Systematic review and meta-analysis of migration after endovascular abdominal aortic aneurysm repair

Aim

To identify patients who are under higher threat for migration because of an old generation stent graft application.

Methods

A systematic review and meta-analysis of the literature was undertaken to identify all studies which included older generation endografts and data reporting on graft migration after EVAR. Outcome data were pooled and combined, and were calculated using fixed or random effects models.

Results

From 2000 to 2014, 22 retrospective studies were identified reporting on stent- graft migration after EVAR (8.6%). From those patients, 39% received re-intervention with the mean time of identification ranging from 12 to 36 months. Six of these retrospective nonrandomized studies were eligible for meta-analysis. AAA diameter (AAA diameter: 0.719 mm; 95% confidence interval [CI]: 0.00065–1.4384 mm; p = 0.00497) and neck length (neck length: 4.36 mm; 95% CI: 1.3277–7.394; p = 0.0048) were the only significant factors associated with stent- graft migration. Neck diameter and neck angulation did not have any important influence on stent-graft migration.

Conclusions

Patients with large AAA and short necks who were treated with older generation stent grafts such as AneurX and Talent are in higher risk for endograft migration than others. Stent- graft migration consists of an insidious and underestimated threat.

The association of simple renal cysts with abdominal aortic aneurysms and their impact on renal function after endovascular aneurysm repair

We validated the association of simple renal cysts with abdominal aortic aneurysm and other cardiovascular factors and assessed simple renal cysts’ impact on renal function before and after endovascular abdominal aortic aneurysm repair. A retrospective analysis of prospectively collected data was conducted. Computed tomography angiograms of 100 consecutive male patients with abdominal aortic aneurysm who underwent endovascular abdominal aortic aneurysm repair (Group 1) were reviewed and compared with 100 computed tomography angiogram of aged-matched male patients without abdominal aortic aneurysm (Group 2). Patients’ demographic data, risk factors, abdominal aortic aneurysm diameter, the presence of simple renal cyst and laboratory tests were recorded. No difference was observed between the two groups in respect to other cardiovascular risk factors except hyperlipidemia with higher prevalence in Group 1 ( p < 0.05). Presence of simple renal cysts was independently associated with age ( p < 0.05) and abdominal aortic aneurysm ( p = 0.0157). There was no correlation between simple renal cysts and abdominal aortic aneurysm size or pre-operative creatinine and urea levels. No difference was observed in post-operative creatinine and urea levels either immediately after endovascular abdominal aortic aneurysm repair or in 12-month follow-up. In male patients, the presence of simple renal cysts is associated with abdominal aortic aneurysm and is increasing with age. However, their presence is neither associated with impaired renal function pre-endovascular abdominal aortic aneurysm repair and post-endovascular abdominal aortic aneurysm repair nor after 12-month follow-up.

A survey of the European Venous Forum on education and training in venous surgery and phlebology in Europe

AIM

Venous training in Europe is lacking a formal curriculum among various specialties related to management of venous diseases. We conducted a survey in order to have a snapshot on the actual education and training level among physicians practicing currently venous surgery and phlebology in Europe.

METHODS

From April 7, 2014 to June 11, 2014 a survey was carried out using the Survey Monkey system, including 11 main questions covering all the domains of training and education in venous surgery and phlebology. The questionnaire was sent to all physicians included in the current mailing list of the European Venous Forum (EVF) and the Mediterranean League of Angiology and Vascular Surgery. Two questions were particularly addressed to those physicians who had attended the EVF hands-on workshop (HOW) at least once.

RESULTS

The response rate was 24% (97/400) and 51.5% of them were practicing in a hospital service. Most responders were vascular surgeons (67.7%), followed by angiologists (19.4%). Only half of the responders felt as being competent to manage the whole spectrum of venous diseases successfully after completion of their training, while a few were able to perform endovenous ablations and even less more advanced venous interventions. Formal training in Duplex ultrasound was undertaken only in 55.2%. The majority suggested that a venous training program should be a separate part of their specialty rotation and should be organized at a national or European level, or even by a specific scientific society. Over 95% of those physicians who already participated in the EVF HOW considered the knowledge they acquired there as useful for their practice.

CONCLUSION

There is currently an important need for more specialized venous training for all physicians involved in the diagnosis and management of venous diseases. Therefore all local, national and international initiatives should be encouraged to improve education in this field.

Detection of human papillomavirus DNA in esophageal carcinoma in Greece

AIM: To detect human papillomavirus (HPV) in the esophageal mucosa and the possible relationship with esophageal cancer in Greece.

