGROUND/AIMS: The purpose of this study was to evaluate the relationship between prophylactic antibiotic use and complications following endoscopic retrograde cholangiopancreatography (ERCP). METHODOLOGY: We retrospectively evaluated 605 consecutive patients who underwent ERCP in our hospital between September 2009 and November 2011. The antibiotic group included patients who underwent their procedure before October 2010, while the control group included patients after October 1, 2010, who did not receive antibiotics. We compared the incidence of postoperative pancreatitis and cholangitis between the groups. RESULTS: There were no significant differences in the backgrounds of the 304 control and the 301 antibiotic-treated patients. The incidence of post-ERCP pancreatitis was 4.9% in the control group and 4.3% in the antibiotic group (p = 0.72). The incidence of postoperative cholangitis was 2.0% in the control group and 1.7% in the antibiotic group (p = 0.99). Choledocholithiasis, pancreatic duct injection, and female gender were detected as significant risk factors for postoperative pancreatitis by multivariate analysis; sclerosing cholangitis and incomplete biliary drainage were significant risk factors for postoperative cholangitis. Even in cases with these risk factors, prophylactic antibiotic use did not influence the incidence of pancreatitis or cholangitis. CONCLUSION: Prophylactic antibiotics do not reduce the incidence of either pancreatitis or cholangitis following ERCP.

Coronary subclavian steal syndrome detected during coronary bypass surgery in a hemodialysis patient.

Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery.

Thoracic endovascular aortic repair for ruptured descending thoracic aortic aneurysm.

BACKGROUND: We evaluated clinical outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA). METHODS: Twenty-three patients with rDTAA (mean age, 76.8 ± 8.8 years) underwent TEVAR at our center between January 2008 and April 2013. RESULTS: In twenty-three patients, five patients (21.7%) were in shock before surgery. Technical success was achieved in 21 patients. After TEVAR, retrograde Type A aortic dissection occurred in one patient, Type I endoleak in one patient, and Type II endoleak in three patients. The 30-day mortality rate was 4.3% (n = 1), and there were five in-hospital deaths (21.7%). Six patients (26.1%) developed cerebral complications and two patients suffered from paraplegia. In the late phase, four patients died because of the following aortic events: re-rupture in one patient, rupture of another untreated aneurysm in two patients, and esophageal perforation in one patient. CONCLUSIONS: TEVAR is associated with relatively low early morbidity and mortality and can be performed in older and high-risk patients. However, because aortic events during follow-up after TEVAR are not rare, we recommend close follow-up and application of early and aggressive reintervention.

Timing of radiological improvement after steroid therapy in patients with autoimmune pancreatitis.

OBJECTIVE: We retrospectively studied the timing of radiological improvement after steroid therapy in patients with autoimmune pancreatitis (AIP). MATERIAL AND METHODS: Patients with AIP (n = 31) received steroids followed by diagnostic imaging within 1 month. Pancreatic swelling, pancreatic and bile duct features, and apparent diffusion coefficient (ADC) were compared before and after treatment. The period from treatment initiation to evaluation was divided into five phases: early phase (days 3-5), week 1 (days 6 and 7), week 2 (days 8-14), week 3 (days 15-21), and week 4 (days 22-28). Five gastroenterologists evaluated pancreatic swelling and duct features (good/intermediate/no response), and the "good response" rate (response rate) was calculated for each phase. In addition, pancreatic volumes were measured with a 3D workstation before and after treatment, and the percentage change in volume was calculated. ADC values were calculated in 14 patients. RESULTS: The median ratio of pancreatic volume after relative to before treatment was 0.89, 0.79, 0.67, 0.59, and 0.47 for early phase, week 1, week 2, week 3, and week 4, respectively. The response rate of the pancreatic swelling was 37.5%, 57.1%, 83.3%, 100%, and 100%; response rate of the pancreatic duct was 0%, 20%, 75%, 75% and 100%; and response rate of the bile duct was 0%, 66.7%, 83.3%, 100%, and 80%. The ADC increased after treatment in all 14 patients, including the 7 patients evaluated in the early phase. CONCLUSIONS: Evaluation of pancreatic swelling and duct features is recommended in week 2 and thereafter. The ADC increased soon after treatment initiation, suggesting its usefulness for evaluating early treatment responses.

Comparative study of 4 Fr versus 6 Fr nasobiliary drainage catheters: a randomized, controlled trial.

BACKGROUND AND AIM: Despite the benefits of endoscopic nasobiliary drainage (NBD) in endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) and nose/throat discomfort can result. We aimed to determine whether the use of a smaller catheter alleviates these complications. METHOD: A randomized, controlled trial at a tertiary care center compared 4 Fr and 6 Fr NBD catheters; 165 ERCP patients with naïve papillae were randomly assigned to a catheter-size group. RESULTS: The prevalence of PEP was significantly lower in the 4 Fr group (3.7%; 3/82) than in the 6 Fr group (15.7%; 13/83; P = 0.019). No spontaneous catheter displacement occurred within 24 h. Discomfort visual analog scores were 2.6 and 4.3 in the 4 Fr and 6 Fr groups, respectively (P = 0.0048) on procedure day; on the following day, the scores were 2.3 and 3.6 (P = 0.028). Bile output was 16.3 mL/h and 21.4 mL/h in the 4 Fr and 6 Fr groups (P = 0.051). On obstructive jaundice subgroup analysis, bile drainage was 19.2 mL/h and 22.1 mL/h in the 4 Fr and 6 Fr groups (P = 0.40). The 4 Fr group required 5.6 days to reduce bilirubin levels versus 6.1 days in the 6 Fr group (P = 0.51). CONCLUSIONS: In patients with naïve papillae, lower rates of PEP and less nose/throat discomfort are associated with the use of 4 Fr NBD catheters. In patients with obstructive jaundice, 4 Fr and 6 Fr catheters are comparable with regard to bile output and bilirubin level reduction.

