Color Doppler ultrasound for surveillance following EVAR as the primary tool.

OBJECTIVE: As aneurysm-related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair (EVAR). For surveillance colored Doppler ultrasound (CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness, and lack of nephrotoxicity and radiation. We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. METHODS: Between January 2018 and March 2020, 84 consecutive post-EVAR patients were evaluated. First, CDUS was performed by two Doppler operators from the Radiology Department and then computed tomographic angiography (CTA) was performed. The operators were blind to CTA reports. A reporting protocol was organized for endoleak detection and largest aneurysm diameter. RESULTS: Among 84 patients, there were 11 detected endoleaks (13.1%) with CTA and seven of them was detected with CDUS (r = .884, p < .001). All Type I and III endoleaks were detected perfectly. There is an insufficiency in detecting low flow by CDUS. Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r = .777, p < .001). The sensitivity and specificity of CDUS was 63.6% and 100%, respectively. The accuracy was 95.2%. Positive and negative predictive values were 100% and 94.8%. Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5 ± 2.2 mm, p = .233). CONCLUSIONS: For surveillance, CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak. Lack of detecting Type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement, detection of an endoleak, inadequate CDUS, or in case of unexplained abdominal symptomatology. By this way we not only avoid ionizing radiation and nephrotoxic agents, but also achieve cost saving issue also.

Change from Cardioinhibitory Syncope to Iatrogenic Positional Syncope: Superior Vena Cava Syndrome Treated by Superior Vena Cava Stenting and Leadless Pacemaker Implantation.

Symptomatic obstruction of the superior vena cava can be caused by either intrathoracic malignancy or nonmalignant etiology, resulting in superior vena cava syndrome (SVCS). The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign SVCS. We present a post-pacemaker-implantation case of SVCS manifesting as positional syncope. The percutaneous intervention of stent implantation after lead removal followed by reimplantation of the leadless pacemaker may be a potential alternative treatment for pacemaker-induced SVCS, since some cases eventually may require repeat intervention.

A Single-Center Retrospective Comparison of Doxorubicin-Loaded HepaSphere Transarterial Chemoembolization with Conventional Transarterial Chemoembolization for Patients with Unresectable Hepatocellular Carcinoma.

PURPOSE: To compare doxorubicin-loaded HepaSphere transarterial chemoembolization versus conventional transarterial chemoembolization in terms of survival, time to recurrence, acute reversible hepatotoxicity, postembolization syndrome, and chemoembolization-related mortality and morbidity. MATERIALS AND METHODS: One hundred twenty-six patients (103 men, 23 women; mean age, 64.3 y) with unresectable hepatocellular carcinoma (HCC) who underwent conventional chemoembolization between January 2007 and March 2011 or drug-eluting embolic (DEE) chemoembolization (after the protocol change) between March 2011 and October 2014 were included in a retrospective analysis. Primary outcome measures were survival and time to recurrence. Secondary outcome measures were frequency of recurrence, technical success, acute reversible hepatotoxicity, postembolization syndrome, and chemoembolization-related mortality and morbidity. RESULTS: The technical success rate was 97.1%. There were no significant differences between the conventional and DEE chemoembolization groups with regard to mean survival duration (39.0 vs 37.4 mo), recurrence (32.9% vs 39.6%), postembolization syndrome (90% vs 89%), and chemoembolization-related mortality (5.5% vs 1.9%) and morbidity (9.6% vs 9.4%; P > .05). The time to recurrence was shorter in DEE chemoembolization-treated patients than in conventional chemoembolization-treated patients (5.0 vs 11.5 mo; P = .006), and acute reversible hepatotoxicity occurred more frequently after conventional chemoembolization (P = .019). CONCLUSIONS: Conventional chemoembolization and DEE chemoembolization were safe and effective interventions for unresectable HCC. DEE chemoembolization was not better than conventional chemoembolization in terms of survival and was associated with a shorter time to recurrence. Acute reversible hepatotoxicity occurred more frequently after conventional chemoembolization.

Splenic infarction after N-butyl-2-cyanoacrylate injection for gastric varices: why does it happen?

Recent guidelines and consensus reports recommend endoscopic injection therapy with N-butyl-2-cyanoacrylate as the first-line treatment for bleeding-isolated gastric varices and gastroesophageal varices types 1 and 2. Embolization is a rare but serious complication of cyanoacrylate injection, which may be fatal in some cases. Herein, we present a patient who developed splenic infarction after N-butyl-cyanoacrylate injection for gastroesophageal varices type 2 and discuss the potential reasons and tips to prevent the occurence of embolization.

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas.

PURPOSE: The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy-esophagojejunostomy (EJ) operations. MATERIALS AND METHODS: Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality-morbidity, and mortality related with factors other than the procedure were noted. RESULTS: Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months). CONCLUSION: From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure.

Long-term results of percutaneous biliary balloon dilation treatment for benign hepaticojejunostomy strictures: are repeated balloon dilations necessary?

PURPOSE: To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting. MATERIALS AND METHODS: PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19-84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II. RESULTS: Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II. CONCLUSIONS: PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful.

Is celiac artery compression syndrome genetically inherited?: a case series from a family and review of the literature.

The median arcuate ligament is a tendinous arch joining the two medial borders of the diaphragm crura together. In 13-50% of asymptomatic subjects it is responsible for significant angiographic celiac trunk compression. The significance of median arcuate ligament-associated celiac artery compression has been a source of some controversy in the past literature, and the etiology remains unclear. We report here a case series from a family that was diagnosed by the use of multidetector computed tomography. The observation of this syndrome in a family suggests that the responsible anatomic relationships are congenital and may be genetically inherited.

Branching patterns of the main portal vein: effect on estimated remnant liver volume in preoperative evaluation of donors for liver transplantation.

OBJECTIVES: To compare estimated remnant liver volume (ERLV) ratios among the major main portal vein (MPV) variants. METHODS: Eighty-five potential donors underwent multidetector CT examination. Arterial, portal and hepatic venous phase images were obtained. CT volumetric measurements were performed by using summation-of-area method. MPV variants were classified into three groups. In type 1 (group 1), the MPV branches into the right portal vein (RPV) and the left portal vein (LPV). In type 2 (group 2), the MPV trifurcates into the right anterior portal vein (RAPV), right posterior portal vein (RPPV) and LPV. In type 3 (group 3), the RPPV arises from the MPV as a first branch, and the RAPV emerges directly from the LPV. RESULTS: No differences were observed between groups 1 and 2 with respect to ERLV ratios. However, significant differences were discovered between groups 1 and 3 and between groups 2 and 3 (p<0.001 and p<0.05, respectively). CONCLUSIONS: The ERLV proportions in the donors with a type 3 MPV variation were significantly lower than those in the donors with type 1 and type 2 MPV variations and six (31.6%) donors in group 3 presented an ERLV percentage below 30% of the total liver volume.