Abdominal Vessels Research Articles

Rare Association of Antiphospholipid Antibody Syndrome, Systemic Lupus Erythematosus and Aortic Dissection: A Striking Presentation with Multi-Organ Failure?

Aortic dissection is a rare lethal clinical condition that always requires prompt diagnosis and early treatment.Signs of multi-organ ischaemia due to obstruction of abdominal and thoracic branch vessels should be kept in mind by clinicians.Venous thrombosis and medial wall necrosis in the aorta may be underlying complex pathophysiological mechanisms in patients with antiphospholipid antibody syndrome.

Radiographic Response of Vessel Involvement and Resectability After Neoadjuvant Chemoradiation in Patients With Locally Advanced Pancreatic Cancer.

Survival of patients with locally advanced pancreatic cancer (LAPC) is improved when neoadjuvant chemoradiation enables subsequent surgical resection. Here, the authors assess changes in vessel involvement as a possible indicator of resectability. Pancreatic gross tumor and all major abdominal vessels were contoured for 49 patients with unresectable LAPC before and after neoadjuvant chemoradiation. Changes were compared by paired t tests. Tumor-vessel relationships were automatically quantified using Medical Imaging Interaction Toolkit and examined for correlation with resectability and outcome. Tumor volumes were significantly reduced by chemoradiation (41 to 33 mL, P<0.0001). Maximum circumferential vessel involvement decreased for most patients and was statistically significant for the superior mesenteric (P<0.003) and splenic veins (P<0.038). Resection was possible in some patients and correlated positively with survival (28 vs. 15 mo, r=0.40), a decrease in CA 19.9 levels (r=0.48), and reduced involvement of most vessels. Nevertheless, surgical resection with a successful detachment of tumor tissue from major vessels was also achieved in some patients who did not show improvement in radiographic vessel involvement, but rather a reduction in tumor volume and CA 19.9 levels. The present analysis demonstrates that neoadjuvant chemoradiation can enable subsequent surgical resection in patients with LAPC. Complete resection substantially prolongs survival. Therefore, surgical exploration should be offered if vessel involvement is improved by chemoradiation and considered in radiographic unchanged vessel involvement if size and CA 19.9 levels decrease, as these factors may indicate resectable disease, too.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for prophylactic bilateral salpingo-oophorectomy

BackgroundProphylactic bilateral salpingo-oophorectomy (BSO) is an important option for reducing the risk of developing ovarian and fallopian tube cancers in women with a hereditary ovarian cancer syndrome. Conventional laparoscopy is generally preferable since it is associated with less morbidity compared to laparotomy. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging surgical approach that offers several advantages over conventional laparoscopy including reduced postoperative pain, low rate of surgical site infections, fast patient recuperation and better cosmetic outcome [1-6]. The objective of this video is to demonstrate a surgical technique for vNOTES BSO. MethodsThis is a Stepwise demonstration of the vNOTES for prophylactic BSO with narrated video footage. The diameter of Alexis is 7 cm and we used the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA). ResultsA 52-year-old carrier of BRCA1 mutation. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner, using the vaginal GEL POINT system and vNOTES technique. ConclusionsvNOTES for prophylactic BSO via a vaginal port is a feasible technique with promising cosmetic results. This technique allows surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids abdominal wall vessels injury associated with the trocar insertion. Currently, as a result of certain technical limitations, such as when performing BSO without a hysterectomy, there has been a tendency to employ the vaginal access less frequently. In this video presentation, we demonstrate the feasibility of laparoscopic BSO via vNOTES whilst leaving the uterus intact.

Hounsfield Unit for Assessing Vertebral Bone Quality and Asymmetrical Vertebral Degeneration in Degenerative Lumbar Scoliosis.

