Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review.

OBJECTIVES: Emergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical repair for the treatment of RAAA. SETTING: A systematic review of relevant publications was performed. Randomised controlled trials (RCTs) comparing eEVAR with open surgical repair for RAAA were included. PARTICIPANTS: 3 RCTs were included, with a total of 761 patients with RAAA. INTERVENTIONS: Meta-analysis was performed with fixed-effects models with ORs and 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was short-term mortality. Secondary outcome measures included aneurysm-specific and general complication rates, quality of life and economic analysis. RESULTS: Overall risk of bias was low. There was no difference between the 2 interventions on 30-day (or in-hospital) mortality, OR 0.91 (95% CI 0.67 to 1.22; p=0.52). 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation and respiratory failure. Reporting was incomplete, and no robust conclusion was drawn. For complication outcomes that did include at least 2 studies in the meta-analysis, there was no clear evidence to support a difference between eEVAR and open repair. Longer term outcomes and cost per patient were evaluated in only a single study, thus precluding definite conclusions. CONCLUSIONS: Outcomes between eEVAR and open repair, specifically 30-day mortality, are similar. However, further high-quality trials are required, as the paucity of data currently limits the conclusions.

TSH-secreting pituitary adenoma: benefits of pre-operative octreotide.

UNLABELLED: TSH-secreting pituitary adenomas are rare and the optimal investigation and management is uncertain. We describe a case of a 43 year-old woman with a TSH-secreting pituitary adenoma, highlighting diagnostic testing and our use, pre-operatively of somatostatin analogue therapy, which induced biochemical euthyroidism and a reduction in tumour size. LEARNING POINTS: The differential diagnosis of the syndrome of inappropriate TSH secretion is non-thyroidal illness, medications, assay interference due to heterophilic antibodies, thyroid hormone resistance and TSH-secreting pituitary adenoma.TRH stimulation test and triiodothyronine suppression test assist in differentiating thyroid hormone resistance and TSH-secreting pituitary adenoma.Somatostatin analogue therapy can induce biochemical euthyroidism and reduce tumour size.

100 cases of primary aldosteronism: careful choice of patients for surgery using adrenal venous sampling and CT imaging results in excellent blood pressure and potassium outcomes.

OBJECTIVE: Patients with primary aldosteronism (PA) who are suitable for surgery should undergo adrenal computerised tomography (CT) and adrenal venous sampling (AVS). A retrospective study was performed of 100 patients with PA. We determined the optimal AVS lateralisation ratio for unilateral disease and reviewed adrenalectomy outcomes evaluating which characteristics predicted hypertension cure. METHODS: AVS was performed in 93 patients. Lateralisation criteria were assessed using ROC curve analysis. The outcome of adrenalectomy was reviewed in 39 patients and predictive factors for cure determined using univariate and multivariate analysis. RESULTS: Of previously published criteria, ROC curve analysis found a cortisol corrected aldosterone affected to unaffected (Aldo/Cort A:U) cut-off of 2·0 was the best predictor of adenoma identifying 80·4% of patients. A novel ratio calculated by dividing the affected to unaffected ratio by the unaffected to peripheral ratio [(Aldo/Cort A:U)/(Aldo/Cort U:IVC)] was successful in identifying 87·0% of patients. Cure rate for blood pressure after adrenalectomy was 38·5% with improvement in 59·0%. On univariate analysis, predictors of post-operative hypertension were increased weight, raised creatinine, left ventricular hypertrophy (LVH) and male sex. On multivariate analysis, male sex and higher pre-operative systolic blood pressure were predictive. CONCLUSIONS: Patients with PA should have CT scanning and AVS. Aldo/Cort A:U >2·0 is the most accurate of previously published ratios in predicting unilateral disease. When patients were carefully selected for surgery, 97% had cure or improvement in blood pressure control. Further confirmatory work is required on a novel ratio which was even more predictive in our series.

Successful delayed secondary open conversion after endovascular repair using partial explantation technique: a single-center experience.

