Atul Rao

Results of polytetrafluoroethylene-covered nitinol stents crossing the inguinal ligament

OBJECTIVE Placement of arterial endoprostheses across the inguinal ligament is generally thought to be contraindicated for fear of device kinking, fracture, or occlusion and possible obliteration of the deep femoral artery (DFA). We present a series of selected patients who underwent insertion of polytetrafluoroethylene-covered nitinol stents (Viabahn stent grafts. W. L. Gore and Associates Inc, Flagstaff, Ariz) crossing the middle common femoral artery (CFA) on an emergency basis or who were considered high risk for open surgery. METHODS We treated 16 patients with 17 lesions adjacent to or within the CFA with stent grafts that originated in the common iliac (two) or external iliac (15) artery and terminated in the distal CFA (12), DFA (three), or superficial femoral (two) artery. Stent grafts were placed on an elective (10) or emergency (seven) basis for arterial occlusive disease (10), bleeding (six), and aneurysmal disease (one). Comorbidities favoring endovascular treatment were high medical risk (10) previous scarring (four), morbid obesity (two), and dense arterial calcification precluding open surgical repair (one). RESULTS The DFA was deliberately sacrificed in one of the 17 cases. No patient suffered major complications after the procedure. All grafts remained patent based on duplex ultrasound imaging during follow-up (mean, 12.3 months; range, 1-58 months). Two patients required an additional endovascular intervention to treat inflow or outflow stenoses during follow-up, yielding a 2-year primary patency rate of 93.8% and assisted primary patency rate of 100%. CONCLUSIONS These results suggest that selective placement of Viabahn stent grafts across the inguinal ligament to treat arterial occlusive disease or bleeding may prove to be safe, effective, and associated with acceptable patency rates. This strategy helps avoid complicated open arterial surgery in high-risk patients with associated multiple medical risk factors or hostile scarred groins.

Robotic-assisted median arcuate ligament release

Median arcuate ligament syndrome results from external compression of the celiac axis by attachments of the diaphragmatic crura. It has been treated with open or laparoscopic surgical decompression of the celiac axis with neurolysis. We describe our initial experience treating three patients using a robotic-assisted technique with median arcuate ligament release and celiac neurolysis. Average operative time was 2.2 hours. No intraoperative complications occurred. At an average of 11 months postoperative (14, 11, and 8 months), two patients continue with resolution of preoperative symptoms. Our experience affirms that further study using the robotic approach appears warranted.

Peritoneal perfusion with oxygenated perfluorocarbon augments systemic oxygenation.

Background Despite maximal ventilatory support, many patients die from hypoxia in the setting of potentially reversible pulmonary failure. There remains a pressing need for additional pulmonary supportive care measures, especially techniques that do not require systemic anticoagulation. The objective of our experiments was to determine whether systemic oxygenation could be increased in a large animal, with induced hypoxia, by perfusing the abdominal cavity with oxygenated perfluorocarbons. Methods Fifteen pigs with a mean (± SD) weight of 45 ± 5 kg were intubated and rendered hypoxic by ventilating them with a blend of nitrogen and oxygen to achieve subatmospheric concentrations of inspired oxygen ranging from 18 to 10%, resulting in baseline mean Pao2 range of 65.9 ± 9.7 to 26.6 ± 2.8 mm Hg, respectively. Peritoneal perfusion was performed in eight animals with oxygenated perfluorocarbon and in seven control animals with oxygenated saline solution. Results The average increase in Pao2 with oxygenated perfluorocarbon perfusion, compared to oxygenated saline solution perfusion, ranged from 8.1 to 18.2 mm Hg. A common treatment effect was estimated across all fraction of inspired oxygen (Fio2) values, representing the average mean difference in oxygen uptake between oxygenated perfluorocarbon and saline solution, irrespective of the level of Fio2. This average was 12.8 mm Hg (95% confidence interval, 7.4 to 18.2; p < 0.001). The most clinically relevant results occurred at an Fio2 of 14%, resulting in a baseline mean Pao2 of 39.4 ± 5.0 mm Hg with oxygenated saline solution perfusion, and a mean Pao2 of 55.3 ± 7.6 mm Hg with oxygenated perfluorocarbon perfusion. This corresponded to an increase in arterial oxygen saturation from 73 to 89%. Conclusion These results of our principle experiments demonstrate that the peritoneal cavity can be used for gas exchange and, in our model, yielded clinically relevant increases in systemic arterial oxygen levels. This technique may have the potential for the supportive care of patients dying from hypoxia in the setting of reversible lung injury.

