[EVALUATION OF SYSTEMIC PRO-INFLAMMATORY REACTIONS IN SIMULATING REVERSIBLE OCCLUSION OF ANTERIOR MESENTERIC ARTERY TO JUSTIFY MEDICAL REHABILITATION]

The purpose of the work was to analyze the pro-inflammatory reaction caused by different duration of ischemic-reperfusion of intestinal damage in occlusion of anterior mesenteric artery in the experiment. Ischemic reperfusion damage of the intestinal wall was simulated using reversible occlusion of the anterior mesenteric artery with 30 rats. Two types of operations were carried out: operation 1 - the duration of ischemia 20 minutes, reperfusion - 40 minutes, operation 2 - 30 and 30 minutes, respectively. Four groups were formed by simple sampling: the first - false-operated animals (n=5), the second - model-operation 1 (n=8), the third - model-operation 2 (n=6), the 4th - control group (n=7). Lactate level was determined by BM-Lactat test strips and the number of blood leukocytes was calculated before and after the surgery. During the postoperative period, interleukin-1β (IL-1β), tumor necrosis factor α (TNF-α), monocytic chemotoxic factor-1 (MCF-1) in serum were determined. In groups 2 and 3 it was established: a decrease in leukocytes in peripheral blood by 15-20% and an increase in lactate level by 20-120% during the postoperative period with the establishment of direct statistically significant connections between the number of leukocytes in the blood and lactate content (r=+0.83, p=0.01); between the number of leukocytes in the blood and IL-1β blood level (r=+0.96; p=0,00002); reduction of IL-1β level in blood with the animals of group 3 as compared with false-operated and MCF-1 level with the animals of group 2 as compared with false-operated, which may be related to the influence of corrective action of anti-inflammatory response. The increase of TNF-a level with the animals of the second group by 1.5-2 times and in the third group by 3 times compared to false-operated animals, which is the most significant manifestation of pro-inflammatory response to ischemia/reperfusion, depends on the degree of the damage due to the duration of ischemic period. The development of systemic pro-inflammatory reactions in the simulation of reversible occlusion of anterior mesenteric artery is the basis for the rehabilitation of patients after various surgical interventions in the intestine in order to prevent abdominal postoperative complications.

Occlusive Mesenteric Ischemia in Chronic Dialysis Patients

BACKGROUND

Among dialysis patients, occlusive mesenteric vascular disease has rarely been reported.

OBJECTIVES

To report on the experience of one center with regard to diagnosing and treating this complication.

METHODS

The retrospective case-series involved six patients (3 females, 3 males; age 52-88 years; 5/6 were smokers) on chronic hemodialysis at a single center. All patients with symptoms suggestive of occlusive mesenteric disease and a subsequent angiographic intervention were included. Demographic, clinical, and laboratory data were collected from patient charts for the period before and after angioplasty and stenting of the mesenteric vessels. A Wilcoxon signed-rank test was used to compare the relevant data before and after the intervention.

RESULTS

All participants had variable co-morbidities and postprandial abdominal pain, food aversion, and weight loss. CT angiography was limited due to heavy vascular calcifications. All underwent angioplasty with stenting of the superior mesenteric artery (4 patients) or the celiac artery (2 patients). All procedures were successful in resolving abdominal pain, malnutrition, and inflammation. Weight loss before was 15 ± 2 kg and weight gain after was 6 ± 2 kg. C-reactive protein decreased from 13.4 ± 5.2 mg/dl to 2.2 ± 0.4 mg/dl (P < 0.05). Serum albumin increased from 3.0 ± 0.2 g/dl to 3.9 ± 0.1 g/dl (P < 0.05). Two patients underwent a repeat procedure (4 years, 5 months, respectively). Follow-up ranged from 0.5-7 years.

CONCLUSIONS

Occlusive mesenteric ischemia occurs among dialysis patients. The diagnosis requires a high degree of suspicion, and it is manageable by angiography and stenting of the most involved mesenteric artery.

Not all Whipple procedures are equal: Proposal for a classification of pancreatoduodenectomies

BACKGROUND

Pancreatoduodenectomy is the standard treatment for pathologies of the pancreatic head and is performed routinely worldwide. The aim of the study was to analyze this procedure in terms of extent of surgery, technical difficulty, and clinical outcomes and thereby provide a standardized surgical categorization of pancreatoduodenectomies for future reference.

METHODS

For this cohort study, all patients who underwent pancreatoduodenectomy at a single center within an 18-year period (October 2001 to December 2019) were identified in a prospectively maintained database. Based on technical difficulty and extent of surgery, 4 pancreatoduodenectomy types were proposed: (1) standard pancreatoduodenectomy; (2) pancreatoduodenectomy with portal vein/superior mesenteric vein resection; (3) pancreatoduodenectomy with multivisceral resection; and (4) pancreatoduodenectomy with arterial resection. Patient characteristics, surgical parameters, and perioperative morbidity and mortality were analyzed. The 4 types were compared with regard to their surgical outcomes.

RESULTS

A total of 3,953 pancreatoduodenectomies were performed in the study period. Standard pancreatoduodenectomy (type 1) was the most frequent procedure (n = 2,931, 74.1%), followed by pancreatoduodenectomy with portal vein/superior mesenteric vein resection (type 2: n = 568, 14.4%), pancreatoduodenectomy with multivisceral resection (type 3: n = 415, 10.5%), and pancreatoduodenectomy with arterial resection (type 4: n = 39, 1.0%). Demographic baseline characteristics were clinically comparable among pancreatoduodenectomy types. Mortality within 90-days correlated with the type of pancreatoduodenectomy (type 1: 2.9%; type 2: 4.2%; type 3: 6.3%; type 4: 10.3%; P = .0007). Overall surgical morbidity was 41.7% (type 1), 40.8% (type 2), 52.5% (type 3), and 59.0% (type 4) (P < .0001), including postoperative pancreatic fistula type B/C (type 1: 11.9%; type 2: 7.7%; type 3: 14.7%; type 4: 15.4; P = .0031) and delayed gastric emptying (type 1: 19.4%; type 2: 22.5%; type 3: 22.0%; type 4: 25.6%; P = .187) as the most frequent complications. Relaparotomies were more frequent in type 4 (20.5%) and type 3 (20.6%) than in type 2 (12.0%) or type 1 (10.4%) pancreatoduodenectomy (P < .0001). Intensive care unit stay ≥2 days was more frequent in type 4 (48.7%) compared with type 3 (25.7%) or type 2 (27.1%) and type 1 (18.6%) (P < .0001).