Characteristic Features of Cholangiocarcinoma Complicating Primary Sclerosing Cholangitis.

BACKGROUND/AIMS: Primary sclerosing cholangitis (PSC) is often complicated by cholangiocarcinoma (CCA); thus, early detection of CCA is an important way to improve PSC prognosis. METHODOLOGY: In a retrospective study, 23 cases of PSC were included. Seven cases were complicated by CCA (CCA group) and 16 cases were not (control group). Blood examinations, bile duct imagings from direct cholangiography, intraductal ultrasonography (IDUS) findings and pathological diagnosis results (bile juice cytology, brush cytology, and forceps biopsy) were referenced. RESULTS: Blood examinations showed that serum carbohydrate antigen 19-9 (CA19-9), total bilirubin, and aspartate aminotransferase were significantly higher in the CCA group, whereas cholangiography showed that the dominant stricture was significantly longer in the CCA group. No significant difference in the IDUS findings was observed between the 2 groups. Cholangioscopy enabled CCA diagnosis via identification of the papillary mucosa in sites other than the stricture. Forceps biopsy was the most useful pathological diagnostic technique, with a sensitivity of 86% and a specificity of 100%. CONCLUSIONS: The CA19-9 level and bile duct stricture morphology were useful for diagnosing CCA complicating PSC. Aggressive performance of cholangioscopy and pathological diagnostic techniques, such as brush cytology and forceps biopsy, are essential for identification.

The effect of respiratory-gated positron emission tomography/computed tomography in patients with pancreatic cancer.

Our aim of this study was to evaluate prospectively in patients with pancreatic cancer the effects of respiratory- gating during PET/CT acquisition on the determination of lesion volume and to measure tracer uptake. Our research included 36 patients diagnosed with pancreatic cancer. They underwent conventional whole-body PET/CT and subsequently respiratory-gated PET/CT of the upper abdomen. Based on list-mode PET acquisition data, respiratory-gated and non-gated images were created. Maximum standardized uptake values (SUVmax) and lesion volumes were compared between gated and non-gated images and also the rate of increase in SUVmax based on lesion size. Results showed that respiratory gating was successful in 34/36 patients. The median non-gated SUVmax was 6.2±2.1 and was 8.1±2.5 for respiratory- gated (P<0.01). Lesion volumes could be calculated in 27/34 patients. The median non-gated lesion volume was 5.82±5.57cm(3) and 4.31±4.56cm(3) for respiratory-gated (P<0.01). Furthermore, small lesions of ≤2cm had a significantly higher proportion of increased SUVmax compared to large lesions of >2cm (P=0.016). In conclusion, respiratory-gated PET/CT for patients with pancreatic cancer reduced respiratory motion artifacts and allowed significantly higher SUVmax to be obtained. In addition, the rate of increase in SUVmax tended to be higher in patients with pancreatic cancers of less or equal to 2cm diameter.

[Tension hemothorax accompanying rupture of the descending aortic aneurysm].

Although, tension hemothorax appears along with thoracic injuries in many cases, the incidence is rare and the concept itself has not yet been established. Moreover, reports on tension hemothorax caused by the rupture of thoracic aortic aneurysms are very rare. Herein, we report a case in which thoracic endovascular aortic repair( TEVAR) was carried out following chest drainage in order to treat tension hemothorax accompanying rupture of the descending aortic aneurysm, thus leading to the survival of the patient.

[Hepatic artery pseudoaneurysm after endoscopic biliary stenting for pancreatic cancer].

A man in his sixties presented to our hospital with obstructive jaundice and was diagnosed with inoperable pancreatic cancer. Chemoradiotherapy was initiated, and an expandable metallic stent was inserted endoscopically to drain the biliary system. Six months later, he was referred to our hospital with 1-week history of epigastric pain and obstructive jaundice. On admission for further evaluation, he experienced hematemesis and went into severe shock. Upper gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography showed active bleeding from the duodenal papilla. Therefore, we performed endoscopic nasobiliary drainage (ENBD). On day 4, blood was detected in the ENBD tube, and the patient again experienced hematemesis. Emergent enhanced computed tomography revealed a right hepatic arterial aneurysm that had likely ruptured and caused the hemobilia. The aneurysm was successfully embolized, and the patient was discharged on hospital day 21.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula.

BACKGROUND: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach. CASE PRESENTATION: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications. CONCLUSIONS: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection?

PURPOSE: Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site. METHODS: We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area. RESULTS: The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups. CONCLUSION: Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.