A pathological complete response after nivolumab plus ipilimumab therapy for DNA mismatch repair-deficient/microsatellite instability-high metastatic colon cancer: A case report.

The standard treatment for colorectal cancer has always been surgery and chemotherapy, which may be used in combination to treat patients. Immune checkpoint inhibitors have been a significant advancement in the standard treatment of metastatic, unresectable colorectal cancer with deficient mismatch repair. However, little information is available about their use in neoadjuvant and conversion settings with only a few case reports and only one phase 2 trial. The present study reports the case of a large, locally advanced right-sided metastatic deficient mismatch repair/microsatellite instability-high colon cancer, which showed a pathological complete response after combination treatment with nivolumab and ipilimumab. To the best of our knowledge, resected metastatic colon cancer with a pathological complete response after treatment using dual immune checkpoint inhibitors has not been previously reported. Overall, this case report suggests the use of immune checkpoint inhibitors before colorectal surgery.

Ilio-Hepatic Artery Bypass for Hypoplasia of the Celiac Axis and Its Branches with an Inferior Pancreaticoduodenal Artery Aneurysm.

Hemorrhage due to a ruptured pancreaticoduodenal artery aneurysm is potentially fatal. We describe a case of a 51-year-old man, incidentally diagnosed with an inferior pancreaticoduodenal artery aneurysm associated with probable congenital hypoplasia of the celiac axis and its branches. Considering the rupture risk, we performed an ilio-hepatic artery bypass with an autologous vein graft and aneurysmorrhaphy. The postoperative course was uneventful. At the 24-month follow-up, the bypass was patent, with no aneurysm recurrence. The ilio-hepatic artery bypass is effective and preserves visceral blood flow. However, the iliac artery is susceptible to occlusive disease, and long-term follow-up is required.

Platypnea-orthodeoxia syndrome associated with COVID-19 pneumonia: a case report.

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by respiratory distress and/or hypoxia developing in the sitting/upright position, which is relieved in the recumbent position. This syndrome is known to have an intracardiac shunt as its primary etiology. Here, we report the case of a patient who was found to have POS without an intracardiac shunt while recovering from coronavirus disease (COVID-19) pneumonia. CASE PRESENTATION: A 73-year-old woman was diagnosed with severe COVID-19 pneumonia and was managed according to our institutional protocol. Although her oxygenation improved at rest, oxygen saturation dropped to lower than 80% when she was in the sitting position. She had no patent foramen ovale or other intracardiac shunts. She showed gradual improvement and was discharged under home oxygen therapy 28 days after admission. CONCLUSIONS: This report highlights the importance of continuous bedside monitoring of pulse oximetry during positional changes, even if it is stable at rest, in patients with moderate to severe COVID-19.

An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer.

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

Treatment of an Aberrant Arterial Aneurysm with Intralobar Pulmonary Sequestration: A Case Report.

An aberrant arterial aneurysm with pulmonary sequestration is rare. Here, we report about a 35-year-old man who had no symptoms related to pulmonary sequestration. Computed tomography revealed an aberrant arterial aneurysm with an 18 mm in diameter with intralobar pulmonary sequestration, which gradually increased in size to 27 mm over 5 years. The patient underwent thoracic endovascular aortic repair with coil embolization for the aneurysmal distal branches to prevent aneurysm rupture. The postoperative course was unremarkable without a need for lobectomy. During a 1-month follow-up period, the aneurysm shrunk with no endoleaks. Stent-graft placement and coil embolization represent an effective and less invasive treatment option to completely block systemic arterial flow and unexpected retrograde backflow and control the expansion of the aneurysm.

Stent graft treatment for ruptured pseudoaneurysms of the splanchnic arteries after pancreaticoduodenectomy: a case report.