CONCLUSION

The results show different clinical outcomes for the 4 types of pancreatoduodenectomy. Morbidity and mortality correlate with pancreatoduodenectomy type. The proposed pancreatoduodenectomy classification is useful for reporting pancreatoduodenectomy procedures, enhances the comparability of future studies, may be used for training purposes, and may guide intra and postoperative decision-making.

Renal and Mesenteric Artery Intervention

Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.

Multicentric study on total pancreatectomies

INTRODUCTION

Total pancreatectomy (TP) is an uncommon operation, with indications that have not been clearly defined and non-standardized postoperative results. We present a national multicentric study on TP and a comparison with the existing literature METHODS: A prospective observational study using data from the national registry of patients after pancreaticoduodenectomy and TP performed for any indication during the study period: January 1 to December 31, 2015 RESULTS: 1016 patients were included from 73 hospitals, 112 of whom had undergone TP. The percentage of TP from the total number of cases was 11%. The mean age was 63.5 years, and 57.2% were males. The most frequently suspected radiological diagnosis was pancreatic cancer (58/112 cases). The most common TP technique was "mesentery artery first" (43/112 cases). Venous resections were performed in 23 patients (20.5%). The percentage of postoperative complications within 90 days was 50%, but major complications (>IIIA) were only 20.7%. The overall 90-day mortality was 8% (9 patients). The average stay was 20.7 days. The 3most frequent definitive histological diagnoses were: adenocarcinoma of the pancreas, intraductal papillary mucinous neoplasm and chronic pancreatitis. The R0 rate was 67.8%.

CONCLUSIONS

This study shows that the morbidity and mortality results of TP in Spain are similar or superior to previous publications. More precise TP studies are necessary, focused on specific complications such as endocrine insufficiency.

Novel implications of combined arterial resection for locally advanced pancreatic cancer in the era of newer chemo-regimens

INTRODUCTION

In this study, we assessed the prognostic efficacy and feasibility of combined arterial resection (AR) for locally advanced pancreatic cancer (LAPC), and aimed to identify significant prognostic factors for patients who underwent combined AR.

METHODS

Between 1981 and 2018, 733 consecutive patients who underwent pancreatic surgery for PC were identified. The 730 cases with detailed information were enrolled in the analysis.

RESULTS

Among 730 resected PC patients, 44 (6%) underwent AR including 21 hepatic (48%), 12 celiac (27%), five splenic (12%), four superior mesenteric (9%), and two other arteries (4%). The combined AR surgery showed significantly longer operative time (median, 608 vs 451 min, P < 0.0001), and the incidence of intraoperative blood transfusion was significantly higher in AR than surgery without AR (P = 0.0002), whereas there was no significant difference in the intraoperative blood loss (970 vs 1200 mL, P = 0.2) and occurrence of major complications (P = 0.5). In prognostic analysis of AR cases, multivariate Cox proportional hazard models revealed preoperative and postoperative therapy were the independent factors for both recurrence-free survival (RFS) and overall survival (OS) (preoperative therapy: RFS, HR = 0.21, P = 0.007; OS, HR = 0.18, P = 0.01; postoperative therapy: RFS, HR = 0.31, P = 0.003; OS, HR = 0.19, P = 0.002).

CONCLUSION

This study showed the feasibility of combined AR for LAPC and robust association of pre- and postoperative therapy and survival after AR surgery. Preoperative therapy following combined AR surgery is potentially powerful strategy for LAPC.

Novel H-shunt Venovenous Bypass for Liver Transplantation in Cynomolgus Macaques

Cynomolgus monkeys are often used in preclinical transplantation research. Performing liver transplantation in cynomolgus monkeys is challenging because they poorly tolerate portal vein clamping during the anhepatic phase. Finding an alternative to portal vein clamping is necessary before preclinical liver transplant models can be performed with reliable outcomes. We used 3 different techniques to perform 5 liver transplants in male cynomolgus macaques (weight, 7.4-10.8 kg; mismatched for MHC I and II; matched for ABO). In procedure A, we clamped the portal vein briefly, as in human transplants, as well as the superior mesentery artery to minimize congestion at the expense of temporary ischemia (n = 2). In procedure B, we performed a temporary portocaval shunt with extracorporeal venovenous bypass (n = 1). For procedure C, we developed an H-shunt system (modified portocaval shunt) with extracorporeal bypass (n = 2). Postoperative immunosuppression comprised cyclosporine A, mycophenolate mofetil, and steroids. Recipients in procedure A developed hemodynamic instability and were euthanized within 2 d. The recipient that underwent procedure B was euthanized within 11 d due to inferior vena caval thrombosis. The H-shunt in procedure C led to minimal PV congestion during the anhepatic phase, and both recipients reached the 21-d survival endpoint with good graft function. Our novel H-shunt bypass system resulted in successful liver transplantation in cynomolgus macaques, with long-term posttransplant survival possible. This technical innovation makes possible the use of cynomolgus monkeys for preclinical liver transplant tolerance models.

Surgical treatment of chronic multivascular mesenteric ischemia in a patient with antiphospholipid syndrome, abdominal aortic aneurism, and renal cancer: when planning overwhelms complexity

Chronic mesenteric ischemia is a clinical condition caused by obstructive or occlusive disease of the mesenteric vessels, with potentially lethal consequences. We describe a case of open multiple revascularization in a patient affected by antiphospholipid syndrome and diffuse atherosclerosis, with an abdominal aortic aneurism, a contracted kidney, a renal cancer affecting the contralateral kidney, and as a consequence, a chronic renal failure and hypertension. We revascularized the celiac trunk, the superior and inferior mesenteric arteries, and the right renal artery using saphenous grafts; the aneurism was corrected, and the renal tumor was treated by radiofrequency ablation. Despite the invasiveness and complexity, the surgical strategy adopted allowed to save the patient's life, to treat the chronic mesenteric ischemia and the renal cancer, and to improve the chronic renal insufficiency and hypertension.