Malignant Melanoma Presenting as Obstructive Jaundice Secondary to Metastasis to the Ampulla of Vater

CONTEXT Malignant melanoma commonly metastasizes to the small intestine where it can cause pain, bleeding, and obstruction. However, jaundice from metastatic melanoma is relatively uncommon. CASE REPORT A case of known malignant melanoma presenting as new onset obstructive jaundice as a result of a rarely reported metastasis to the ampulla of Vater. CONCLUSION Multidisciplinary management of patients with metastatic melanoma is essential.

An interesting anatomic variant of inferior vena cava duplication: case report and review of the literature:

Congenital anomalies of the inferior vena cava (IVC) occur in roughly 4% of the population. We report an interesting case of an atypical variant of duplicated IVC. A 20-year-old man presented with orthopedic injuries and intracranial hemorrhage following a motorcycle accident. He was taken to the fluoroscopy suite for IVC filter placement; duplication of the IVC was noted. The right and left iliac veins shared a normal confluence but two IVCs drained independently into renal veins before reuniting into a single structure. Both IVC filters were placed via a single puncture in the groin. We performed a search of the PubMed database using ‘inferior vena cava duplication’ and reviewed common anomalies of the IVC. Several variants of duplicated IVC exist; the most common of which is two distinct IVCs that arise from each iliac vein without a normal confluence. Our patient had a unique anomaly which allowed filter placements from a single puncture.

Diagnostic and treatment modalities for autoimmune pancreatitis

Since the recognition of autoimmune pancreatitis (AIP) as a clinical entity, many advances have been made in defining clinical, radiologic, histologie, and laboratory parameters to assist in a complete definition of the disease. Despite all these efforts, a preoperative diagnosis still remains a clinical challenge but is of paramount importance, as these cases have been reported to be steroid-responsive; therefore, early treatment may obviate the need for surgical resection. Although the utilization of recently proposed guidelines by the Japanese Pancreas Society and an Italian study group may further assist the clinician and prompt the initiation of steroid treatment, the response to therapy should be observed within 2 to 4 weeks and reflected in progressive resolution of the presenting radiologic and laboratory abnormalities. Should these fail to demonstrate improvement, the diagnosis of AIP should undergo re-evaluation, and consideration for surgical exploration should be made, as the patient may be harboring a malignancy. Surgical resection in the form of pylorus-preserving pancreaticoduodenectomy remains the optimal solution in the attempt to clarify the diagnosis and offer treatment with low complication rates.

Coral reef aorta: case report and review of the literature.

Coral reef aorta (CRA) is a rare form of atherosclerosis that affects the paravisceral and pararenal aorta and its branches. Patients typically present with arterial insufficiency of the bowels, kidneys and lower extremities. The current mainstay of treatment is operative, typically involving transaortic endarterectomy. Herein, we describe a 54-year-old woman with incapacitating lower extremity claudication secondary to a paravisceral coral reef atheroma treated successfully with transaortic endarterectomy via a left retroperitoneal approach. In addition, we present a complete review of modern English literature on CRA.

Contained rupture of a pseudoaneurysm of the descending thoracic aorta related to remnant outflow graft of left ventricular assist device after heart transplantation.

The Jarvik 2000 left ventricular assist device is inserted via a left thoracotomy with the outflow graft anastomosed to the descending thoracic aorta. Removal of the device during heart transplantation involves division of the outflow graft, resulting in a retained remnant. We describe the first reported case of a mycotic pseudoaneurysm of the descending thoracic aorta related to the remnant of a left ventricular assist device outflow graft in an immunosuppressed heart recipient complicated with systemic Pseudomonas infection. The pseudoaneurysm was temporarily treated with endovascular stent grafting followed by delayed thoracotomy, pseudoaneurysm excision, and placement of an aortic interposition graft using an aortic allograft.