Nii-Kabu Kabutey

Lymphangiography in the diagnosis and localization of various chyle leaks.

PurposeChyle leaks are rare entities infrequently encountered by most physicians. However, large centers providing advanced surgical care are inevitably confronted with chyle leaks as a complication of surgery, an extension of disease, or as a primary disorder. Regardless of the etiology, proper diagnosis and localization are paramount in the management of any chyle leak.Materials and MethodsHere we present 16 patients with 17 chyle leaks (5 chyluria, 8 chylothorax, and 4 chylous ascites) who underwent bipedal lymphangiography (LAG) and postprocedure computed tomography (CT) imaging.ResultsIn each case, the source of the chyle leak was identified and properly localized to guide further treatment. Of the 16 patients who underwent LAG and postprocedure CT imaging, the initial LAG alone provided the diagnosis and localized the chyle leak in 4 patients (25%); the postprocedure CT imaging provided the diagnosis and localized the chyle leak in 6 patients (37.5%); and the two modalities were equal in the diagnosing and localizing the chyle leak in the remaining 6 patients (37.5%)ConclusionThese cases highlight the unparalleled abilities of LAG and the added benefit of post-LAG CT imaging in the diagnosis and fine anatomic localization of chyle leaks. In addition, these cases demonstrate the retained utility of LAG in these investigations despite the development of alternative tests involving CT, magnetic resonance imaging, and nuclear medicine imaging.

The Role of Stent Grafts in the Management of Traumatic Tibial Artery Pseudoaneurysms: Case Report and Review of the Literature

Tibial artery pseudoaneurysms can occur in the setting of trauma. Operative exposure and repair of these injuries can be challenging, and surgical management options include direct arterial repair, interposition grafting, or arterial ligation. Other techniques including duplex-guided compression, thrombin injection, and endovascular intervention have been described. We present the case of a 39-year-old man who sustained blunt trauma to his right lower extremity and developed a delayed symptomatic pseudoaneurysm of the posterior tibial artery. He was successfully managed with endovascular stent graft exclusion of the pseudoaneurysm. Endovascular stent-grafting techniques can be successfully applied to the management of traumatic tibial pseudoaneurysms.

Vascular reconstruction plays an important role in the treatment of pancreatic adenocarcinoma

OBJECTIVE Previous studies have proved the feasibility of performing a pancreaticoduodenectomy (Whipple operation) in patients with portal vein-superior mesenteric vein and hepatic artery invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma. METHODS A retrospective review was performed identifying all patients undergoing a Whipple operation or total pancreatectomy procedure from January 2003 to December 2013. All venous (portal vein-superior mesenteric vein) and arterial (superior mesenteric artery-hepatic artery) reconstructions were extracted and reviewed to determine survival and perioperative complications. RESULTS During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. Of the 183 operations, a total of 60 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, four (6.7%) reconstructions with CryoVein (CryoLife, Inc, Kennesaw, Ga), three (5.0%) repairs with autologous vein patch, three (5.0%) autologous saphenous reconstructions, and two (3.33%) portacaval shunts. In addition, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). The 1-year survival for all reconstructions was 71.1%, which is equivalent to T3 lesions that did not receive vascular reconstruction (70.11%), with a median survival time of 575.28 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). There was a total thrombosis rate of seven of 60 (11.6%), all of which were portal vein thrombosis: three in the primary repair group and four delayed thromboses seen in primary repair, CryoVein repair, and vein patch repair. There was no thrombosis in any patients after arterial reconstruction. CONCLUSIONS An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when it is executed by an experienced institution with skilled oncologic and vascular surgeons.

Pancreaticoduodenal Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome May Not Need Celiac Artery Revascularization or Ligament Release

INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed. METHODS Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up. RESULTS PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment. CONCLUSION Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.

Ultrasound-guided needle localization to aid foreign body removal in pediatric patients.

Patients with podiatric foreign body injury commonly present to the emergency department. Often, the foreign object cannot be easily located or removed, and radiographs are frequently obtained to aid in localization. In cases requiring tissue dissection to remove the foreign bodies, accurate localization is required for safe removal of small and difficult to visualize bodies. We present 2 pediatric cases in which an ultrasound-guided needle localization technique was used to facilitate successful removal of small, difficult to visualize foreign bodies from the plantar foot. Ultrasound-guided needle localization reduced the required incision length and depth and helped to minimize the risk of damage to surrounding tissue.