KEY WORDS

Graft, Mesenteric ischemia, Occlusion, Revascularization.

Transaortc Endarterectomy for Primary Mesenteric Revascularization

The optimal approach to revascularization for chronic mesenteric ischemia has not been firmly established during the past three decades. The present study was undertaken to evaluate the safety and results of primary mesenteric revascularization for chronic mesenteric ischemia by transaortic endarterectomy. A descriptive retrospective analysis of 14 patients who underwent trap-door transaortic endarterectomy for primary mesenteric revascularization was performed. Clinical presentations of the patients included abdominal pain (n = 13) and weight loss (n = 7). All patients underwent preoperative aortography and subsequent elective reconstruction. Demographic features, perioperative, and long-term outcomes were analyzed. The study population consisted of 12 females and two males with a mean age of 67 years. The mean operative duration was 3 hours with an ischemic time of 33 minutes. The initial success rate of mesenteric revascularization was 93%. One early graft failure was salvaged with urgent embolectomy without bowel resection. There was no hospital mortality, but the overall postoperative morbidity rate was 50% (n = 7). Thirteen patients (93%) were discharged within 2 weeks. Late recurrent ischemia and intestinal infarction developed in one patient, requiring emergency bowel resection. Sustained relief of symptoms was achieved in 13 of 14 patients (93%). The overall survival rates were 85% ± 10.0% and 77% ± 11.7% at 1 and 3 years, respectively. Transaortic endarterectomy is a safe and effective technique for elective primary mesenteric revascularization for patients with chronic mesenteric ischemia. This approach allows simultaneous revascularization of multiple visceral arteries and achieves durable relief of symptoms.

Visceral Artery Aneurysms: A Symptomatic Aneurysm of the Ileocolic Artery

Visceral artery aneurysm is a rare but clinically important form of vascular pathology, showing a high mortality rate in emergency surgery. Most often these aneurysms cause no symptoms and are therefore incidental findings. Reports on ileocolic artery aneurysms are rare and often anecdotal. Therapeutic procedures can be performed either surgically or by interventional therapeutic techniques. This article presents a case of ruptured ileocolic artery aneurysm and reviews the literature on this topic.

[SURGICAL TREATMENT OF AN ACUTE MESENTERIAL ISCHEMIA]

Experience of surgical treatment of 143 patients, suffering an acute mesenterial ischemia, was summarized. Isolated intestinal resection was performed in 41 patients (lethality 65.9%), intestinal resection with the mesenterial vessels thrombembolectomy--in 9 (lethality 33.3%). After performance of the combined intervention postoperative lethality was in two times lower, than after isolated intestinal resection.

Non-parametric frequency response function tissue modeling in bipolar electrosurgery

High-frequency radio energy is applied to tissue therapeutically in a number of different medical applications. The ability to model the effects of RF energy on the collagen, elastin, and liquid content of the target tissue would allow for the refinement of the control of the energy in order to improve outcomes and reduce negative side-effects. In this paper, we study the time-varying impedance spectra of the circuit. It is expected that the collagen/elastin ratio does not change over time such that the time-varying impedance is a function of the liquid content. We apply a non-parametric model in which we characterize the measured impedance spectra by its frequency response function. The measurements indicate that the changing impedance as a function of time exhibit a polynomial shift which we characterize by a polynomial regression. Finally, we quantify the uncertainty to obtain prediction intervals for the estimated polynomial describing the time variation of the impedance spectra.

[Surgical treatment of a female patient with type III nonspecific aortoarteritis]

Described herein is a case report of a severe lesion of the arterial system in non-specific aortoarteritis: lesion of the aortic arch branches, thoracoabdominal segment of the aorta, abdominal aorta, visceral and renal arteries, thus underlining a multiple nature of the lesion of the aorta and its branches in the pathology concerned. Diagnosis of lesions of the aorta and its branches was made by means of multispiral computed tomography (MSCT), being the most informative method of examination in this cohort of patients, making it possible to accurately diagnose both the degree of the lesion and its extension, to choose an optimal surgical policy, to carry out dynamic follow up of the condition of the reconstructed arterial segments.

Colorectal resection in deep pelvic endometriosis: Surgical technique and post-operative complications

AIM: To investigate the impact of different surgical techniques on post-operative complications after colorectal resection for endometriosis.

METHODS: A multicenter case-controlled study using the prospectively collected data of 90 women (22 with and 68 without post-operative complications) who underwent laparoscopic colorectal resection for endometriosis was designed to evaluate any risk factors of post-operative complications. The prospectively collected data included: gender, age, body mass index, American Society of Anesthesiologists risk class, endometriosis localization (from anal verge), operative time, conversion, intraoperative complications, and post-operative surgical complications such as anastomotic dehiscence, bleeding, infection, and bowel dysfunction.

RESULTS: A similar number of complicated cases have been registered for the different surgical techniques evaluated (laparoscopy, single access, flexure mobilization, mesenteric artery ligation, and transvaginal specimen extraction). A multivariate regression analysis showed that, after adjusting for major clinical, demographic, and surgical characteristics, complicated cases were only associated with endometriosis localization from the anal verge (OR = 0.8, 95%CI: 0.74-0.98, P = 0.03). After analyzing the association of post-operative complications and each different surgical technique, we found that only bowel dysfunction after surgery was associated with mesenteric artery ligation (11 out of 44 dysfunctions in the mesenteric artery ligation group vs 2 out of 36 cases in the no mesenteric artery ligation group; P = 0.03).