METHODS: Forty-nine patients underwent esophagogastroduodenoscopy (EGD) and esophageal biopsy at a university hospital that acts as a referral center for Northern Greece. Nineteen of these patients (14 male and 5 female) had esophageal squamous cell carcinoma (ESCC) and 30 (15 male and 15 female) did not have any reported esophageal malignancy. Histopathological assessment was followed by polymerase chain reaction analysis of all the samples. Patient demographic data (age, sex, and place of birth) and information regarding smoking habits, alcohol consumption or sexual habits were collected. A method of statistical interference, verification of hypotheses based on homogeneity and independent χ² test, was used.

RESULTS: From the 49 patients that underwent EGD and biopsy, 19 had ESCC and 30 had normal esophageal mucosa, with a mean age of 65.2 years. Regarding the prevalence of oncogenic risk factors for esophageal carcinoma, an interesting conclusion was that 78% of the patients used tobacco and almost one-third had multiple sexual partners, whereas only 20% of the patients consumed alcohol, which was not statistically significant, when compared to the control group. In the ESCC group, the only two positive samples were among the male patients (2/14 male patients with ESCC, 14.5%). No HPV was identified in the control group. The predominant HPV types identified were 11 and 31, which have a low malignancy potential. The presence of HPV DNA in the ESCC group was not statistically significant, 95% confidence interval (χ² = 3.292, P = 0.07).

CONCLUSION: This is the first relevant study in Greece, and despite the lack of statistical significance, the issue of HPV infection and ESCC does merit further investigation.

Complexity of persistent type II endoleak associated with sac expansion after endovascular abdominal aortic aneurysm repair

Type II endoleak after endovascular aortic aneurysm repair still remains the Achilles' heel of the treatment, the source of which regularly is difficult to identify and treat. We present a patient with a persistent type II endoleak associated with a continuous aneurysm sac expansion after endovascular aortic aneurysm repair for which many diagnostic modalities were used during his follow-up such as duplex scan, computed tomography angiography and magnetic resonance angiography. Attempts were undertaken to treat the source of endoleak including coil micro-embolisation of lumbar arteries and subsequent open ligation of the inferior mesenteric artery, but they failed to eliminate the endoleak. Finally, a middle sacral artery was identified as the source of the endoleak. At that time, the patient was subjected to surgery for sigmoid carcinoma, and simultaneously, a ligation of the sacral artery was undertaken which eventually eliminated the endoleak completely. This case highlights that type II endoleak may be evoked by various sources and there can be a great difficulty to identify these feeding vessels; thus, careful planning for its management is mandatory.

Combined coronary artery bypass grafting and open abdominal aortic aneurysm repair is a reasonable treatment approach: a systematic review

We reviewed the literature for studies investigating the outcomes of combined 1-stage coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) open repair (OR) procedures. An electronic search of the English literature was conducted using the PubMed, EMBASE, and Cochrane databases. Age, coronary heart disease severity, AAA size, mean duration from CABG to AAA OR procedures, details of each procedure, mortality, and morbidity rates were analyzed. Between 1994 and 2012, 12 studies (256 patients) with 1-stage treatment fulfilled the inclusion criteria and were analyzed. There were 20 early (30 days) deaths, accounting for a 30-day mortality rate of 7.8%. The early morbidity was 53% (136 of 256). One-stage treatment when necessary can be undertaken with acceptable mortality and reasonable morbidity rates considering the complexity of both the operations. Nowadays, endovascular AAA repair is preferred over OR. The outcomes of combined cardiac surgery and endovascular AAA repair have not been extensively evaluated.

Ileosigmoid fistula and delayed ileal obstruction secondary to blunt abdominal trauma: a case report

INTRODUCTION

Abdominal trauma is a source of significant mortality and morbidity. Bowel injury as a result of blunt abdominal trauma is usually evident within hours or days of the accident.

CASE PRESENTATION

A 38-year-old Caucasian Greek man presented with a subtle and delayed small bowel obstruction caused by a post-traumatic ileosigmoid fistula and ileal stricture four months after a road traffic accident.

CONCLUSION

Delayed occurrence of post-traumatic small bowel stricture and ileosigmoid fistula is an uncommon surgical emergency. General surgeons as well as emergency physicians should bear this manifestation in mind should a patient return to the hospital several weeks or even years after blunt abdominal trauma with symptoms or signs of bowel obstruction.