Lymphangiography in the Diagnosis, Localization, and Treatment of a Lymphaticopelvic Fistula Causing Chyluria: A Case Report

We present a 25-year-old man with chyluria resulting from a posttraumatic, postinflammatory lymphaticopelvic fistula. This aberrant connection between the lymphatic system and the urinary tract is rarely seen in the United States and can be difficult to diagnose. In this particular case, lymphangiography and postprocedure computed tomography (CT) imaging were used to diagnose and localize a fistula involving the right renal pedicle lymphatics and right urinary collecting system. This fistula ultimately resolved after the procedure and did not require sclerotherapy or surgical intervention. Lymphangiography is now rarely performed at most centers due to advancements in alternative diagnostic imaging modalities. However, this procedure remains a useful tool for the investigation and treatment of chyluria and other chyle leaks.

Symptomatic Fibromuscular Dysplasia of the External Iliac Artery

The aim of this article is to report a case of symptomatic fibromuscular dysplasia (FMD) involving the external iliac arteries (EIAs). An 88-year-old woman was admitted to the vascular service, with a painful right posterior ankle ulcer that had progressively worsened during the course of a month. Her medical history included diabetes and hypertension. Bilateral lower-extremity pulses were absent, and femoral and tibial Doppler waveforms were monophasic. Pelvic and bilateral lower-extremity angiograms were obtained, which revealed findings in both EIAs consistent with a diagnosis of extrarenal FMD. Percutaneous transluminal angioplasty with subsequent stenting of the right EIA was performed, using a self-expanding stent. Completion digital subtraction angiography demonstrated a widely patent right EIA with brisk flow of contrast across the stent. Postprocedural arterial duplex scan showed a biphasic waveform pattern in the common femoral artery. FMD can involve the EIA and be associated with critical limb ischemia. FMD of the EIA responds well to endovascular management.

Incapacitating Pelvic Congestion Syndrome in a Patient With a History of May–Thurner Syndrome and Left Ovarian Vein Embolization

BACKGROUND The aim of this article is to report a rare case of unresolved incapacitating pelvic congestion syndrome (PCS) in a patient with a history of May-Thurner syndrome previously treated with stenting and left ovarian vein embolization. Additionally, this article highlights the role of pelvic venography in patients with PCS and reviews the coexistence. METHODS A 32-year-old woman was referred to us for the evaluation of recurrent pelvic pain and dyspareunia requiring analgesics. Initially, she developed left lower-extremity deep vein thrombosis a few months after her first pregnancy. On further workup, she was diagnosed with May-Thurner syndrome and underwent left common iliac and left external iliac vein stenting. Furthermore, left ovarian vein coil embolization was performed for symptoms suggesting PCS at the same outside facility. The patient was referred to us for persistent pelvic pain approximately 1 year after she underwent left ovarian vein coil embolization. A diagnosis of incompletely resolved PCS was considered. RESULTS Iliocaval venogram demonstrated patent left common iliac and external iliac venous stents in situ. Subsequent right ovarian venogram revealed a patent, but grossly dilated, right ovarian vein with retrograde flow and cross-pelvic collaterals confirming grade III PCS. Right ovarian vein coil embolization was performed, with excellent patient outcome. CONCLUSION In the setting of a combined diagnosis of PCS and May-Thurner syndrome, persistent incapacitating PCS after initial iliac stenting should be followed with a complete pelvic venous evaluation including ovarian and left renal venography to rule out residual pelvic congestion secondary to any coexisting ovarian vein incompetencies or nutcracker syndrome.

Percutaneous transgluteal coil embolization of bilateral internal iliac artery aneurysms via direct superior gluteal artery access

Proximal surgical ligation of internal iliac artery aneurysms without occlusion of the outflow vessels can lead to continued aneurysm expansion and possible rupture from retrograde flow. Percutaneous embolization options are limited because there is no direct transarterial antegrade access to the aneurysm if the internal iliac artery has been ligated. We describe the first case of bilateral percutaneous transgluteal coil embolizations to treat surgically excluded bilateral internal iliac artery aneurysms.

Bronchial artery pseudoaneurysm with symptomatic mediastinal hematoma

PURPOSE To discuss the rare finding of bronchial artery aneurysms and pseudoaneurysms as well as describing available endovascular treatment options. CASE REPORT A 61-year-old male presented to the emergency department and was found to have a paraesophageal hematoma and 1cm bronchial artery pseudoaneurysm. The patient was taken for successful endovascular exclusion by embolization. CONCLUSION Bronchial artery pseudoaneurysms are rare but have a chance of rupture. Percutaneous embolization is a reasonable treatment option for these patients.