CONCLUSION: Although further randomized clinical trials are needed to give a definitive conclusion, laparoscopic colorectal resection for deep infiltrating endometriosis appears to be both feasible and safe. Surgical technique cannot be considered a risk factor of post-operative complications.

[Management of complications after reconstruction of mesenteric arteries]

Because of the low ischemia tolerance of abdominal organs and the comorbidities of patients with abdominal ischemic syndromes, complications after the reconstruction of visceral arteries are often severe and associated with a significant mortality rate. The possible complications after interventions on the visceral arteries and their treatment are presented. Endovascular procedures have gained an increasingly important role in many primary interventions as well as in the treatment of complications.

Ischemic colitis due to a mesenteric arteriovenous malformation in a patient with a connective tissue disorder

Ischemic colitis is a rare, life-threatening, consequence of mesenteric arteriovenous malformations. Ischemia ensues from a steal phenomenon through shunting, and may be compounded by the resulting portal hypertension. Computed tomographic angiography is the most common first-line test because it is quick, non-invasive, and allows for accurate anatomic characterization. Also, high-resolution three-dimensional images can be created for treatment planning. Magnetic resonance angiography is similarly sensitive for vascular mapping. Conventional angiography remains the gold standard for diagnosis and also allows for therapeutic endovascular embolization. Our patient underwent testing using all three of these modalities. We present the first reported case of this entity in a patient with a vascular connective tissue disorder.

[Modern approach to diagnosis and treatment of acute mesenteric ischemia]

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.

[Occlusive stenosis of unpaired visceral branches--diagnosis and treatment]

Peculiarities of clinical signs, diagnosis and results of surgical treatment for the occlusion-stenotic affection of truncus coeliacus (TC) and upper mesenterial artery in 46 patients were analyzed. Algorithm of diagnosis of abdominal ischemia syndrome was elaborated. Angiography or multispiral computeric tomography constitute a definite method for the TC stenosis diagnosis. The presence of the TC stenosis more than 50% of its lumen and the hemodynamics disorder, in accordance to the ultrasound duplex scanning data, constitute the indication for surgical treatment of patients. Good results of treatment were achieved in 86.4% of the patients.

Augmented reality-guided artery-first pancreatico-duodenectomy

BACKGROUND

Augmented Reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim to visualize unapparent anatomical details. The potential of AR navigation as a tool to improve safety of the surgical dissection is presented in a case of pancreatico-duodenectomy (PD).

METHODS

A 77-year-old male patient underwent an AR-assisted PD. The 3D virtual anatomical model was obtained from thoraco-abdominal CT scan using customary software (VR-RENDER®, IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM®, Karl Storz, Tüttlingen, Germany) as well as different visible landmarks (inferior vena cava, left renal vein, aorta, superior mesenteric vein, inferior margin of the pancreas). A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Dissection of the superior mesenteric artery and the hanging maneuver were performed under AR guidance along the hanging plane.

RESULTS

AR allowed for precise and safe recognition of all the important vascular structures. Operative time was 360 min. AR display and fine registration was performed within 6 min. The postoperative course was uneventful. The pathology was positive for ampullary adenocarcinoma; the final stage was pT1N0 (0/43 retrieved lymph nodes) with clear surgical margins.

CONCLUSIONS

AR is a valuable navigation tool that can enhance the ability to achieve a safe surgical resection during PD.

Emergency pancreaticoduodenectomy for bleeding pancreatic pseudoaneurysm in patient with common mesentery and replaced right hepatic artery

Pancreaticoduodenectomy is infrequently performed in emergency, so much the less in lack of traumatic evidence.A rare vascular complication of the pancreatic pseudocyst,the pseudoaneurysm, presents as a pulsating malformation which may lead to life-threatening bleeding if left untreated.Its optimal treatment remains controversial. Most authors agree that angioembolization is the first step to stabilize the patient's condition, with further surgery if such be the case.We herein report an unusual case of pancreatic head pseudocyst complicated with a bleeding pseudoaneurysm arising from the inferior pancreaticoduodenal artery, in a patient with multiple comorbid conditions, common mesentery,hepatic artery variant and hemodynamic instability. An emergency early retropancreatic approach pancreaticoduodenectomy was performed with uneventful immediate and long-term outcome. We highlight that emergency surgery allowed both rapid control over the bleeding with hemostasis and removal of the pseudocyst. This is particularly relevant in high-risk patients in whom selective angioembolization is no more of choice.

Tumor necrosis factor-α mediates JNK activation response to intestinal ischemia-reperfusion injury

AIM: To investigate whether tumor necrosis factor-α (TNF-α) mediates ischemia-reperfusion (I/R)-induced intestinal mucosal injury through c-Jun N-terminal kinase (JNK) activation.

METHODS: In this study, intestinal I/R was induced by 60-min occlusion of the superior mesenteric artery in rats followed by 60-min reperfusion, and the rats were pretreated with a TNF-α inhibitor, pentoxifylline, or the TNF-α antibody infliximab. After surgery, part of the intestine was collected for histological analysis. The mucosal layer was harvested for RNA and protein extraction, which were used for further real-time polymerase chain reaction, enzyme-linked immunosorbent assay and Western blotting analyses. The TNF-α expression, intestinal mucosal injury, cell apoptosis, activation of apoptotic protein and JNK signaling pathway were analyzed.

RESULTS: I/R significantly enhanced expression of mucosal TNF-α at both the mRNA and protein levels, induced severe mucosal injury and cell apoptosis, activated caspase-9/caspase-3, and activated the JNK signaling pathway. Pretreatment with pentoxifylline markedly downregulated TNF-α at both the mRNA and protein levels, whereas infliximab pretreatment did not affect the expression of TNF-α induced by I/R. However, pretreatment with pentoxifylline or infliximab dramatically suppressed I/R-induced mucosal injury and cell apoptosis and significantly inhibited the activation of caspase-9/3 and JNK signaling.

CONCLUSION: The results indicate there was a TNF-α-mediated JNK activation response to intestinal I/R injury.