Retrospective analysis. The aim of this study was to demonstrate the correlation between degenerative lumbar scoliosis (DLS) and osteoporosis based on Hounsfield unit (HU) measurement from computed tomography (CT) scans, and to investigate the asymmetrical vertebral degeneration in DLS. The correlation between DLS and osteoporosis measured by dual-energy x-ray absorptiometry (DEXA) is debated, since T-scores measured by DEXA scan can be overestimated due to abdominal vessel wall calcification, degenerative bony spurs, and facet hypertrophy. The reliability and accuracy of HU to determine osteoporosis are shown in many reports, but it has never been used to assess the vertebral bone quality for DLS patients. Nighty-five DLS patients were retrospectively reviewed. Regions of interest for HU were measured on three coronal images of the lumbar vertebrae. HU measurement of the whole vertebrae from L1 to L5 was obtained, then HU measurement within concave and convex sides were obtained separately in L5, upper and lower end vertebrae, apex vertebrae, neutral vertebrae, stable vertebrae. HU value presented a gradually increasing trend from L1 to L5. No correlation was detected between Cobb angle and mean HU value of the 5 lumbar vertebrae, or between Cobb angle and HU value of every lumbar vertebrae separately. HU value was higher within concavity than that within convexity of the same vertebrae both in major and compensatory curve. Asymmetric HU ratio in apex vertebrae positively correlated with Cobb angle. Stable vertebrae were the first proximal vertebrae that present opposite orientation of asymmetric HU ratio from the other lumbar vertebrae. Progression of degenerative scoliosis presents no correlation with osteoporosis based on HU measurement but could increase the asymmetrical vertebral degeneration, especially in apex vertebrae. Distraction of the pedicle screws at concave side, instead of compression of pedicle screws at convex side, should be a priority to correct lumbosacral curve. 3.

Diagnostic reference levels for fluoroscopically guided procedures in a South African tertiary hospital.

The burgeoning usage and complexity of fluoroscopically guided procedures (FGPs) contribute to extended examination times and increased risk of adverse radiation effects. Diagnostic reference levels (DRLs) play a pivotal role in dose optimization. There are limited DRL data for FGPs in low- and middle-income countries (LMICs). To determine local DRLs (LDRLs) for common FGPs in the South African (SA) context and compare these with published international data. A three-year, retrospective study of the 15 most frequently performed FGPs at a SA institution. For each procedure, the 50th and 75th percentiles of kerma area product (KAP), reference point air kerma (Ka,r), and fluoroscopy time data were derived. Published international FGP DRL data were collated and compared with the 75th percentiles of local institutional dosage parameters. The commonest FGPs were aorto-bifemoral diagnostic angiography (n = 590), aorto-bifemoral interventional angiography (n = 287), nephrostomy (n = 265), and bronchial arterial embolization (BAE) (n = 208). Selective abdominal vessel interventional angiography (KAP = 170 Gy . cm2; Ka,r = 877 mGy) recorded the highest LDRL dosages; BAE was the longest procedure (LDRL = 38 min). Nephrostomies achieved the lowest LDRLs across all parameters (KAP = 10 Gy . cm2; Ka,r = 63 mGy, fluoroscopy time = 4.3 min). All Tygerberg Hospital LDRLs with comprehensive comparable data were within or below published ranges. This study advances international radiation protection initiatives, addresses the paucity of LMIC DRL data, demonstrates broad alignment of Tygerberg Hospital FGP practice with international norms and highlights areas for optimization of institutional practice.

Three-dimensional printing - Assisted planning for complete and safe resection of retroperitoneal tumor.

Surgery is usually recommended to treat retroperitoneal tumors. However, complete surgical resections often remain challenging. To assess the assistant role of three-dimensional (3D) imaging and printing model in retroperitoneal tumor resection, as well as compare the difference between 3D printing and computed tomography (CT) in preoperative planning and confidence building. We admitted a patient with retroperitoneal mass (13.0×6.4×14.8 cm) adjacent to important abdominal blood vessels whose surgery was thought to be difficult. 3D printing and CT was arranged. A novel questionnaire and scoring system consisting of surgery difficulty and safety were designed to compare doctors understanding and confidence for surgery based on 3D printing and CT. Twenty-four doctors completed the scoring table based on CT and then 3D imaging, respectively. Paired t-test was applied for statistics analysis. Preoperative evaluation based on 3D printing indicated that the tumor could be removed completely. The operation lasted 120 minutes to successfully remove the tumor and the estimated blood loss was less than 100 ml. Scores based on 3D printing is significantly higher than CT in difficulty and safety of surgery (p < 0.001). Interestingly, the junior doctors seem to benefit more from 3D printing than the senior doctors. 3D imaging and printing model provides greater help for preoperative planning and confidence building than using CT in resection of retroperitoneal tumor, especially for the junior doctors.

A new technique for the 3D reconstruction of the incisional hernia: A pilot study

PurposeThis study aimed to accurately evaluate incisional hernias with a new three-dimensional (3D) reconstruction technology, proving surgeons more information for intuitive and accurate judgments about incisional hernia to minimize the perioperative complications and recurrence rate. MethodThis was a pilot study using a new technique, 3D reconstruction, based on computed tomography (CT) scans to measure abdominal wall defect, herniary area, herniary volume, abdominal cavity volume, and the volume of transverse, oblique, and recti abdominis in three patients with incisional hernias. ResultsThe 3D reconstruction technique made automated segmentation of the bony skeleton, skin, outer abdominal wall, vessel, and hernia sac. The hernia sac, abdominal muscles, and their anatomic relationship were clearly illustrated in 3D reconstruction images. Moreover, abdominal cavity volume; herniary diameter, area, and volume; and the volume of transverse, oblique, and recti muscles could be evaluated through 3D reconstruction images. Surgeons can also freely combine, rotate, scale, and move the 3D reconstruction mode, modify the name and transparency of the 3D reconstruction model, and observe the internal structure of the tissue and the size, shape, and location of the lesion from multiple angles for better and accurate judgments. ConclusionThe herniary diameter, area, and volume and the volume of transverse, oblique, and recti abdominis can be accurately calculated through this 3D reconstruction technology. A three-dimensional vision of the abdomen through this technology can objectively and quantitatively evaluate the situation of incisional hernia, providing a more realistic means for diagnosis and treatment of incisional hernias.

Novel Diagnostic Options without Contrast Media or Radiation: Triggered Angiography Non-Contrast-Enhanced Sequence Magnetic Resonance Imaging in Treating Different Leg Venous Diseases.

Objectives: Venous diseases in the lower extremities long lacked an objective diagnostic tool prior to the advent of the triggered angiography non-contrast-enhanced (TRANCE) technique. Methods: An observational study with retrospective data analysis. Materials: Between April 2017 and June 2019, 66 patients were evaluated for venous diseases through TRANCE-magnetic resonance imaging (MRI) and were grouped according to whether they had occlusive venous (OV) disease, a static venous ulcer (SU), or symptomatic varicose veins (VV). The clinical appliance of TRANCE-MRI was analysed by groups. Results: In total, 63 patients completed the study. TRANCE-MRI could identify venous thrombosis, including that of the abdominal and pelvic vessels, and it enabled the timely treatment of underlying diseases in patients with OV disease. TRANCE-MRI was statistically compared with the duplex scan, the gold standard to exclude deep vein thrombosis (DVT) in the legs, with regard to their abilities to detect venous thrombosis by using Cohen’s kappa coefficient at a compatible value of 0.711. It could provide the occlusion degree of the peripheral artery for treating an SU. Finally, TRANCE-MRI can be used to outline all collateral veins and occult thrombi before treating symptomatic or recurrent VV to ensure a perfect surgical plan and to avoid complications. Conclusions: TRANCE-MRI is an innovative tool in the treatment of versatile venous pathology in the lower extremities and is widely used for vascular diseases in our institution.

An Immunological Model for Heterotopic Heart and Cardiac Muscle Cell Transplantation in Rats

Heterotopic heart transplantation in rats has been a commonly used model for diverse immunological studies for more than 50 years. Several modifications have been reported since the first description in 1964. After 30 years of performing heterotopic heart transplantation in rats, we have developed a simplified surgical approach, which can be easily taught and performed without further surgical training or background. After dissection of the ascending aorta and the pulmonary artery and ligation of superior and inferior caval and pulmonary veins, the donor heart is harvested and subsequently perfused with ice-cold saline solution supplemented with heparin. After clamping and incising the recipient abdominal vessels, the donor ascending aorta and pulmonary artery are anastomosed to the recipient abdominal aorta and inferior vena cava, respectively, using continuous running sutures. Depending on different donor-recipient combinations, this model allows analyses of either acute or chronic rejection of allografts. The immunological significance of this model is further enhanced by a novel approach of in-ear injection of vital cardiac muscle cells and subsequent analysis of draining cervical lymphatic tissue.

Virtual mono-energetic images and iterative image reconstruction: abdominal vessel imaging in the era of spectral detector CT

To compare the quality of virtual mono-energetic (VMI) and polychromatic images reconstructed with hybrid iterative (PCIHIR) or model-based reconstruction (PCIMBR) derived from dual-layer spectral detector computed tomography (SDCT) in arterial phase images to visualise the aorta and abdominal main branches. A retrospective review of 50 patients with abdominal arterial phase scans was undertaken. Attenuation, intraluminal noise, and signal-/contrast-to-noise ratio (S-/CNR) were assessed in the PCIHIR, PCIMBR and VMI40keV, VMI70keV, and VMI100keV images. Contrast, noise, and visualization of soft-plaque, and macro-/micro-calcifications were scored in a blinded reading by two radiologists. VMI40keV yielded highest S-/CNR (p≤0.001). VMI70keV and PCIMBR showed comparable SNR (p≥0.999) and yielded higher SNR than PCIHIR. VMI70keV yielded higher CNR than PCIHIR (p<0.001) and PCIMBR (p<0.045). VMI100keV yielded lowest CNR (p≤0.001) and SNR (p≥0.104). In the subjective analysis, VMI40keV outperformed PCIMBR for contrast and noise, PCIMBR scored better than VMI70keV, and the latter scored better than PCIHIR for these categories (all p<0.001). PCIMBR was superior for depiction of soft-plaque and micro-calcifications (p<0.001). VMI100keV visualized micro-calcifications second best (p<0.001) and matched PCIMBR for the depiction of macro-calcifications (p>0.999), while VMI40keV scored second best for depiction of soft-plaque (p<0.020). VMI40keV and VMI70keV yield better S-/CNR than PCIHIR and PCIMBR; however, PCIMBR visualized arteriosclerotic plaques best, followed by VMI40keV for depiction of soft-plaque and VMI100keV for macro- and micro-calcification. Based on the present findings, PCIMBR on conventional CT and VMI40keV supplemented by VMI100keV on SDCT are recommended for the diagnostic assessment of abdominal arteries.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry

Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Geometric and hemodynamic analysis of fenestrated and multibranched aortic endografts

ObjectiveThe objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair. MethodsPatients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations. ResultsTwenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10−3 N ± 18.7 × 10−3 N vs 12.31 × 10−3 N ± 6.8 × 10−3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively. ConclusionsLonger stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.

Assessment of imaging protocol and patient radiation exposure in pediatric computed tomography angiography

Computed tomography angiography (CTA), a noninvasive imaging procedure, is frequently used for the diagnosis of blood vessel diseases. Pediatric patients are more sensitive to radiation than adults due to their rapidly dividing cells and long life expectancy. Thus, evaluation of pediatric exposure is crucial to ensure that the procedure is justified and the practice is optimized. The objectives of this study were to evaluate pediatric patients' exposure and imaging protocols for different CTA procedures and to estimate the cancer risk incidence. A total of 147 pediatric CTA procedures were performed at King Fahad Medical City using three CT machines (Philips Brilliance CT- 64-slice scanner, Siemens Somatom Definition Flash dual source 128 CT slice scanner and GE 750 HD DISCOVERY dual energy 64 CT slice scanner). The image protocol and patient safety measures were evaluated according to American College of Radiology (ACR) criteria. The Ethics and Research Committee approved the study and informed consent was obtained from children's parents. The mean, standard deviation (sd) and range of patients weight (kg) was 8.1 ± 13.2 (3.5–58.7). The mean, sd, median and range of patient dose (mGy.cm) for circle of willis, carotid arteries, thoracic and abdominal aorta, heart and vessels, renal artery, pulmonary artery, abdominal aorta, thoracic aorta, upper lim and lower limb were 992 ± 798, 759.0 (204–2829), 285 ± 157, 660.0 (56.7–652), 500 ± 457, 210.1 (112–1387), 472 ± 317, 411.4, (175–3909) and 350 ± 346, 589.7 (284–1431), respectively. Pediatric average radiation cancer risk incidence was 36 × 10−4. Patients' doses showed wide variation among the three CT machines and even for the same machine and the same clinical investigation. The dose per procedure is higher compared to previous studies, suggesting that the dose is not yet optimized. Protection of radiosensitive organs is highly recommended for pediatric patients.

First-trimester sonographic diagnosis of sirenomelia: A multicenter series of 12 cases and review of the literature.

To determine the key sonographic features for the diagnosis of sirenomelia in the first trimester of pregnancy. Cases of sirenomelia from several prenatal diagnosis centers were retrospectively identified and reviewed. The diagnosis was established through the detection of fused lower limbs. Additional sonographic findings were also noted. A total of 12 cases were collected. The most striking sonographic finding was the detection of malformed lower limbs, which appeared to be fused and in an atypical position. Nuchal translucency thickness was mildly increased in three cases (25%). An abdominal cyst, representing the dilated blind-ending bowel, was noted in seven cases (58%). Color flow imaging detected a single umbilical artery in six cases (50%) and the associated intra-abdominal vascular anomalies in three cases (25%). No cases of aneuploidy were detected. The pregnancy was terminated in nine cases (75%) and intrauterine demise occurred in the remaining three cases (25%). The sonographic detection of abnormal lower limbs or an intra-abdominal cyst located laterally during the first-trimester scan may be warning signs of sirenomelia. This should prompt a detailed examination of the fetal lower body and intra-abdominal anatomy, including the main abdominal vessels, in order to look for additional confirmatory findings.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction.

BackgroundPreoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan.MethodsWe conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.ResultsTwo hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were “miscellaneous.” In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation.ConclusionsCTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

Vascular repairs in gynecologic operations are uncommon but predict major morbidity and mortality

ObjectiveGynecologic surgery has potential for adjunct vascular interventions, given the proximity of major intra-abdominal and pelvic blood vessels. Our goal was to determine contemporary incidence, associations, and outcomes of vascular repairs in gynecologic operations. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database (2005-2017) was queried for patients undergoing elective gynecologic operations. Vascular repairs were performed concurrently or during reoperation. Univariable and multivariable analyses evaluated associations with vascular repairs and 30-day morbidity. ResultsA total of 201,224 gynecologic operations were identified: hysterectomy (88.3%), myomectomy (5.9%), adnexal surgery (3.5%), vulvovaginectomy/other (1.1%), nonadnexal tumor or cyst excision (0.5%), ectopic pregnancy treatment (0.4%), and pelvic lymphadenectomy (0.3%). There were 187 vascular repairs in 176 (0.09%) patients. Repairs were typically concurrent (89.8%) and most commonly included open abdominal blood vessel repair (51.8%), major abdominal artery ligation (25%), vena cava reconstruction/ligation (6%), common iliac vein ligation (4.2%), and aorta/great vessel repair (4.2%). A minority were performed endovascularly (1.7%). Patients undergoing vascular repairs were older (56 vs 46 years), were more likely to have an open vs minimally invasive/vaginal operation (71.6% vs 28.4%), and were more likely to have a hysterectomy (85.2%; P < .001 for all). In multivariable analysis, vascular repairs were observed more often with hysterectomy (odds ratio [OR]; 7.63, 95% confidence interval [CI], 2.28-25.55; P = .001) and open vs minimally invasive/vaginal operations (OR, 5.24; 95% CI, 2.64-10.42; P < .001). Vascular repairs were also more common for patients with malignant disease (OR, 2.84; 95% CI, 1.78-4.53; P < .001), patients assigned to American Society of Anesthesiologists class 3 or class 4 (OR, 1.85; CI, 1.36-2.53; P = .002), and patients without obesity (OR, 1.45; 95% CI, 1.08-1.96; P = .014). Vascular repairs independently predicted major morbidity and mortality (OR, 7.26; 95% CI, 5.26-10.03; P < .001) after adjustment for open operative approach, American Society of Anesthesiologists class 3 or class 4, and hysterectomy. ConclusionsWhereas vascular repairs during gynecologic operations are rare, they are associated with morbidity and mortality. These findings provide an evidence base for risk assessment and informed consent.

Dipeptidyl peptidase-4 is increased in the abdominal aortic aneurysm vessel wall and is associated with aneurysm disease processes.

BackgroundAbdominal aortic aneurysm (AAA) is a potentially life-threatening disease, and until today there is no other treatment available than surgical intervention. Dipeptidyl peptidase-4 (DPP4)-inhibitors, used clinically to treat type 2 diabetes, have in murine models been shown to attenuate aneurysm formation and decrease aortic wall matrix degradation, inflammation and apoptosis. Our aim was to investigate if DPP4 is present, active and differentially expressed in human AAA.Methods and resultsDPP4 gene expression was elevated in both media and adventitia of AAA tissue compared with control tissue, as measured by microarrays and qPCR, with consistent findings in external data. The plasma activity of DPP4 was however lower in male patients with AAA compared with age- and gender-matched controls, independently of comorbidity or medication. Immunohistochemical double staining revealed co-localization of DPP4 with cells positive for CD68, CD4 and -8, CD20, and SMA. Gene set enrichment analysis demonstrated that expression of DPP4 in AAA tissue correlated with expression of biological processes related to B- and T-cells, extracellular matrix turnover, peptidase activity, oxidative stress and angiogenesis whereas it correlated negatively with muscle-/actin-related processes.ConclusionDPP4 is upregulated in both media and adventitia of human AAA and correlates with aneurysm pathophysiological processes. These results support previous murine mechanistic studies and implicate DPP4 as a target in AAA disease.

Tuning molecular aggregation to achieve highly bright AIE dots for NIR-II fluorescence imaging and NIR-I photoacoustic imaging.

Currently, bright aggregation-induced emission luminogens (AIEgens) with high photoluminescence quantum yields (PLQYs) in the NIR-II region are still limited, and thus an efficient strategy to enhance NIR-II fluorescence performance through tuning molecular aggregation is proposed here. The synthesized donor–acceptor tailored AIEgen (DTPA-TBZ) not only exhibits an excellent absorptivity in the NIR-I region, but also good fluorescence signals in the NIR-II region with an emission extending to 1200 nm. Benefiting from such improved intramolecular restriction and aggregation, a significant absolute PLQY value of 8.98% was obtained in solid DTPA-TBZ. Encouragingly, the resulting AIE dots also exhibit a high relative PLQY of up to 11.1% with IR 26 as the reference (PLQY = 0.5%). Finally, the AIE dots were applied in high performance NIR-II fluorescence imaging and NIR-I photoacoustic (PA) imaging: visualization of abdominal vessels, hind limb vasculature, and cerebral vessels with high signal to background ratios was performed via NIR-II imaging; Moreover, PA imaging has also been performed to clearly observe tumors in vivo. These results demonstrate that by finely tuning molecular aggregation in DTPA-TBZ, a good NIR-I absorptivity and a highly emissive fluorescence in the NIR-II region can be achieved simultaneously, finally resulting in a promising dual-modal imaging platform for real-world applications to achieve precise cancer diagnostics.

