Leiomyosarcoma of the inferior vena cava: Clinical experience with four cases

BACKGROUND: Leiomyosarcoma of the inferior vena cava is a rare tumor that presents in an insidious manner with non-specific symptoms. Given its rarity, there are no consensus guidelines to its management. The aim of this study was to report the clinical experience in the management of patients presenting to our institution during a 12 year period. PATIENTS AND METHODS: Four patients with leiomyosarcomas of the inferior vena cava were managed at our institution during the period reviewed. Patient details were identified through a search of the pathology department computerized database, and case notes were retrospectively reviewed to obtain details of presentation and management. RESULTS: There were 3 females and 1 male with a mean age of 59 years. All tumors were identified within 2 months of first symptoms. Three of the 4 had localized tumors whilst 1 patient had lung metastases at presentation. The three patients with resectable tumors underwent radical surgical excision of the tumor, and two patients had postoperative radiotherapy. One patient died of recurrence at 7 months, and another at 30 months. The third patient is currently well and disease free at 16 months. The fourth patient with metastatic disease was treated with chemotherapy alone and survived 36 months. CONCLUSION: Leiomyosarcoma of the inferior vena cava is an uncommon tumor that presents with non-specific symptoms. At the time of presentation, tumors are usually large and resection is challenging but probably offers the best opportunity for long-term survival

Mid-Term Outcomes of the Iliac Branch Endoprosthesis with Standardized Combinations of Bridging Stent-Grafts for Endovascular Treatment of Aortoiliac Disease with or Without Co-existing Hypogastric Aneurysms (The HYPROTECT Study)

Purpose: To evaluate retrospectively the 2-year outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) in patients with and without coexisting hypogastric artery (HA) aneurysms in a large contemporary multicentric European experience using dedicated bridging devices.Methods: The study included all consecutive patients treated at participating institutions with the Gore Excluder IBE device who received a covered stent (i.e., stent-graft) from the same manufacturer. Technical success was defined as deployment of endografts with complete exclusion of the aneurysm(s), patency of target vessels, and absence of type 1 and 3 endoleak. Assessment of follow-up outcomes included freedom from HA branch instability defined as the composite cumulative endpoint of any HA branch-related complication.Results: A total of 437 patients were included for analysis from 22 European vascular surgery centers. Patients were categorized into two subgroups: subgroup A (n = 269) if they did not have concomitant hypogastric aneurysms, otherwise they were categorized into subgroup B (n = 168). Finally, 78 (18%) had bilateral IBE with a total of 515 IBE included in the study. Balloon expandable stents were deployed in 19 (6.3%) subgroup A patients compared with 46 (21.7%,) in subgroup B, p &lt;.001. The two-year estimate for freedom of HA branch instability was significantly higher for patients in group A as compared with patients in group B (94% vs. 90%, p =.045). At univariate regression, the number of stent-grafts used was associated with higher risk of iliac branch instability (p =.021), while in multivariate regression for the use of more than 2 bridging stent-grafts the risk of instability increased by 2.35 times.Conclusions: This large contemporary European multicentric experience with the use of the Gore Excluder IBE in patients with or without associated HA aneurysms shows satisfactory mid-term outcomes when the device is used in conjunction with both self-expandable and balloon-expanding stent-grafts from the same manufacturer. Although primary patency of the iliac branch was as high as 90%, caution and strict follow-up must be exercised when multiple bridging stent-grafts are used over longer distances.</p

Percutaneous mechanical thrombectomy for limb graft occlusion after endovascular aneurysm repair: Results of a case series