[Mobilization of the stomach and colon using high-frequency electric welding of tissues apparatus]

The experience of the native high-frequency electrical generator 300M EC-1 "Patonmed" for mobilization of advanced vascular network, particularly stomach and colon are presented. The variants of modes depending on the diameter of blood vessels and accompanied diseases are suggested.

Softball injury causing haemoperitoneum due to ruptured Meckel's mesodiverticular band

A 16-year-old male sustained an intra-abdominal haemorrhage after diving for last base during a softball game. At laparotomy a ruptured patent mesodiverticular band supplying a large Meckel's diverticulum was found. Traumatic rupture of a mesodiverticular band leading to massive intra-abdominal haemorrhage is a rare event, and has never been reported as a single injury or in the context of a sport's injury.

Outcome following mesenteric artery revascularisation for chronic mesenteric ischemia

AIM

The purpose of this study was to review the clinical presentation and diagnosis of chronic mesenteric ischaemia (CMI) and to evaluate the early results and late outcome of mesenteric revascularisation.

METHODS

This retrospective study included 15 patients with CMI diagnosed between January 2000 and September 2006. Mesenteric revascularisation was done using either transluminal angioplasty, stenting, endarterectomy or bypass graft. Patients were followed up with Duplex scan and/or computed tomographic angiogram to confirm graft patency.

RESULTS

Sixteen revascularisation procedures were done in 15 patients. Aorto-superior mesenteric artery (SMA) bypass in 9 patients, SMA endarterectomy in 2 patients, transluminal angioplasty in 2 patients, stenting in 2 patients and right common iliac to common hepatic artery bypass in 1 patient with previous failed aorto-SMA graft. There were no perioperative deaths or early procedural complication. Two patients had late graft thrombosis and symptomatic recurrence. One of the three late deaths was due to graft thrombosis and bowel infarction, and the other two died of acute myocardial infarction and disseminated bronchogenic carcinoma respectively.

CONCLUSION

We conclude that mesenteric revascularisation for CMI is successful for most patients with symptomatic relief, low mortality and a good long term graft patency.

Changes in the activities of semicarbazide-sensitive amine oxidase in inferior mesenteric artery segments and in serum of patients with type 2 diabetes

This study aimed to evaluate the semicarbazide-sensitive amine oxidase (SSAO) activity in human arterial tissues and in serum of patients with type 2 diabetes. The SSAO activity, with (14)C-benzylamine as substrate, was measured in homogenates of human inferior mesenteric arteries obtained at surgery, from 10 patients with type 2 diabetes and 16 non-diabetic patients and in the serum of 39 patients with type 2 diabetes and 40 non-diabetic control patients. The SSAO activity in the homogenates of vascular tissue was significantly lower in the diabetics than in the non-diabetics (P = 0.001). The SSAO activity in the serum of patients with type 2 diabetes was higher when compared with control group (P = 0.0001). In conclusion, the SSAO activity increased in the serum and decreased in the arterial tissue. These findings suggest damage in the vascular tissue and support the hypothesis that serum SSAO may be a useful biochemical marker for diabetes.

[Long-term follow up after surgery for intractable ascites]

The aim of the study is to evaluate the outcome of a selected group of 24 patients who underwent surgery for refractory ascites, in a 10 years period, 1995-2005.

CLINICAL DIAGNOSIS

Alcoholic cirrhosis (n=18), inferior cava thrombosis (n=2), splenic vein thrombosis (n=1), cryptogenic cirrhosis (n=3), with association of variceal bleeding and refractory ascites. The surgical procedures consisted of porto-sistemic shunts (n=12), peritoneo-saphene shunts (n=10), mesenterico-caval shunt (n=1), mesenterico-right atrium shunt (n=1). Early results were very good: no postoperative mortality, no general haemo-dinamic failure, no renal fonctional failure, no encephalopathy. 7 of 10 peritoneo-saphene shunts had an excelent evolution, but in three cases the results were unsatisfactory, the patients continuing the medical treatment. Except one patient who died after 2 years, for B virus and alcoholic abuse, all the patients survived 5 or more years. There was not evidence of digestive hemorrhage or uncontrolable encephalopathy and thrombocytopenia. The grade of esophageal varices was mantained lower than II, ascites remained minimum or absent, and biological parameters were normal or slightly elevated.

CONCLUSIONS

In the absence of the technical and economical possibilities of TIPS and liver transplantation, surgery for intractable ascites is a good option in selected patients, especially in the absence of viruses and alcohol consumption, and can improve complications in the natural evolution of the disease.

Mesenteric revascularisation in a young patient with antiphospholipid syndrome and fibromuscular dysplasia: report of a case and review of the literature

Fibromuscular dysplasia or fibromuscular hyperplasia is a rare non-atherosclerotic and non-inflammatory vascular disease that primarily involves medium-size and small arteries, most commonly the renal and carotid arteries, and less frequently the vertebral, iliac, subclavian or visceral arteries (mesenteric, hepatic, splenic). Antiphospholipid syndrome is one of the most commonly acquired hypercoagulable states, defined by the association of laboratory evidence of anti-phospholipid antibodies with arterial or venous thrombosis or recurrent pregnancy losses. The presence of these antibodies is associated with an increased risk of thromboembolic phenomena, including peripheral thrombophlebitis, pulmonary thromboembolism, stroke, retinal artery occlusion, myocardial infarction, placental thrombosis and Budd-Chiari syndrome. In this report we discuss the uncommon case of a young male patient with both antiphospholipid syndrome and fibromuscular dysplasia that came to our attention for pulmonary embolism and "angina abdominis" due to occlusion of three mesenteric vessels. The possible relationship between antiphospholipid syndrome and fibromuscular dysplasia encountered in our patient still remains unclear. We treated the patient as if he had the two different diseases. After partial failure of endovascular surgery, the patient underwent surgery with reimplantation of three visceral arteries to the aorta. Subsequently he was treated with stent placement after development of a re-stenosis of one of the three reimplanted visceral arteries. The patient was treated conservatively for antiphospholipid syndrome with anticoagulant oral therapy for life.