BACKGROUND: Endovascular aneurysm repair (EVAR) reduces the morbidity and mortality associated with abdominal aortic aneurysm repair, but in some patients endoleak or aneurysm expansion may necessitate secondary open conversion (SOC). We reviewed the outcomes after delayed SOC following EVAR in consecutive patients at a single center. METHODS: We retrospectively reviewed all patients undergoing EVAR to identify a cohort undergoing delayed SOC in a single center between 1998 and 2008. We analyzed delayed SOC patients for operative indications, technique, and early outcomes. We made specific comment on the surgical techniques used, with respect to partial or total endograft explantation. RESULTS: Delayed SOC was carried out in 10/285 (3.5%) consecutive patients implanted with the Zenith endograft; during this period, two further patients had SOC after initial EVAR in another center. Graft types were Zenith (n = 10), Talent (n = 1), and AneuRx (n = 1). Indications for open conversion were infected graft (n = 3), sac expansion (n = 3), type 1 endoleak (n = 2), type 2 endoleak (n = 2), juxtarenal aneurysm (n = 1), and rupture (n = 1). Explantation techniques were partial explantation with in situ replacement (n = 7), full explantation with axillobifemoral bypass (n = 3), in situ replacement (n = 1), and suturing (n = 1)Complete stent explantation was required in 4 patients with axillo-bifemoral bypass in three of them. 7 patients had partial stent explantation and one patient stent was left insitu. Postoperative morbidities included myocardial infarction (n = 1), renal dialysis (n = 1), and chest infection (n = 3). No 30-day mortality was noted, and all patients were discharged from hospital and remain well with median follow-up of 5 months (interquartile range 1.7-26.7). CONCLUSION: SOC after EVAR is feasible in selected patients with low morbidity and mortality. Partial explantation with in situ replacement, in the absence of sepsis, may be the preferred revascularization option but may require long-term follow-up.

Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases.

Thromboembolic disease during pregnancy is an important cause of obstetric morbidity and mortality. Pregnant patients with venous thromboembolism are usually managed by conventional anticoagulation. However, this must be discontinued during vaginal or caesarian delivery to avoid haemorrhage and to reduce the risk of possible epidural haematoma. Retrievable inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during this high-risk period, when anticoagulation is discontinued, while avoiding potential long-term sequelae of a permanent IVCF. Here we report two patients who presented in the third trimester of pregnancy with floating ileofemoral deep vein thrombosis. Both patients were initially treated with standard anticoagulation; however, shortly before delivery both patients had a retrievable IVCF placed in a suprarenal position. In both patients, retrieval failed at 28 days after insertion because of filter tilt. The timing and mechanism of filter tilt remains uncertain. We believe that a number of factors could have been involved, including change in the anatomic configuration with lateral displacement of the IVCF as a result of the gravid uterus as well as forceful uterine contractions during labour, which modified the shape and diameter of the IVC. We showed that failure to retrieve the IVCF has had considerable implications for the two young patients regarding long-term anticoagulation and have highlighted the need for further clinical trials regarding the safe use of retrievable IVCFs during pregnancy.

Endovascular ruptured abdominal aortic aneurysm repair (EVRAR): a systematic review.

BACKGROUND: To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA). METHODS: A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications. RESULTS: There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality. CONCLUSIONS: For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

CT-guided fine-needle aspiration of lung nodules: effect on outcome of using coaxial technique and immediate cytological evaluation.

PURPOSE: To evaluate the risk of pneumothorax during CT-guided fine-needle aspiration (FNA) of lung nodules with single needle and coaxial needle techniques and to assess the effect on diagnostic accuracy of immediate cytological examination of lung FNA samples. MATERIALS AND METHODS: This prospective study analysed 53 patients undergoing transthoracic FNA biopsy of lung. 36 cases were performed by a radiologist using a coaxial technique, with 17 cases performed by a radiologist using a direct single-needle method. Effect of technique on occurrence of pneumothorax was recorded. FNA samples from all the patients in the study were examined immediately on-site by a cytologist or MLSO to determine whether sufficient aspirate had been obtained. Provisional diagnosis at immediate examination was compared to final diagnosis following full pathological evaluation. RESULTS: Coaxial and non-coaxial groups were comparable for age and gender. Number of pleural passes was significantly lower in coaxial group (P < 0.01). Pneumothorax occurred in six (17%) of the 36 patients biopsied by coaxial technique, compared to four (24%) of the 17 patients by non-coaxial method (P = 0.55). Chest tube placement was required in four patients (11%) in the coaxial group, and two patients (12%) in the non-coaxial group (P = 0.85). A provisional cytological diagnosis was recorded for 74% of the patients in the study. 83% of the provisional reports were accurate on comparison with full pathology report. Specimen size was sufficient in 81% of cases. CONCLUSIONS: The use of coaxial technique for CT-guided lung FNA biopsy reduced the number of pleural passes but did not significantly reduce the occurrence of pneumothorax. Immediate cytological examination of FNA specimens provided an accurate provisional diagnosis in the majority of cases, and should be routinely employed.