BACKGROUND: Hemorrhage due to a ruptured splanchnic pseudoaneurysm followed by the formation of a postoperative pancreatic fistula is the most severe complication of a pancreatectomy, sometimes leading to a fatal outcome. Stent graft placement to control the hemorrhage due to the pseudoaneurysm is a validated treatment option, but once the stent graft is infected, infection control is complicated. We report a case of a ruptured pseudoaneurysm of the splanchnic artery after pancreaticoduodenectomy to evaluate the stent graft treatment. CASE PRESENTATION: A 77-year-old man underwent pylorus-preserving pancreaticoduodenectomy for suspected distal bile duct cancer. Hemorrhage from a pseudoaneurysm of the common hepatic artery due to the formation of the pancreatic fistula was detected on postoperative day 9, and a stent graft was successfully placed with the preservation of hepatic arterial blood flow. On postoperative day 12, new-onset hemorrhage from a pseudoaneurysm of the right hepatic artery developed, and a stent graft was similarly placed, but immediately occluded. Refractory pancreatic and biliary fistulas developed and required continuous drainage. On postoperative day 85, computed tomography revealed the presence of air within the latter stent graft, which indicated infection of the stent graft. The patient died due to sepsis caused by the graft infection. CONCLUSION: Stent graft placement for the treatment of hemorrhage of a pseudoaneurysm secondary to a postoperative pancreatic fistula, following pancreaticoduodenectomy, is an effective treatment option as it achieves immediate hemostasis and maintains end-organ perfusion. However, stent graft infection is the most detrimental complication.

Aortoduodenal Fistula After Endovascular Abdominal Aortic Aneurysm Repair.

Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.

Spontaneous Regression of Cystic Adventitial Disease of the Popliteal Artery: A Case Report.

Spontaneous regression of cystic adventitial disease (CAD) of the popliteal artery is rare. In this report, we describe a 53-year-old woman who presented with left calf pain and was diagnosed with CAD with popliteal artery stenosis, which regressed without therapy. The disease was diagnosed via computed tomography, and a surgical intervention was planned at the time of diagnosis. However, her symptoms disappeared 2 months after the initial presentation. Ultrasonography and computed tomography revealed spontaneous regression of the cystic lesions and resolution of the popliteal artery stenosis. During the 29-month follow-up period, her symptoms did not recur. Although CAD often requires surgical intervention, it may be acceptable to carefully observe patients with spontaneous regression for some time to check for recurrence.

Acute Type B Aortic Dissection Associated with Acute Pancreatitis, Pancreatic Pseudocysts, and Acalculous Cholecystitis.

Acute aortic dissection can result in fatal conditions when associated with organ malperfusion. A rare complication of aortic dissection with organ malperfusion is ischemic pancreatitis with cholecystitis. Here, we present the case of acute type B aortic dissection complicated by concurrent acute ischemic pancreatitis and acalculous cholecystitis. Prompt diagnosis and specific multidisciplinary treatment are crucial to improving patient outcomes in cases of visceral ischemia.

Outcomes of conservative management of spontaneous celiac artery dissection.

OBJECTIVE: Spontaneous celiac artery (CA) dissection without associated aortic dissection is a rare condition. Although this condition has been diagnosed more frequently with the advent of improved diagnostic imaging modalities, its pathogenesis and treatment strategy remain to be established. The present study examined the clinical features and outcomes of conservative management of this disease. METHODS: The study included 12 patients (10 men and two women) in whom spontaneous CA dissection was diagnosed between 2007 and 2015. The medical records of each patient were retrospectively reviewed. RESULTS: The mean age at diagnosis was 56.4 years (range, 42-77 years). Eight patients presented with abdominal or back pain, and the remaining four patients were asymptomatic and diagnosed incidentally. Four patients had a history of hypertension, and six had a history of smoking. Celiac trunk compression by the median arcuate ligament was found in two patients. The dissection extended into the common hepatic artery in five patients and into the splenic artery in four patients. Retroperitoneal hemorrhage was found in 2 patients, splenic infarction in 3, and transient mild liver dysfunction in 2. All patients were treated conservatively: two patients received short-term anticoagulation and antiplatelet therapy, and antihypertensive treatment was initiated in three patients. The mean follow-up period was 35.5 months (range, 5-101 months). Distal extension of the dissection occurred in one patient within a week of the initial symptom, which was also managed conservatively. Late aneurysmal degeneration was not observed in any of the patients, and none required endovascular or surgical treatment. CONCLUSIONS: If the general condition of the patient is stable, then CA dissection can be managed with careful conservative treatment, even in patients with associated retroperitoneal hemorrhage. Long-term anticoagulation or antiplatelet medication may not be necessary in most patients with this condition.

Xenopericardial roll graft replacement for infectious pseudoaneurysms and graft infections of the aorta.

BACKGROUND: Which graft material is the optimal graft material for the treatment of infected aortic aneurysms and aortic graft infections is still a matter of controversy. Orthotopic aortic reconstruction with intraoperatively prepared xenopericardial roll grafts without omentopexy was performed as the "initial" operation to treat aortic infection or as a "rescue" operation to treat graft infection. Mid-term outcomes were evaluated. METHODS: Between 2009 and 2013, orthotopic xenopericardial roll graft replacement was performed to treat eight patients (male/female: 6/2; mean age: 69.5 [55-80] yr). Graft material: equine/bovine pericardium: 2/6; type of operation: initial 4/rescue 4; omentopexy 0. Additional operation: esophagectomy 2. Mean follow-up period: 2.6 ± 1.6 (1.1-5.1) years. RESULTS: Replacement: ascending 3, arch 1 (reconstruction of neck vessels with small xenopericardial roll grafts), descending 3, and thoracoabdominal 1. Pathogens: MRSA 2, MSSA 1, Candida 1, E. coli 1, oral bacillus 1, and culture negative 2. Postoperative local recurrence of infection: 0. Graft-related complications: stenosis 0, calcification 0, non-infectious pseudoaneurysm of anastomosis 2 (surgical repair: 1/TEVAR 1). In-hospital mortality: 2 (MOF: initial 1/rescue 1); Survival rate exclusive of in-hospital deaths (~3 y): 100 %, but one patient died of lung cancer (3.6 yr). CONCLUSIONS: Because xenopericardial roll grafts are not composed of synthetic material, the replacement procedure is simpler and less invasive than the standard procedure. Based on the favorable results obtained, this procedure may have the possibility to serve as an option for the treatment of aortic infections and aortic graft infections not only as a "rescue" treatment but as an "initial" treatment as well.

Long-Term Results of Treatment for Critical Limb Ischemia.

From 2001 to 2012, arterial reconstruction was performed in 306 out of 497 limbs (62%) with critical limb ischemia. The reasons for non-vascularization include high operative risk (36%), extended necrosis or infection (20%), and technical issues (15%). Cumulative patency and limb salvage in collagen disease were significantly worse compared to arteriosclerosis obliterans. Cumulative limb salvage, amputation free survival (AFS), and major adverse limb event and perioperative death (MALE + POD) in patients with end-stage renal disease (ESRD) were significantly worse compared to patients without ESRD, but not significant with regards to graft patency. Our finding suggests that aggressive arterial reconstruction provides satisfactory long-term results in critical limb ischemia so long as case selection for revascularization is properly made. (This article is a translation of J Jpn Coll Angiol 2014; 54: 5-11.).

Adequate Selection of a Therapeutic Site Enables Efficient Development of Collateral Vessels in Angiogenic Treatment With Bone Marrow Mononuclear Cells.

BACKGROUND: Induction of angiogenic mechanisms to promote development of collateral vessels is considered promising for the treatment of peripheral arterial diseases. Collateral vessels generally develop from preexisting arteriolar connections, bypassing the diseased artery. We speculated that induction of angiogenic mechanisms should be directed to such arteriolar connections to achieve efficient collateral development. The aim of this study was to verify this hypothesis using autologous transplantation of bone marrow mononuclear cells in the rabbit model of chronic limb ischemia. METHODS AND RESULTS: The left femoral artery was excised to induce limb ischemia in male rabbits. In this model, arteriolar connections in the left coccygeofemoral muscle tend to develop into collateral vessels, although this transformation is insufficient to alleviate the limb ischemia. In contrast, arteriolar connections in the closely located adductor muscle do not readily develop into collateral vessels. At 21 days after ischemia initiation, a sufficient number of automononuclear cells were selectively injected in the left coccygeofemoral muscle (coccygeo group) or left adductor muscle (adductor group). Evaluation of calf blood pressure ratios, blood flow in the left internal iliac artery, and angiographic scores at day 28 after injection revealed that collateral development and improvement of limb ischemia were significantly more efficient in the coccygeo group than in the adductor group. Morphometric analysis of the coccygeofemoral muscle at day 14 showed similar results. CONCLUSIONS: Specific delivery of mononuclear cells to the coccygeofemoral but not the adductor muscle effectively improves collateral circulation in the rabbit model of limb ischemia and suggests that adequate site selection can facilitate therapeutic angiogenesis.

Effect of suprarenal aortic cross-clamping.

BACKGROUND: Renal insufficiency is the most frequent complication of surgeries that involve suprarenal aortic cross-clamping. Although some studies have assessed the risk of intraoperative renal ischemia by comparing juxtarenal abdominal aortic aneurysms (AAAs) and infrarenal AAAs, a critical limitation is the difference in these patients' clinical backgrounds and aneurysmal features. The present study evaluated the effect of suprarenal aortic clamping by comparing a juxtarenal AAA group with a subgroup of infrarenal AAAs (ie, short and/or large neck). METHODS AND RESULTS: Among patients who underwent open surgery for AAA, the 2 types of AAA were selected and compared: juxtarenal AAA (JR group: n=35) and infrarenal AAA with short (<15 mm) and/or large (>28 mm) aneurysmal neck that only required infrarenal aortic clamping (SL group: n=26). Postoperative renal function was evaluated using the RIFLE classification. There were no significant differences between groups in baseline characteristics, comorbidities, and intraoperative variables. There were no adverse events leading directly to in-hospital mortality in either group. The rate of postoperative renal insufficiency (estimated glomerular filtration rate decrease ≥-25%) was not significantly different between groups. CONCLUSIONS: The outcomes of the 2 groups were similar, indicating that intraoperative renal ischemia with no specific intraoperative protection would not adversely affect postoperative outcomes.

Study Design of PROCEDURE Study. A Randomized Comparison of the Dose-Dependent Effects of Pitavastatin in Patients with Abdominal Aortic Aneurysm with Massive Aortic Atheroma: Prevention of Cholesterol Embolization during Endovascular and Open Aneurysm Repair with Pitavastatin (PROCEDURE) Study.

Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma (excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or 4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.

Statins reduce extensive aortic atheromas in patients with abdominal aortic aneurysms.

OBJECTIVE: Statins have been used widely to reduce dyslipidemia and recently have been reported to have pleiotropic effects such as plaque reduction and stabilization. This study retrospectively evaluated the regression of extensive thoracic atheromas ("shaggy aorta") in abdominal aortic aneurysm (AAA) patients who underwent contrast-enhanced computed tomography (CECT) before and after statin administration. MATERIALS AND METHODS: CECT was used to examine thoracic aortas of 29 patients (statin group; n = 22, non-statin group; n = 7) with extensive atheromas from the ostium of the left subclavian artery to that of the more proximal renal artery. Extensive thoracic atheroma was defined by: (1) thickness >5 mm, (2) involved circumference of thoracic aorta >50%, and (3) length >30 mm. The areas of atheroma (cm(2)) were measured before and after administration of statins, and the atheroma reduction ratio (ARR) was evaluated. RESULTS: The area of atheroma decreased after administration of statins, and the ARR was significant (P <0.01). The ARR increased with all cases in non-statin group. No complications associated with extensive atheroma were observed during the follow-up period. CONCLUSION: This pilot study indicates statins can reduce extensive thoracic atheromas and lower lipid concentrations.