Clinical Approach to Chronic Gastrointestinal Ischaemia: From 'Intestinal Angina' to the Spectrum of Chronic Splanchnic Disease

Stenotic disorders of the splanchnic arteries are not rare, and it is generally assumed that symptoms are rare in patients with a single splanchnic stenosis, and even in patients with multiple-vessel stenoses. Currently, only gastric exercise tonometry aids the diagnostic evaluation, as it indicates actual ischaemia. Patients with stenotic disorders without complaints are referred to as having chronic splanchnic disease (CSD) and those with ischaemic complaints as having chronic splanchnic syndrome (CSS). The classical presentation of CSS, including the triad postprandial pain, weight loss and upper abdominal bruit, is also known as 'intestinal angina'. From the experience of our multidisciplinary working team on gastrointestinal ischaemia in 110 patients with stenoses of at least one splanchnic artery, two different clinical patterns were observed. In our series approximately 60% of patients with single-vessel stenoses, including the coeliac artery compression syndrome, have CSS. They have fewer complications, very low mortality, but most can be successfully treated by stenting or surgical treatment. Patients with multivessel splanchnic stenoses have more classical ischaemic complaints. Progression to a bowel infarction was seen in 34%, and mortality was 21%, mostly from bowel or myocardial infarction. Treatment should be tailored based upon perioperative risk assessment and local vascular anatomy. This may consist of autologous arterial bypass of one or two vessels, preferably antegrade. stenting or a combination of both. This differentiation between single- and multivessel splanchnic disease has considerable consequences for optimal work-up and treatment.

Activated protein C prevents deleterious effects of remote reperfusion injury caused by intestinal ischemia on wound healing in the left colonic anastomoses: an experimental study in the murine model

BACKGROUND

Activated protein C (APC) is a serine protease with anticoagulant and antiinflammatory activities. The delaying effects of remote reperfusion injury on the wound-healing process in colonic anastomoses have been previously shown. In this study, we aimed to investigate whether APC protects against deleterious systemic effects of intestinal ischemia/reperfusion (I/R) injury on colonic anastomotic wound healing process.

METHODS

Male Wistar-albino rats were randomly allocated into 4 groups, and a left colonic anastomosis was performed in all animals: (1) sham-operated group, simultaneously with left colonic anastomosis, the superior mesenteric artery and collateral branches were divided from the celiac axis, and the inferior mesenteric artery were isolated but not occluded (group 1, n = 12), (2) sham + APC group, identical to group 1 except for APC treatment (100 microg/kg, intravenously, 15 minutes before construction of the colonic anastomosis), (group 2, n = 12), (3) intestinal I/R group, 60 minutes of superior mesenteric ischemia followed by reperfusion (group 3, n = 12), and (4) APC-treated group, (100 microg/kg, intravenously, 15 minutes before reperfusion) (group 4, n = 12). All animals were sacrificed, and colonic anastomotic bursting pressures were measured in vivo on day 7. Tissue samples were obtained for analysis of hydroxyproline contents, nitrate/nitrite levels, and activities of oxidative and antioxidative enzymes. The plasma levels of proinflammatory cytokines and D-dimer were also measured.

RESULTS

Intestinal I/R led to significant decreases in colonic anastomotic bursting pressures, tissue hydroxyproline contents, and activities of antioxidative enzymes, along with increases in tissue nitrate/nitrite levels, activities of oxidative enzymes, and plasma levels of proinflammatory cytokines and D-dimer (P < .05). However, APC treatment led to significant increases in colonic anastomotic bursting pressures, tissue hydroxyproline contents, and activities of antioxidative enzymes, along with decreases in tissue nitrate/nitrite levels, activities of oxidative enzymes, and plasma levels of proinflammatory cytokines and D-dimer (P < .05).

CONCLUSION

This study clearly showed that APC treatment prevented the delaying effects of remote I/R injury on colonic anastomotic wound healing process. Further clinical studies are required to determine whether APC has a useful role in the enhancement of colonic anastomotic wound healing after particular operations in which I/R injury occurs.

[Acute mesenteric ischemia]

Acute mesenteric ischemia is not an isolated clinical entity, but a complex of diseases, including acute mesenteric arterial embolus and thrombus, mesenteric venous thrombus, and nonocclusive mesenteric ischemia. These diseases have common clinical features caused by impaired blood perfusion to the intestine, bacterial translocation, and systemic inflammatory response syndrome. There is substantial evidence that the mortality associated with acute mesenteric ischemia varies according to its trigger cause. Nonocclusive mesenteric ischemia is the most lethal form of the acute mesenteric ischemia, because of the poor understanding of its pathophysiology and its mild and nonspecific symptoms, which often delay its diagnosis. Mesenteric venous thrombosis is much less lethal than acute thromboembolism of the superior mesenteric artery and nonocclusive mesenteric ischemia. In this articles we presents an overview of acute mesenteric ischemia, based on the research. Although the mortality rates, in acute mesenteric ischemia, have remained high over the last few decades, accumulated knowledge on this condition is expected to improve its prognosis.

Successful treatment of postoperative acute hepatic artery obstruction with mesenteric arterioportal shunt

Fatal biliary complications and liver abscesses are likely in cases of acute hepatic arterial occlusion after hepatobiliary surgery with bilioenteric anastomosis. A 60-year-old man with hilar hepatic metastasis of gastric cancer underwent curative surgery. While the recurrent nodule was removed with the involved bile duct, vascular structures were preserved. Massive bleeding from the hepatic artery occurred suddenly on postoperative day 3, and the hepatic artery was ligated to stop bleeding. As Doppler ultrasonography indicated no arterial flow in the liver, a side-to-side mesenteric arterioportal shunt was created to prevent ischemic complications. Postoperative angiography showed fine patency of the shunt, and ischemic complications were avoided. However, the patient suddenly experienced massive hematemesis and fell into shock four months after the shunt operation. Upper gastrointestinal fiberoscopy showed serious varices throughout the whole esophagus. Angiographic examination indicated excessive shunt flow and markedly expanded mesenteric veins. The shunt was then occluded by coil embolization, but the patient did not recover from shock and eventually died. In the present case, the mesenteric arterioportal shunt appeared to be effective in relieving postoperative acute hepatic arterial occlusion. However, the shunt should be closed as soon as collateral blood flow is completed.