CT virtual intravascular endoscopy of abdominal aortic aneurysms treated with suprarenal endovascular stent grafting.

BACKGROUND: We investigated the clinical applications of virtual intravascular endoscopy (VIE) in patients with abdominal aortic aneurysms (AAA) treated by endovascular stent grafting with a suprarenal component. METHODS: Thirty-four patients with AAA undergoing endovascular stent grafting were included in the study (28 male, six female; mean age = 76 years). Helical computed tomography (CT) scanning was performed within 1 week after stent graft implantation. All patients received a Zenith/AAA endovascular graft with uncovered suprarenal struts 2.5 cm long placed around the level of the renal arteries. VIE images were created for each patient. The follow-up periods ranged from 3 to 18 months (mean = 8.3 +/- 3.7 months). RESULTS: Three of 34 celiac arteries, 22 of 34 superior mesenteric arteries, 32 of 34 right renal arteries, and 30 of 35 left renal arteries were affected by the suprarenal stent struts (wires) to different extents. VIE was able to demonstrate the struts, arterial ostia, and the strut/ostia configuration. Follow-up CT showed that all of these aortic branches were patent. CONCLUSION: Our preliminary experience has demonstrated that VIE is a novel imaging technique to visualize the three-dimensional intralumenal relationship of the aortic stent struts to the arterial ostia in patients with AAA after suprarenal stent graft placement.

Abdominal aortic aneurysm and stent graft phantom manufactured by medical rapid prototyping.

A novel human aorta phantom built by medical rapid prototypingfor use in computed tomography (CT) scanning is described. The phantom contained a stent graft that was deployed internally to mimic a repaired aortic aneurysm. The phantom was produced to allow assessment of the CT appearance of a stent graft inside an aorta using the new virtual intravascular endoscopy image presentation technique. The stent graft utilized contained suprarenal components (metalfixation struts), and these were placed with these struts covering the renal artery ostia. The phantom was filled with iodinated contrast medium at a concentration that produced a density similar to that found in normal CT angiographic scanning. The model was scanned at a variety of slice thicknesses, pitch and image reconstruction intervals. Visualization of the stent suprarenal components in relation to the renal artery ostia is shown and the overestimation of stent wire strut diameter demonstrated.

Laboratory and clinical experience in 55 patients with macroprolactinemia identified by a simple polyethylene glycol precipitation method.

PRL exists in different forms in human serum. The predominant form is little PRL (molecular mass 23 kDa) with smaller amounts of big PRL (molecular mass 50--60 kDa) and at times big big or macroprolactin (molecular mass 150--170 kDa). The frequency and clinical consequences of macroprolactinemia have not been clearly established, mainly because of difficulty in identifying these patients biochemically. This previously required the use of gel filtration chromatography, which could not be used routinely. Recently, a screening test using polyethylene glycol (PEG) has been used to identify macroprolactin in serum. Consequently, this study was designed to examine the use of PEG precipitation in the identification of patients with a predominance of macroprolactin and to establish the clinical characteristics of such a cohort. Over 12 months, 18,258 requests for serum PRL were received and of these 1225 patients had a serum PRL more than 700 mU/L. A total of 322 of these patients (26%) had a percentage recovery after PEG precipitation of less than 40%, thus indicating the presence of a predominance of macroprolactin. Fifty-five of these patients were referred for detailed clinical assessment. Symptoms typical of hyperprolactinemia were not common in this cohort. None had sustained amenorrhea and eight have had oligomenorrhea at age less than 40 yr. One had galactorrhea. All had pituitary imaging, and four had a microadenoma with none having a macroadenoma. PEG precipitation allows easy identification of macroprolactin in routine clinical practice. As the clinical consequences of this entity at this stage seem relatively benign, referral and intensive investigation of these patients may not be necessary. However, follow-up of a large cohort is required to ensure that the long-term outlook is likewise benign. This would have important implications for both patients and healthcare systems.

