Xiaojun Song

Intravenous leiomyomatosis with inferior vena cava and heart extension

BACKGROUND Intravenous leiomyomatosis (IVL) is a rare tumor that is histologically benign but biologically malignant. Less than 200 cases of IVL have been reported, most of them were individual reports. METHODS Six patients with IVL involving the inferior vena cava were analyzed. RESULTS Three patients received one-stage operations and two received two-stage operations. All operations were successful. No perioperative death or other complications were observed. Primary tumors and intravenous tumorous emboli were completely resected from four patients. Residual tumor remained in one patient who had serious adhesions due to multiple previous surgeries; however, with antiestrogen therapy, the residual tumor significantly regressed. All patients had tumor relapse after the operation. CONCLUSIONS IVL should be given more attention by vascular surgeons, although it is extremely rare. Many therapeutic methods are available for uterine leiomyomatosis involving inferior vena cava, among which operation is the best choice.

Surgical Resection of the Inferior Vena Cava for Leiomyosarcoma

Our case of primary leiomyosarcomas involved retrohepatic, suprarenal, and infrarenal inferior vena cava (IVC). Preoperative phlebography proved that there was adequate collateral circulation formed, which allowed us to achieve en bloc resection including segment I and II IVC without either extracorporeal circulation or prosthetic revascularization of the IVC and renal vessels. Our choice of en bloc resection including segment I and II IVC without extracorporeal circulation or prosthetic replacement of the vessels was justified as the patient had normal liver and kidney function after the operation.

Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm.

The rarely occurring vertebrovertebral arteriovenous fistula (VVAVF) is characterized by abnormal direct communications between the vertebral artery or its branches and the neighboring venous system. We present our experience using a stent graft to occlude a chronic, traumatic VVAVF. A 40-year-old woman with dizziness and loud bruits from the occiput underwent digital subtraction angiography (DSA), which revealed a VVAVF with pseudoaneurysm at the C5-C6 level, with retrograde flow from the right vertebral artery. A stent graft was placed across the fistula after balloon dilation. The fistula and pseudoaneurysm disappeared immediately. After 9 months, the patient remained asymptomatic with a patent stent.

Pre-reconstruction of cervical-to-petrous internal carotid artery: An improved technique for treatment of vascular lesions involving internal carotid artery at the lateral skull base.

Reconstruction of the internal carotid artery (ICA) is an operative challenge for lesions involving the lateral skull base because of excessive blood loss, intraoperative cranial nerve injury, and difficulties in cerebral protection.

Incidence, Risk Factors, Treatment and Prognosis of Popliteal Artery Embolization in the Superficial Femoral Artery Interventions

Objective Percutaneous transluminal angioplasty and stenting (PTA + stent) has gained acceptance as a primary treatment modality for the superficial femoral artery (SFA) diseases. Popliteal artery embolization (PAE) is a severe complication in SFA interventions. The purpose of this study was to evaluate the incidence, risk factors, treatment and prognosis of PAE in primary SFA PTA + stent. Methods Chronic SFA arteriosclerosis cases that underwent primary PTA + stent were reviewed from a retrospectively maintained database. Runoff vessels were evaluated in all cases before and after the interventions for PAE detection. The primary patency, secondary patency and limb salvage rates were calculated using Kaplan-Meier analysis and compared using log-rank analysis. Cox multivariate regression was performed to evaluate predictors of patency and limb salvage rates. Results There were 436 lesions treated in 388 patients with 10 PAE events (2.3%) in total. PAE rate was significantly higher in Transatlantic Inter-Society Consensus (TASC) C/D group compared with TASC A/B group (OR = 8.91, P = .002), in chronic total occlusion (CTO) lesions compared with stenotic lesions (P<.0001), and in group with history of cerebral ischemic stroke (OR = 6.11, P = .007). PAE rates were not significantly affected by age, sex, smoking, hypertension, diabetes, hyperlipidemia and runoff status. The binary logistic regression showed that only the TASC C/D was an independent predictor of PAE (P = .031). The 12-month and 24-month primary patency, secondary patency and limb salvage rates in PAE group showed no significant differences comparing with non-PAE group. Conclusions PAE is a rare event in primary SFA PTA + stent. TASC C/D lesion, CTO and cerebral ischemic stroke history are risk factors for PAE. PAE is typically reversible by comprehensive techniques. If the popliteal flow is restored in time, PAE has no significant effect on long-term patency and limb salvage rates.

Revascularization of midaortic dysplastic syndrome

A 15-year-old boy presented with an incidental finding of severe hypertension (190/100 mm Hg). Computed tomography angiography (CTA) showed marked narrowing of the aorta, the orifice of the celiac artery, the superior mesenteric artery (SMA), and the bilateral renal arteries. The three-dimensional image reconstructions demonstrated coarctation of aorta, the arch of Riolan, the stenosis of the bilateral renal arteries, and multiple collateral vessels (A). An aortoaortic bypass with a polytetrafluoroethylene graft and aortobirenal arterial bypasses with autologous great saphenous veins were performed. We obtained a satisfactory exposure through a transperitoneal approach with a longitudinal paramedian laparotomy incision. Operative findings included aorta coarctation extending 10 cm, with a 4-mm diameter, and severe stenosis of the bilateral renal arteries. An end-to-side anastomosis from the artificial graft (8 mm diameter) to the aorta was completed. A significant graft curve was reserved for future development of the young boy. Two individual autologous saphenous vein grafts were subsequently anastomosed end-to-side to the artificial aortic bypass graft (B). Evaluationat8months showedthat thepatient’shighestbloodpressurewas 130/80 mm Hg, without therapy with antihypertensive medication.