Laparoscopic D3 lymph node dissection with preservation of the superior rectal artery for the treatment of proximal sigmoid and descending colon cancer

In this paper we report a technique for laparoscopic lymph node (LN) dissection for descending and proximal sigmoid colon cancer with the preservation of the superior rectal artery (SRA) to maintain the blood supply to the distal sigmoid colon. Five (5) cases were included from November 2004 to March 2005. For D3 LN dissection, the root of inferior mesenteric artery was exposed with ultrasonic cutting and coagulating surgical device to avoid bleeding. The arterial wall was then exposed with a spatula-type electric cautery down to the left colic artery (LCA). The LCA was then clipped and cut while preserving the SRA. The inferior mesenteric vein was divided at the caudal side of the LCA and prior to joining to the splenic vein. All cases underwent a LN dissection laparoscopically. There were no cases of complications originating from the LN dissection. Although long-term outcomes should be investigated, our results indicate that this is a safe, applicable method.

Impact of genetic background and aging on mesenteric collateral growth capacity in Fischer 344, Brown Norway, and Fischer 344 x Brown Norway hybrid rats

Available studies indicate that both genetic background and aging influence collateral growth capacity, but it is not known how their combination affects collateral growth. We evaluated collateral growth induced by ileal artery ligation in Fischer 344 (F344), Brown Norway (BN), and the first generation hybrid of F344 x BN (F1) rats available for aging research from the National Institute on Aging. Collateral growth was determined by paired diameter measurements in anesthetized rats immediately and 7 days postligation. In 3-mo-old rats, significant collateral growth occurred only in BN (35% +/- 11%, P < 0.001). The endothelial cell number in arterial cross sections was also determined, since this precedes shear-mediated luminal expansion. When compared with the same animal controls, the intimal cell number was increased only in BN rats (92% +/- 21%, P < 0.001). The increase in intimal cell number and the degree of collateral luminal expansion in BN rats was not affected by age from 3 to 24 mo. Immunohistochemical studies demonstrated that intimal cell proliferation was much greater in the collaterals of BN than of F1 rats. The remarkable difference between these three strains of rats used in aging research and the lack of an age-related impairment in the BN rats are novel observations. These rat strains mimic clinical observations of interindividual variation in collateral growth capacity and the impact of age on arteriogenesis and should be useful models to investigate the molecular mechanisms responsible for such differences.

Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms

AIM

This study demonstrates the therapeutic value of the hybrid open and endovascular procedure in anatomically challenging thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients.

METHODS

Between January 2000 and February 2006, 8 patients were treated with open visceral vessel revascularization and endovascular repair for TAAAs. Patient data were available from medical records. Pre- and postoperative physical examination, intra-arterial angiography, and spiral computed tomography scanning was performed in prearranged examinations.

RESULTS

A total of 28 visceral bypasses were performed in the 8 patients: 6 patients with complete visceral vessel revascularization and 2 with an aorto-mesenteric-celiac bypass. Aneurysm exclusion was achieved through the deployment of in total 23 stent-grafts. Seven out of the 8 procedures were conducted electively and one under urgent conditions. The mean follow-up period was 21 months. We recorded one procedure-related death due to postoperative hemorrhage resulting from diffuse retroperitoneal bleeding with consecutive multiorgan failure. Moreover, one patient developed acute renal insufficiency, but returned to normal values after temporary hemodialysis. Major adverse events included 2 cases of pneumonia and one myocardial infarction. Two reoperations were performed due to one mesenteric bypass occlusion and one groin hematoma. No neurological complications were observed.

CONCLUSION

The combined hybrid endovascular and open surgical approach in the treatment of complex TAAAs remains a feasible and effective operation technique. The less invasive character of the procedure and avoidance of aortic-cross clamping are clear advantages. Nevertheless, further study is mandatory to establish this alternative therapeutic option for complex TAAAs.

Modification in the technique of pancreaticoduodenectomy: supracolic division of jejunum to facilitate uncinate process dissection

Pancreaticoduodenectomy remains the recommended procedure for periampullary and pancreatic head tumors. The dissection of the uncinate process from the superior mesenteric vessels is a key step in this surgery. We describe a modification in the existing practice of infracolic division of the jejunum in order to facilitate this step. In this modification, the duodenojejunal (DJ) flexure and the proximal jejunum are delivered into the supracolic compartment and then the jejunum is divided. This exposes the uncinate process completely and facilitates the separation from the Superior Mesenteric Artery (SMA) and the Superior Mesenteric Vein (SMV). We have successfully employed this modified technique for 33 resections since February 2004. This modification of dividing the jejunum in the supracolic compartment is based on sound anatomic and embryologic grounds. It helps in aligning the uncinate process with the jejunal mesentery thereby making the dissection of uncinate process from the superior mesenteric vessels safe and complete.

Ileocolon Graft Pedicled on Ileocolic Artery: An Alternative Esophageal Substitute for Corrosive Injury

A variety of bowel interpositions have been well-developed for esophageal replacement surgery. However the choices are often limited in the case of alimentary corrosive injury due to frequent associated injuries. Herein we present a case of caustic injury with compromised mesocolon. Successful reconstruction of the alimentary integrity was accomplished using an ileocolic graft pedicled on an ileocolic artery.

Preliminary retrograde visceral artery reconstruction for thoracoabdominal aortic aneurysms

The recent availability of thoracic endografts has expanded the options for treatment of thoracoabdominal aortic pathology. However, disease that involves the visceral aortic segment presents a special challenge due to the need to preserve mesenteric perfusion. We present three patients in whom preliminary retrograde visceral artery reconstruction was used as an adjunct prior to endovascular repair.

Blood gas analysis of the jejunum in the supercharge technique: to what degree does circulation improve?