Objective Limb graft occlusion (LGO) is a recognised complication after endovascular aneurysm repair (EVAR). We present outcomes of a case series of LGO treated by percutaneous mechanical thrombectomy (PMT). Methods Six male patients (mean age 70.5 ± 7.5 years) presented with LGO after EVAR ( n = 4), fenestrated EVAR with an iliac branch device ( n = 1), branched EVAR ( n = 1). Median time to occlusion was 28.5(IQR 90) weeks; all occlusions were unilateral. The presenting symptom was intermittent claudication ( n = 4), chronic limb-threatening ischaemia ( n = 1) or acute limb ischaemia ( n = 1). PMT was undertaken using the 10F Rotarex Rotational Excisional Atherectomy System (Becton, Dickinson and Company, Franklin Lakes, USA) with optional stenting/reline of the affected limb. Results LGO was cleared in all 6 cases by PMT with limb stenting ( n = 4)/limb reline ( n = 2)/outflow stenting ( n = 2). Post-operatively, novel oral anticoagulant therapy supplemented prior antiplatelet therapy in all cases. Length of stay was 2 (IQR 19) days. All cleared limbs remain patent at median 15 (IQR 185) weeks follow-up. Conclusion This case series indicates that percutaneous mechanical thrombectomy is associated with high technical success rates and subsequent acceptable ensuing short-to-midterm patency. This approach is a valid alternative to surgical interventions in such cases, and represents our primary approach when LGO is encountered after EVAR. </jats:sec

The Feasibility of Reentry Device in Recanalization of TASC C and D Iliac Occlusions

Aim: To determine the feasibility of subintimal angioplasty (SIA), aided by reentry device in iliac artery occlusions. Methods: Forty-eight patients with severe claudication (Fontaine-III, n = 24) or critical limb ischaemia (Fontaine-IV, n = 24) had SIA, aided with a reentry device, for chronic iliac occlusions TASC C (n =28) and D (n = 20). The primary outcome was arterial patency at duplex follow-up. Secondary outcomes were primary failure, postprocedural complications, stent use, late occlusions, and length of hospital stay. Results: The patency rate was 89% at a mean follow-up of 13 (±11) months. There were 2 primary failures, no postprocedural complications, and 5 late occlusions. Almost 80% of patients were ready for discharge within 24 hours. Conclusions: Subintimal angioplasty with a reentry device for long iliac occlusions provides a feasible option with excellent results and short hospital stay. A randomized trial of SIA of iliac occlusion versus open reconstruction is now required. </jats:p

Emergency Repair of a Symptomatic Arch Aneurysm due to a Type B Aortic Dissection Using a Repurposed Three Vessel Branched Endograft

Introduction: Thoracic endovascular aortic repair (TEVAR) has replaced open surgery for descending thoracic aortic pathology. Achieving a suitable proximal seal may necessitate hybrid repair involving cervical debranching, which carries risks. Alternatively, if a total endovascular solution is being attempted, parallel grafts or physician modified devices can be used. These have not, however, been designed specifically for this purpose. Branched thoracic endografts represent an evolution in stent graft design for the aortic arch. Single branched off the shelf designs are available, but multibranched designs are custom made, limiting their emergency use. Here, the successful use of a repurposed custom made triple branched endograft for a complicated acute type B aortic dissection (TBAD) with rapid false lumen expansion is reported. Report: An 84 year old man presented with a three day history of chest pain and worsening breathlessness. He had had a previous episode of acute TBAD a month earlier, managed with blood pressure control. Computed tomography angiography (CTA) revealed a left pleural effusion and an aortic dissection extending from the left subclavian artery to the aortic bifurcation. The proximal descending aortic diameter had rapidly expanded to 67 mm. To treat the patient, a custom made triple branched endograft, initially intended for a different patient, was used. Follow up CTA showed satisfactory positioning of the stent graft with no evidence of endoleak, complete false lumen thrombosis, and satisfactory aortic remodelling. Discussion: Acute TBAD remains a significant therapeutic challenge, especially when complications arise. TEVAR is recommended, but standard endografts may require full head and neck vessel debranching to ensure a proximal seal, which can be achieved by either open surgery or through endovascular means. This case demonstrates the applicability of a multibranched arch endograft in the emergency setting, which fortunately was available in the unit. Although these cases are rare, it is believed that development of a three vessel off the shelf solution should be considered

Technique for Retrieval of a Knotted and Entrapped Guide Wire After Central Venous Catheterization

Central venous catheterization is a common procedure performed in the critically ill patient. The complication associated with this invasive procedure is well established. However, complication related to the guide wire is rare. We present a case of knotted and entrapped guide wire following central venous catheterization using the Seldinger method and technique to retrieve it nonoperatively. </jats:p