Ultrasound, antisperm antibody, and hormone profiles after testicular Trucut biopsy.

OBJECTIVE: To assess the effect of Trucut needle biopsy on the ultrasound appearances of the testis in obstructive and nonobstructive azoospermia to test serum samples for antisperm antibodies and gonadotropin and testosterone levels. DESIGN: Prospective case analysis. SETTING: IVF unit. PATIENT(S): Sixteen subjects with obstructive azoospermia had postbiopsy ultrasound scans, 18 had assessment of hormone profiles, and 20 had evaluation of antisperm antibodies. INTERVENTION(S): Trucut needle testicular biopsies under local anesthetic. MAIN OUTCOME MEASURE(S): Postbiopsy testicular ultrasound, the presence of serum antisperm antibodies, and follicle stimulating and luteinizing hormone and testosterone levels. RESULT(S): There were no postbiopsy hematomas or scars, antisperm antibodies did not develop, and pituitary gonadotropins did not rise nor testosterone levels fall. CONCLUSION(S): Trucut needle testicular biopsy in men with obstructive azoospermia is not associated with defects of parenchymal structure or function.

Pathologic features of uterine leiomyomas following uterine artery embolization.

Bilateral uterine artery embolization has recently been employed as an alternative to operational treatment of uterine leiomyomas. The pathologic features induced by uterine artery embolization have not been previously described in detail. Usually patients experience symptomatic improvement with a reduction in size of the leiomyomas. This report describes the pathologic features in a series of 10 uterine leiomyomas where tissue was available for histologic examination following uterine artery embolization. Characteristic histologic features within the leiomyomas included massive necrosis, sometimes with dystrophic calcification, vascular thrombosis, and intravascular foreign material that elicited a histiocytic and foreign-body giant cell reaction. In some cases, intravascular foreign material was present elsewhere in the myometrium, the cervix, or paraovarian region. In occasional cases, there were foci of myometrial necrosis and microabscess formation beyond the confines of the leiomyomas. Foci of extrauterine inflammation were also occasionally identified. Histopathologists should be aware of these findings because the use of uterine artery embolization will possibly become more widespread in the future.

Systemic vasculitis and aneurysm formation in the Wiskott-Aldrich syndrome.

A 24 year old male who suffered from the Wiskott-Aldrich syndrome developed intra-abdominal bleeding on two occasions. Radiological investigations showed aneurysmal dilatation of branches of the hepatic and superior mesenteric arteries. The second abdominal bleed necessitated laparotomy and the bleeding was localised to the kidneys. Right nephrectomy was performed and histological examination showed a necrotising vasculitis, mainly involving medium and small sized renal blood vessels. Steroids, immunosuppressive treatment, and control of blood pressure resulted in resolution of the vasculitic process and prevented further haemorrhage. Vasculitis and aneurysm formation are rarely described complications of Wiskott-Aldrich syndrome and may account for the life threatening haemorrhage which occurs in this condition.

Small intestinal ulceration secondary to carcinoid tumour arising in a Meckel's diverticulum.

A solitary small intestinal ulcer associated with a carcinoid tumour in a nearby Meckel's diverticulum was found in a 77 year old man presenting with massive rectal bleeding. Angiography and a radioisotope study localised the bleeding to the ileum. At operation, the Meckel's diverticulum was identified, with bleeding from an ulcer just distal to it. Pathological examination revealed a small carcinoid tumour confined to the Meckel's diverticulum. Close to the opening of the diverticulum, within the ileum, a well demarcated ulcer was present. Histology showed a non-specific ulcer which eroded a large blood vessel. This is the first documented occurrence of solitary small intestinal ulceration in association with a carcinoid tumour. Carcinoid tumour should be added to the list of possible causes of small intestinal ulceration. The ulceration may be secondary to release of cytokines by the tumour.