BACKGROUND

The supercharge technique has become widely prevalent in the field of esophageal reconstruction. Despite the logical advantages with this technique, the actual degree of its effect on the blood circulation is not clear. There may be cases in which the supercharge technique is not necessary for survival of the jejunum. To decide whether or not the supercharge technique is indicated, it is crucial to know how effective it is in improving blood flow to the jejunum.

METHODS

The effect of the additional vessel anastomosis in the pedicled jejunal transfer was evaluated by blood gas analysis of the venous blood in the mesenteric vein. In 27 patients undergoing pedicled jejunal transfer with additional vessel anastomosis using the internal mammary vessels for reconstruction of the thoracic esophagus, intraoperative blood sampling was performed three times: before anastomosis, after venous anastomosis, and after venous and arterial anastomosis.

RESULTS

The venous partial pressure of oxygen showed little increase after the venous anastomosis (mean, 115.7 percent; p = 0.0022). In contrast, venous partial pressure of oxygen increased markedly after the arterial and venous anastomosis in most of the patients (mean, 177.8 percent; p < 0.0001). Similarly, venous partial pressure of carbon dioxide, after both anastomoses, decreased to a lower level than before the additional anastomosis in most patients (mean, 93.1 percent; p = 0.035).

CONCLUSION

The authors conclude that the additional anastomosis of both the artery and the vein is recommended if it is possible.

Durch Thrombelastographie gesteuertes perioperatives Gerinnungsmanagement

Uncontrolled bleeding is one of the main reasons for a lethal outcome of severe trauma. Loss, consumption and dilution of clotting factors and platelets induce a complex acquired coagulopathy. Beside surgical control of bleeding, early and precise coagulation therapy is essential for successful treatment. We report on a patient whose life-threatening bleeding and perioperative coagulopathy after a knife injury to the aorta was successfully treated by surgical control of the bleeding and subsequent targeted coagulation therapy with factor concentrates and fresh-frozen plasma. The coagulopathy was diagnosed and managed by means of bed-side thrombelastography.

CTA and MRA in Mesenteric Ischemia: Part 2, Normal Findings and Complications After Surgical and Endovascular Treatment

OBJECTIVE

A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting.

CONCLUSION

We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.

Short to Midterm Outcomes of Fenestrated Endovascular Grafts in the Treatment of Abdominal Aortic Aneurysms:A Systematic Review

PURPOSE

To perform a systematic review of the short to midterm outcomes of fenestrated endovascular grafts in patients with abdominal aortic aneurysms (AAA).

METHODS

A search of PubMed and Medline databases for English-language literature was performed to find studies published between 1999 and 2006. Studies investigating the short to midterm results of fenestrated endovascular grafts for AAA were analyzed for clinical outcomes and postprocedural complications.

RESULTS

Nineteen studies involving fenestrated endovascular grafting were retrieved, and 6 of them met criteria for inclusion in the analysis. The remaining studies were excluded because they dealt with technical or case reports or cumulative addition of previous cases. Pooled estimates (95% confidence interval) of postprocedural complications were 1.1% (0.4%-2.7%) for 30-day mortality; 8.3% (2.9%-13.6%) for late mortality; 97% (92%-100%) and 90% (85%-95%) for perfusion of fenestrated vessels at perioperative and late follow-up, respectively; 13.3% (4.1%-22.5%) for postprocedural renal dysfunction; and 11.2% (3.2%-22.5%) and 9.4% (2.6%-16.3%) for early and late endoleak, respectively. There was correlation between preoperative renal insufficiency and postprocedural renal dysfunction, although this was not a statistically significant difference (p=0.2).

CONCLUSION

Our systematic review showed that fenestrated endovascular grafting provides an alternative technique to treat patients with complex aneurysm necks, achieving lower mortality than open repair under comparable conditions. Preoperative renal impairment is a strong indicator of postoperative renal dysfunction. Long-term stability and patency of the fenestrated vessels deserves to be validated.

[Augmented regional pancreatoduodenectomy ensures an excellent pain control for the case with pancreatic cancer invading the superior mesenteric artery and vein]

A 49-year-old woman with a complaint of severe abdominal pain and lumbargo was diagnosed with pancreatic cancer invading the superior mesenteric artery and vein. Since the lesion was unresectable by general Whipple's procedure, she was treated with gemcitabine and opiate. However, these treatments resulted in failure due to the side effects such as bone marrow suppression, severe nausea, and constipation. After the bone marrow suppression disappeared, she received augmented regional pancreatoduodenectomy, which is a pylorus preserving pancreatoduodenectomy with resection of the superior mesenteric artery and vein. Consequently, she could have a good QOL without opiates.

Antegrade revascularization for chronic mesenteric ischaemia

OBJECTIVE

to evaluate the short- and long-term results, obtained after open revascularization for chronic mesenteric ischaemia as a reference in a field with growing interest for PTA and stenting.

MATERIALS AND METHODS

we reviewed 14 patients with 15 antegrade revascularizations for chronic intestinal ischaemia, between 1996 and 2003: ten bypasses either to the celiac trunk or to the mesenteric artery and five bifurcated bypasses to both arteries were performed. There was one reimplantation for Wilki syndrome. Graft patency was monitored for a mean period of 24 months (range 1-84 months) by clinical examination and duplex scanning.

MAIN RESULTS

one patient had recurrence of symptoms that disappeared after successful reoperation. There was one perioperative death All the other patients (84%) had a long-term symptom free survival.

CONCLUSION

antegrade mesenterial revascularization through an upper abdominal approach is an excellent technique with good long-term results. It sets a high standard that will be difficult to obtain with mesenteric PTA and stenting. It remains the preferred method of revascularization in low-risk patients.

Combined Staged Procedures for the Treatment of Thoracoabdominal Aneurysms

PURPOSE

To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair.

METHODS

A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33-77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV).

RESULTS

The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7-30) for the visceral bypass and 12 (3-25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0-14) in hospital.

CONCLUSION

Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated.