Exercise Intolerance That Resolved After venous Stenting of the Inferior Vena Cava.

Venous stenting could alleviate exercise intolerance associated with chronic inferior vena cava (IVC) obstruction. We describe a 36-year-old male patient with an unknown IVC-obstruction. The obstruction was discovered after a bi-iliac deep vein thrombosis (DVT). The thrombus was resolved using thrombolysis. In the chronic phase, the patient developed exercise intolerance without any leg-specific symptoms or signs. Venous stenting was performed to open the IVC-obstruction, 1 year after the acute DVT. His physical condition improved, but cardiac magnetic resonance imaging at rest did not reveal hemodynamical changes after stenting. The Short Form Health Survey (SF-36) physical and mental component summaries were increased from 40.3 to 46.1 and 42.2 to 53.7, respectively. In patients with iliocaval obstruction, improved venous flow without changes in resting hemodynamics can enhance exercise intolerance and quality of life, even in the absence of leg symptoms. Diagnostic tools performed only at rest may miss abnormalities.

Aneurysm Sac Shrinkage After EVAR Can Lead to Complications: A Case Report of Complete Endograft Thrombosis Due to Kinking.

BACKGROUND: Bilateral limb occlusion after endovascular repair of abdominal aortic aneurysms (EVAR) is an uncommon entity. The relationship between graft kinking and unilateral limb occlusion is widely described in the literature. Our aim is to report a case of complete endograft thrombosis due to bilateral limb kinking secondary to aneurysm sac shrinkage, treated by endovascular means. CASE REPORT: A 67 year-old male with history of EVAR with an Incraft® endograft (Cordis, Bridgewater, NJ, USA) four years before, presented at the emergency department with disabling claudication of the right lower extremity and a better tolerated 10-month left extremity claudication. Complete endograft thrombosis with bilateral limb kinking and a remarkable reduction of the aneurysm sac was observed in the computed tomography angiography. An endovascular repair was performed, through bilateral open femoral access and with angiographic control through percutaneous left brachial access. Bilateral recanalization was achieved and the endograft was re-lined with two 10x150 mm Viabahn (WL Gore & Ass., Flagstaff, AZ, USA). Both sides were extended with a 11 × 50 mm Viabahn (WL Gore & Ass., Flagstaff, AZ, USA). The final angiographic control showed bilateral patency with no residual stenosis and the patient recovered distal pulses. Follow-up showed complete patency and no complications at 17 months. CONCLUSIONS: Bilateral limb occlusion is a rare complication with technically challenging treatment options. Aneurysm sac shrinkage can affect the endograft configuration, leading to limb distortion and occasionally to bilateral limb occlusion after EVAR. Special attention should be put on imaging follow-up to detect these complications before occlusion occurs.

Novel Technique for Intentional Occlusion of Directional Branches During Complex Endovascular Aortic Repair Using Microvascular Plugs.

PURPOSE: To demonstrate the feasibility and outcomes of using the microvascular plug (MVP) for intentional occlusion of directional branches (DB) during complex endovascular aortic procedures. CASE REPORT: Two patients were treated with the off-the-shelf four-branched Zenith t-Branch thoracoabdominal stent-graft (Cook Medical, Bloomington, Ind). In both cases, the renal arteries (on one side in patient #1 and on both sides in patient #2, respectively) were occluded at time of index intervention. Preoperative planning included the intentional occlusion of each DB with one 7Q-MVP. Technical success was achieved in all cases and maintained at mid-term follow-up (12 months and 36 months, respectively). CONCLUSIONS: Use of the MVP appears to be feasible and effective for intentional occlusion of DB during complex endovascular aortic repair. This novel and simple technique may present some unique technical advantages, allowing precise placement of the device while avoiding extension using a bridging stent and DB cannulation with larger sheaths.

Effect of unsoluble corrosion products of WE43 alloys in vitro on macrophages.

Magnesium alloys have been used to manufacture biodegradable implants, bone graft substitutes, and cardiovascular stents. WE43 was the most widely used magnesium alloy. The degradation process begins when the magnesium alloy stent is implanted in the body and comes into contact with body fluid. The degradation products include hydrogen, Mg2+ , local alkaline environment, and unsoluble products. A large number of studies focused on Mg2+ and pH in vitro, and in vivo of magnesium alloys, but few studies on unsoluble corrosion products (UCPs). In this study, UCPs of WE43 alloy were prepared by immersion in vitro, and their effects on macrophages were investigated. The results showed that the unsoluble corrosion products were Mg24Y5, Mg12YNd, and MgCO3 ·3H2 O, which were dose-dependent on the apoptosis and necrosis of macrophages. After phagocytosis of UCPs, macrophages mainly metabolize in lysosome, and autophagy also participates in the metabolism of UCPs. It also decreases mitochondrial membrane potential and increases lysosomes, endoplasmic reticulum stress, and P2X7 receptor activation. These will increase reactive oxygen species (ROS) in cells, activating NLRP3 inflammatory corpuscles, activating the downstream pro-IL18 and pro-IL1ß, and converting it to IL-18, and IL-1ß. However, its pro-inflammatory effect is far lower than that of the classical Lipopolysaccharide (LPS) pro-inflammatory pathway. This work has increased our understanding of magnesium alloy metabolism and provides new ideas for the clinical application of magnesium alloys.

Endoscopic Palliative Therapies for Esophageal Cancer.

Endoscopic palliation of dysphagia for patients with inoperable esophageal cancer is complex, highly dependent on local expertise, and best done in a multidisciplinary fashion. Systemic therapy is the standard of care because it has been shown to improve survival. Esophageal stenting has traditionally been the most used endoscopic modality. Some modalities such as laser and photodynamic therapy are rarely used. There has been an increasing amount of data on cryotherapy, especially for patients with mild-to-moderate dysphagia on systemic chemotherapy. This article will discuss the latest evidence guiding the palliation of esophageal cancer.

Extravascular Migration of a Stentgraft Into the Bladder: A Rare Complication After Endovascular Treatment of an Arterio-Ureteral Fistula.

Endovascular repair has gained acceptance for the treatment of arterio-ureteral fistula (AUF). However, data on associated postoperative complications are relatively scarce. We report the case of a 59-year-old woman with an external iliac artery (EIA)-ureteral fistula treated by endovascular stentgraft placement. Hematuria resolved after the procedure; however, occlusion of the left EIA and migration of the stentgraft into the bladder occurred 3 months postoperatively. Endovascular repair is a safe and effective method for the treatment of AUF, but it needs to be carefully followed. Extravascular migration of a stentgraft is a rare but possible complication.

Results of the Chimney Technique in a Community Hospital.

BACKGROUND: The chimney technique, fenestrated or branched endovascular aortic repair are endovascular options in patients with a juxtarenal, suprarenal or type IV thoraco-abdominal aneurysm. The chimney technique has specific advantages and disadvantages. A retrospective single center study was performed to describe the results. PATIENTS AND METHODS: All consecutive patients in whom the chimney technique was used between 1th January 2011 and 31th December 2020 were included. We excluded patients who needed a revision of an existing EVAR and patients with a para-anastomotic aneurysm. Outcomes were reported in accordance with the reporting standards. RESULTS: 38 Patients were included in the study, a total of 59 chimney grafts were deployed. At a median follow-up duration of 26.6 months, there were 9 patients with occlusion of the chimney graft. In 1 patient an iliac renal bypass was performed. In the other patients the renal function stabilized and no further therapy was necessary. All chimneys in the mesenteric arteries remained patent. Gutter endoleak was seen in 5 patients, 3 patients were successfully treated and in the other 2 patients the gutter endoleak disappeared spontaneously. CONCLUSIONS: Conclusions should be drawn carefully as this is a retrospective non-comparative study. Results from 38 patients treated with the chimney technique are presented. Chimney graft occlusion rate was 15.3% at the end of follow-up. However, the majority (77.8%) of the occluded stents were self-expandable stents, stressing the importance of selecting the right devices.

Endoscopic Management of Colonic Obstruction.

Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.

Endoscopic Treatment of Gastric Outlet Obstruction.

Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.

Feasibility of Percutaneous Pancreatic Stent Placement in Postoperative Pancreaticojejunostomy Stenosis.

OBJECTIVE: To evaluate the role of percutaneous pancreatic stent placement in postoperative pancreaticojejunostomy stenosis (PJS). MATERIALS AND METHODS: This retrospective single-center study included seven procedures in five patients (four males and one female; median age, 63 years) who underwent percutaneous pancreatic stent placement for postoperative PJS between January 2005 and December 2021. The patients were referred to interventional radiology because of unfavorable anatomy or bowel abnormalities. The pancreatic duct was accessed under ultrasound and/or computed tomography guidance. A stent was placed after balloon dilatation of the PJS. Moreover, plastic stents were placed for the first two procedures, whereas bare-metal stents were used for the remaining five procedures. Technical success was defined as the successful placement of stents for the PJS, meanwhile, clinical success was defined as the normalization of pancreatic enzymes without recurrence of pancreatitis. RESULTS: Pancreatic duct access and stent placement were successfully performed in all patients (technical success rate: 100%). All the procedures initially yielded clinical success. However, recurrence of pancreatitis was observed after two procedures that used plastic stents because of stent migration at 0.3 and 3 months after the procedure. In contrast, no instances of recurrent pancreatitis were noted after metal stent placement for a follow-up duration of 1-36 months. No serious procedure-related adverse events were observed. CONCLUSION: Percutaneous pancreatic stent placement may be a viable option for patients with postoperative PJS in whom an endoscopic approach is not feasible. Metal stents may be considered over plastic stents for the management of PJS, considering the possible lower stent migration and infeasibility of frequent endoscopic stent exchange due to the altered anatomy.

Fasting blood glucose predicts high risk of in-stent restenosis in patients undergoing primary percutaneous coronary intervention: a cohort study.

Objectives. Studies have shown that fasting blood glucose (FBG) is closely associated with poor prognosis in patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI), but its association with in-stent restenosis (ISR) is still unclear. Therefore, this study was to explore the association between FBG with ISR in patients with CHD after PCI. Design. In this cohort study, we included 531 patients with CHD who underwent PCI. Logistic regression, receiver operating characteristic (ROC), subgroup analysis and restricted cubic spline (RCS) were used to assess the association between FBG with ISR. Results. A total of 124 (23.4%) patients had ISR. Patients with higher levels of FBG had higher incidence of ISR compared to those with lower levels of FBG (p = 0.002). In multivariable logistic regression analyses, higher levels of FBG remained strongly associated with higher risk of ISR (as a categorical variable, OR: 1.89, 95% CI: 1.21-2.94, p = 0.005; as a continuous variable, OR: 1.12, 95% CI: 1.03-1.23, p = 0.011). ROC analysis also showed that FBG might be associated with the occurrence of ISR (AUC = 0.577, 95% CI: 0.52-0.64, p = 0.013). Subgroup analyses showed the association of FBG with ISR was also stable in several subgroups (< 60 years or ≥ 60 years, male, with or without smoking, without diabetes and without hypertension). And RCS analysis showed that FBG was linearly and positively associated with the risk of ISR. Conclusions. Higher levels of FBG were closely associated with higher risk of ISR in patients with CHD after PCI.

[Current State of the Flow Diverter in Endovascular Treatment].

Since Pipeline Flex(Covidien/Medtronic)was approved in April 2015, flow diverter(FD)treatment has started in Japan. Three kinds of FDs(Pipeline, FRED and Surpass)are available now, and we have been able to treat a variety of aneurysms, including those that are giant-sized and located posterior circulation, which had been difficult to treat safely before the appearance of the FD. In addition, indications for FDs have been expanding with increasing evidence. However, there are some challenges that need to be overcome. First, thromboembolic complications due to high metallic amounts in FD must be considered. The long duration of antiplatelet therapy must be continued to reduce thromboembolic complications, but the precise required-duration of this therapy has not yet been determined. Second, FD treatment requires a few months before an aneurysmal cure is achieved. Therefore, there is a possibility of an aneurysmal rupture after FD deployment. In addition, there are some kinds of aneurysms for which FD treatment is less effective, such as aneurysms with a large branch vessel. In this review, I describe the details of each FD and the current state of FD, based on the evidence.

Perioperative Outcomes in Transcarotid Artery Revascularization Versus Carotid Endarterectomy or Stenting Nationwide.

BACKGROUND AND OBJECTIVES: Transcarotid artery revascularization (TCAR) is a newer treatment for carotid stenosis where the carotid artery is accessed directly in the neck for stenting. It is less invasive than carotid endarterectomy (CEA) and has less embolic potential than carotid artery stenting (CAS), but population-level utilization of TCAR and outcomes are currently unknown. Our study compares outcomes of TCAR with those of CEA and CAS. METHODS: The National Inpatient Database was used for years 2015 to 2019. A multivariate logistic regression model was used to compare CEA, CAS, and TCAR outcomes with age, sex, race, hospital teaching status, symptomatic carotid disease status, side of procedure, intraoperative monitoring, and the weighted Elixhauser comorbidity score as covariates. RESULTS: TCAR comprised 0.69% of these procedures in 2016, rising to 1.35% in 2019. The inpatient rates of death, stroke, and myocardial infarction for TCAR were 0.63% (95% confidence interval: 0.36%, 1.06%), 0.42% (0.21%, 0.80%), and 1.46% (1.04%, 2.05%), respectively. Compared with CEA, TCAR had statistically insignificant difference odds of death, odds ratio (95% CI) for stroke was 0.47 (0.25, 0.87), and for myocardial infarction, it was 0.66 (0.37, 0.94). Compared with CAS, for TCAR, the odds ratio for death was 0.41 (0.24, 0.71), and for stroke, it was 0.48 (0.26, 0.91). CONCLUSION: TCAR is underutilized relative to other revascularization techniques yet has favorable outcomes compared with CEA and CAS. TCAR may be preferred to CAS in patients not surgical candidates for CEA and has a less invasive possibility for those eligible for CEA.

Application of Sofia Plus catheter tip shaping in the treatment of acute middle cerebral artery occlusion: A case control study.

To explore the safety and efficacy of Sofia Plus distal access catheter tip shaping for treatment of acute middle cerebral artery embolism. This single-center retrospective study involved patients eligible for acute embolic middle cerebral artery occlusion from January 2020 to October 2021. They were divided into a shaping and non-shaping group according to whether the Sofia Plus catheter tip was shaped intraoperatively. Baseline data, preoperative Alberta Stroke Program Early Computed Tomography (ASPECT) score, National Institutes of Health Stroke Scale (NIHSS) score, onset-to-admission time, admission-to-puncture time, Sofia Plus-clot time, puncture-to-reperfusion time, surgical approach, and use of a stent for rescue thrombectomy were compared between the 2 groups. Postoperative symptomatic intracerebral hemorrhage and the modified Rankin scale score at the 90-day follow-up were observed. In total, 54 patients were enrolled in this study (shaping group, 26 patients; non-shaping group, 28 patients). Their mean age was 64.8 ±â€…14.6 years, and the proportion of men was 68.5% (37/54). Successful recanalization was achieved in all patients. There were no differences in the baseline data (age, sex, history, pre-admission ASPECT score, or NIHSS score) between the shaping and non-shaping groups. Patients treated with a shaped Sofia Plus catheter had a shorter Sofia Plus-clot time [median (25th, 75th percentile: 4 (4, 7) vs 10.5 (5.25, 14) min, P = .006] and puncture-to-reperfusion time [16.5 (12, 30.5) vs 26 (16.25, 38.25) min, P = .036]. There were significant differences in the surgical approaches between the 2 groups. The rates of a favorable outcome (57.7% vs 64.3%, P = .62) and postoperative symptomatic intracerebral hemorrhage (7.7% vs 3.6%, P = .60) were not significantly different between the groups. Sofia Plus catheter tip shaping improved catheter trafficability and reduced the operative time. It was safe and effective for treatment of acute middle cerebral artery thrombotic occlusion.

Effectiveness of pancreatic stent placement in pediatric patients with acute recurrent and chronic pancreatitis.

BACKGROUND: The use of pancreatic prostheses in children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) has evolved. The main established indication is the treatment of persistent abdominal pain. This study aimed to evaluate the efficacy of pancreatic stenting for refractory abdominal pain in pediatric patients with ARP and CP. METHODS: We conducted a retrospective case series study. We included patients under 16 years of age diagnosed with ARP and CP in the study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with the insertion of one and later two pancreatic stents. We evaluated abdominal symptoms before and after treatment, number of changes, duration of treatment, and complications with follow-up at 24 months and after withdrawal. RESULTS: Nine patients with ARP and CP were included in the study: six with undetermined etiology and three with pancreas divisum. The mean age was 12.4 years. Prosthesis placement relieved abdominal pain in 100% of cases, with 3.2 replacement sessions every 6.2 months for 27.4 months, and mild complications (15.7%). One patient experienced pain on removal of the prosthesis and required bypass surgery. CONCLUSION: Pancreatic stent placement in patients with refractory abdominal pain with ARP and CP proved to be effective and safe, providing medium-term symptom relief and minimal complications.

INTRODUCCIÓN: El uso de prótesis pancreáticas en niños con pancreatitis aguda recurrente (PAR) y crónica (PC) ha evolucionado. La principal indicación establecida es el tratamiento del dolor abdominal persistente. El objetivo de este estudio fue evaluar la eficacia del uso prótesis pancreática para el dolor abdominal refractario en pacientes pediátricos con PAR y PC, sin respuesta a manejo conservador. MÉTODOS: Se llevó a cabo un estudio retrospectivo de serie de casos. Se incluyeron pacientes menores de 16 años con diagnóstico de PAR y PC. Se realizó una colangio pancreatografía retrograda endoscópica (CPRE) para introducir inicialmente una y posteriormente dos prótesis pancreáticas. Se evaluaron síntomas abdominales antes y después del tratamiento, número de recambios, duración del tratamiento y complicaciones con seguimiento a 24 meses y posterior a su retiro. RESULTADOS: Se incluyeron 9 pacientes con PAR y PC: seis de etiología no determinada y tres con páncreas divisum. La edad promedio fue de 12.4 años. La colocación de prótesis alivió el dolor abdominal en el 100%, con 3.2 sesiones de recambio cada 6.2 meses en 27.4 meses, y complicaciones leves (15.7%). Un paciente presentó dolor al retirar las prótesis y requirió cirugía derivativa. CONCLUSIONES: El uso de prótesis pancreática en pacientes con dolor abdominal refractario con PAR y PC demostró ser eficaz y seguro al aliviar los síntomas a mediano plazo con mínimas complicaciones.

Prevention of Migration of Esophageal Self-Expandable Metallic Stents Using Endoscopic Clips.

Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications.

Clinical application of a novel stent-assisted in situ intestinal bypass in preventing postoperative anastomotic leakage for low-mid rectal cancer: A retrospective study.

This study aimed to investigate the safety and feasibility of a novel stent-assisted in situ intestinal bypass for low-mid rectal cancer patients. Patients who were diagnosed with rectal cancer and received laparoscopic low anterior rectal resection plus a novel stent-assisted in situ intestinal bypass were respectively included from March 2022 to June 2022. Biofragmentable intestinal stent with a protective sleeve was placed in the proximal colon before anastomosis, and feces could be discharged through the protective sleeve without touching the anastomosis, which achieved an in situ bypass of feces. Perioperative characteristics and short-term outcomes were collected. Rectal imaging was performed each week after surgery for the first 3 weeks to surveil the stent and feces delivery. Follow-ups were conducted for more than 3 months. Thirty patients who successfully received surgery were included in this study. There were 18 (60.0%) males and 12 (40.0%) females. As for perioperative characteristics, operation time was 213.8 ± 43.0 minutes, blood loss was 53.3 ± 24.6 mL, time to first flatus via protective sleeve after surgery was 3.2 ± 1.1 days, postoperative hospital stay was 11.8 ± 1.6 days, and time to discharge stent was 22.4 ± 3.2 days. As for short-term outcomes, 6 patients suffered from pneumonia, urinary tract infection or incision infection. During the follow-up, there was no anastomotic leakage or mortality. This novel stent-assisted in situ intestinal bypass is safe and feasible, it might be an applicable way to prevent postoperative anastomotic leakage for patients with low-mid rectal cancer.