Radical correction for Budd-Chiari syndrome through a transabdominal approach.

BACKGROUND To describe radical correction for Budd-Chiari syndrome through a unique transabdominal approach. METHOD After the liver was turned leftward through a transabdominal approach, segments II and III of the inferior vena cava (IVC), the second porta hepatis, and third porta hepatis were visualized. Then, radical correction and angioplasty of the IVC were performed. Three patients operated through this approach recovered well. RESULT All procedures were performed successfully, without any perioperative mortality. There were two cases of postoperative ascites. The elevated venous pressure and the liver function returned to normal at follow-up. CONCLUSION Radical correction for Budd-Chiari syndrome through a transabdominal approach without extracorporeal circulation minimizes the surgical injury and has a good curative effect.

Dealing with a challenging carotid body tumor.

A 30-year-old woman presented with a painless swelling in her right neck for 1 year. On physical examination, a large pulsatile and nontender mass (w15 10 cm in size) was present in the right anterolateral neck region. Selective carotid arteriography and computed tomography angiography confirmed an intensely enhancing mass at the bifurcation of the internal (ICA) and external carotid arteries (ECA), extending from the base of the skull and almost reaching the clavicle bone (A). The lesion encased the ICA, ECA, common carotid artery (CCA), and the regional nerves, although no symptoms of cranial neuropathy were detected. A temporary balloon occlusion test showed open collateral vessels through the anterior communicans artery. The operation was undertaken by a team of vascular surgeons and otolaryngologists. A 25-cm-long, S-shaped incision was made along the posterior border of the sternocleidomastoid muscle. We removed the mastoid and styloid processes to facilitate adequate skull base exposure. A large, hypervascular tumor (15 10 cm) was visualized extending from the level of the sternoclavicular joint to the base of the skull. As expected, the ICA and CCA were wholly enclosed in the tumor. The vascular walls were infiltrated without a dissection plane between the tumor and the vessel adventitia (white line of Gordon-Taylor). An autologous saphenous vein graft was indicated. After we obtained control of the petrous carotid artery and proximal CCA with vessel loops, the saphenous vein was anastomosed in an end-toside fashion into the CCA in 8 minutes, followed by the end-to-end anastomosis to the petrous portion of the ICA in 11 minutes (B). Finally, the tumor was removed, together with the ICA, after artery reconstruction. The ECA was ligated. The VII and XI cranial nerves were identified and well protected. The X and XII nerves were resected due to direct tumor involvement. Operative blood loss was 600 mL. Histologic analysis showed findings typical of a carotid body paraganglioma. The patient’s postoperative course was uneventful, with a slight XII cranial nerve deficit and temporary hoarseness. No recurrence or any further complications were noted at the 10-month follow-up.

Application of physician-modified fenestrated stent graft in urgent endovascular repair of abdominal aortic aneurysm with hostile neck anatomy: Case report

Background:This study aimed to evaluate the feasibility and effectiveness of the Gore Excluder aortic stent graft (WL Gore & Associates, Inc., Flagstaff, AZ) using the C3 Delivery System after physician modification of fenestration for the urgent treatment of patients with abdominal aortic aneurysm showing hostile neck anatomy. Case summary:Three urgent cases of abdominal aortic aneurysm with hostile neck anatomy symptom with abdominal pain were reported. The same fenestration method was applied to align the target superior mesenteric artery and bilateral renal arteries with 1 scallop and 2 fenestrations, followed by the reconstruction of the target artery using a bare-metal stent or stent graft. Balloon-assisted positioning and image fusion technology were intraoperatively applied to assist the accurate release of the stent graft body. The follow-up periods for all cases exceeded 6 months, showing smooth circulation in the target arteries with no endoleaks. Conclusion:In the absence of other available treatment methods, it is feasible to use a stent graft with physician-modified fenestration for the urgent endovascular repair of abdominal aortic aneurysm with hostile neck anatomy. However, this procedures long-term efficacy needs to be further investigated.

Unconventional Interventional Therapy for Cavernous Transformation of the Portal Vein

Cavernous transformation of the portal vein (CTPV) is a mass-like network of collateral veins around the portal vein as the sequel to extrahepatic portal vein obstruction. The common clinical manifestations include esophageal varices, splenomegaly, and hypersplenism. The patient may present with recurrent hematemesis and tarry stool. We report a woman who presented with CTPV, which was managed with an unconventional interventional method to recanalize the superior mesenteric vein and main portal vein.