Fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is a less invasive treatment for thoracoabdominal aortic aneurysm (TAAA) and complex abdominal aortic aneurysm. Fenestrated and branched (cuff) grafts facilitate safe and durable repair, and bail-out maneuvers for target vessel cannulation and stenting have been established; however, the available bridging stent grafts have differences. The present article discusses the optimal selection of fenestrated or branched grafts, the cannulation of target vessels that have difficult anatomies, and the advantages and disadvantages of various bridging stents. We review the causes and risk factors of spinal cord injury (SCI), the protocol for prevention of SCI, and the outcomes of target vessel stent grafting, including patency and endoleak.
Although conventional open surgery is the gold standard for the repair of thoracoabdominal aortic aneurysm (TAAA), it is highly invasive. To reduce invasiveness, hybrid surgery that combines open surgery and endovascular therapy has been developed [1, 2], and fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is frequently performed at centers in the USA, Europe, and Japan [3-5]. Additionally, a hostile neck may be an independent factor for sac enlargement after EVAR for abdominal aortic aneurysm (AAA) , but a previous study reported that 41% of AAA cases presented with neck lengths outside the range prescribed by the traditional instruction for use . Stark et al. showed that extending the graft above the highest renal artery would create an augmented neck length in 90% of patients with AAA . F/B-EVAR is based on this principle. However, there are some technical tips for, and limitations of, fenestrated and/or branched graft. F/B-EVAR for TAAA and complex AAA will be reviewed in the present article.
EVAR has been used clinically for almost three decades, and it has been widely applied in clinical practice and has been applied to difficult cases as devices and techniques have evolved. Although the major advantage of EVAR is its lower perioperative mortality, compared with open surgery, late-onset complications such as endoleaks have become major issues, requiring lifelong follow-up after EVAR. The clinical guidelines have been updated, and many systematic reviews/meta-analyses and multi-center registries have been published; surgeons must keep up-to-date regarding these changes. In this review, the author reviews evidence on the recent update of the type 2 endoleak management.
Endovascular treatment is effective for symptomatic peripheral arterial disease (PAD). Following recent device improvements, favorable long-term outcomes have been achieved in iliac arteries as well as small arteries such as the femoral and popliteal arteries.
This paper outlines the history and recent advances in endovascular treatment of peripheral vascular diseases as well as the characteristics and usage of devices. The history and the advances in endovascular treatment of peripheral vascular disease have been parallel, with the development of devices such as catheters and stents. Accordingly, endovascular treatment is now recommended in guidelines as the first-line for PAD.
Purpose: To retrospectively evaluate the diagnostic yield and safety of computed tomography (CT) fluoroscopy-guided biopsy of abdominal para-aortic lesions.
Material and Methods: CT fluoroscopy-guided biopsy was performed for 30 lesions (median long diameter 2.4 cm; range, 1.3-12.4 cm) in 30 patients (11 women and 19 men; median age 64.5 years; age range 37-90 years) using 18- and/or 20-gauge needles. The median length of the biopsy needle tracts was 9.3 cm (range, 5.5-13.0 cm). The median number of biopsy fires was 3 (range, 2-6). The median duration of the procedures was 33 min (range, 14-80 min). The diagnostic yield and adverse events (AEs) were retrospectively evaluated. The AEs were categorized using the Society of Interventional Radiology classification system.
Technical success was determined by the acquisition of a sufficient number of specimens for pathological diagnosis. Diagnostic yield was defined as the match between the pathological and final diagnoses.
Results: In all 30 procedures, CT fluoroscopy-guided biopsies of the abdominal para-aortic lesions were technically successful. Twenty-six lesions were malignant (9 malignant lymphomas and 17 lymph node [LN] metastases) and four were benign (one schwannoma, one granular cell tumor, and two normal LNs). One case was insufficiently diagnosed as a B-cell lymphoma; thus, the diagnostic yield of the biopsy was 96.7%. AEs occurred in seven procedures (23.3%), including six cases of class A hemorrhage and one case of class B vasovagal reaction.
Conclusions: CT fluoroscopy-guided biopsy of abdominal para-aortic lesions is a safe procedure and provides a high diagnostic yield.
We report two cases of intraoperative bile duct disruption. In case 1, an isolated bile duct in the remnant of the anterosuperior liver segment after right hepatic lobectomy for cholangiocarcinoma caused bile leakage. In case 2, bile leakage continued from a disrupted accessory hepatic duct during pancreaticoduodenectomy for pancreatic carcinoma. In both patients, a mixture of ethanol and iodized oil at a 10:1 ratio was injected into the disrupted bile duct under balloon occlusion. In case 1, the mixture was injected through a balloon catheter under balloon occlusion overnight. No severe complications developed in either case. Bile leakage stopped postoperatively and did not recur until the patients' death from tumor progression 14 and 16 months after surgery, respectively.
We present a case of a 76-year-old man with submucosal tunnel formation caused by long intestinal tube (LIT) insertion. The patient had undergone an LIT insertion to treat bowel obstruction caused by ascending colon cancer. Although intestinal decompression was achieved successfully, a procedural pre-scheduled endoscopy incidentally revealed that the LIT had penetrated the abdominal esophageal mucosa and re-entered the gastric lumen, passing through the submucosal layer at the gastroesophageal junction. Therefore, the LIT was removed under endoscopic observation during ileocecal resection surgery and the patient was treated conservatively. The current case suggests that this unfamiliar complication can occur without any signs or symptoms.
Percutaneous retrieval of an intravascular foreign body is a minimally invasive technique. Using cone-beam computed tomography and the lateral grasp technique, we successfully retrieved a pigtail catheter straightener that had been misinserted into the right common iliac artery. Some examples of catheter straightener retrieval have been reported; however, it is important to take care not to accidentally insert a catheter straightener into a vessel via an angiographic sheath.
Transarterial vascular access interventional therapy (VAIVT) for non-functioning hemodialysis access has advantages over the venous approach because natural venous outflow through the fistula as well as the stump at the fistula site in total occlusion can be observed, and most strictures and/or occlusions can be treated via one access route. The brachial arterial approach is essential, but the radial arterial approach at the wrist is also necessary for certain patients. The transarterial approach can be applied to all VAIVTs; however, additional venous access is necessary in cases requiring a large device and those with unsuccessful traversal of the occluded segment via the arterial route. The high origin of the radial artery is a disadvantage of the transbrachial approach, and local hematomas are the most frequent complications.