Oncovascular Surgery is Effective in the Treatment of Retroperitoneal Tumors Involving Major Blood Vessels; A Single Centre Retrospective Cohort Study

Introduction - Radical surgery of tumors invading or intimately surrounding major intra-abdominal blood vessels may necessitate vessel resection and reconstruction and the patients with these tumors are often regarded as inoperable. However, tumors that are adjacent to, but separated from, major vessels with a capsule, can be resected without significant damage to the vessels. The aim of this study was to assess the prognosis of patients with retroperitoneal tumors involving major blood vessels operated with and without a vascular reconstruction. Methods - Patients with retroperitoneal tumors surrounding major vessels resected in the years from 2010 to 2018 were included in this retrospective single centre study. We assessed the radicality of the resection, perioperative complications, late vascular complications and disease-free survival. Descriptive statistics were used. Results - Thirty-one patients were included in this study: 23 sarcomas, 7 other malignant tumors, and 1 desmoid. Twenty required vascular reconstruction and 11 did not. The median (range) age of the patients was 54 (26-79) years. Twenty-two patients were female. In the vascular reconstruction group, 13 resections were primary operations. The resection margins were: 16 marginal; 3 intralesional; and 1 wide. Vessel walls were infiltrated by, or the origin of, the tumor in 7. Aorta reconstructions were performed with polyester prosthesis and IVC reconstructions with autologous vein graft, or allograft. Other reconstructed vessels were the iliac and renal vessels, the coeliac trunk and the hepatic artery. Reconstruction materials for these included autologous vein graft and allograft, as well as polyester and PTFE prosthesis. Temporary warm blood visceral perfusion was achieved during clamping in 4 patients with a previously described technique using axillary inflow. Preoperative embolization was used in 1 tumor. In the early post-operative period, significant venous thrombosis occurred in 2 patients and combined venous and arterial thrombosis occurred in 1. Thrombectomies were successfully performed in all 3. Two patients developed late thrombosis of allograft IVC which required no operative intervention. Importantly, early graft thrombosis was not a predictor of later graft failure. The average follow-up time was 21 ± 5 months (average ± SEM). During follow-up, 6 tumors recurred locally and 7 patients developed metastases. At the end of follow-up, 9 patients were disease-free. Five patients had died of the disease. In the tumor resections that did not require vascular resection, 7 were primary resections. The resection margins were: 7 marginal; 2 intralesional; and data on 2 margins not available. No vascular complications occurred during the early post-operative period or during follow-up. The average follow-up time was 23 ± 6 months. During follow-up, 3 tumors recurred locally and 1 patient developed metastases. At the end of follow-up, 6 patients were disease-free. Three patients had died of the disease. Conclusion - Oncovascular surgery is feasible and effective in the treatment of retroperitoneal tumors involving major blood vessels. Graft reconstructions are associated with a risk of early thrombosis but the risk of graft failure in the medium term follow-up is low. Vascular invasion should not be considered an absolute contra-indication for tumor surgery, since free margins can be achieved in resection of tumors invading major abdominal vessels.

Three-dimensional &amp; Hemodynamic Analysis of Fenestrated and Multibranched Aortic Endografts: Relevance of Stent Angulation for Type III Endoleak and Branch Thrombosis

Introduction: Our previous work suggests that after complex endovascular aortic repair, with fenestrated (fEVAR) or multibranched (bEVAR) endografts, a higher stent curvature angle is associated with thrombosis. However, that study was performed with a 2D angle analysis without considering the relevance of the plane of angulation of each branch. The goal of this study was to determine the influence of three-dimensional branch and/or stent angulations for the development of type III endoleak and branch thrombosis after fEVAR or bEVAR. Methods: Prospective, non-randomized, single center study. Including all patients with TAAA treated electively, from 2013 to 2018, with fEVAR of bEVAR, with at least 1 post-operative CTA. Demographic data, aneurysm anatomy and endografts' conformation were collected. The hemodynamic blood force (HBF) was calculated using the Mass and Momentum Conservation equations. Results: All patients were ASAIII, the median age was 73 [49-81] years, and the mean follow-up period was 26.57±20.8 months. 110 abdominal vessels were successfully catheterized. The rate of type III endoleak was 14.3% (n=16). 88% (n=14) of cases were visceral arteries (Figure 1). 6 of cases were related to vessels treated with 2 stents (p=0.000), and 14 cases were vessels treated with branches (p=0.035). A higher rate of endoleak was observed in wider arteries (7.62±0.8mm Vs 6.81±1.9mm, p=0.002) but not with longer stents (p=0.972) or higher stent oversize (p=0.561). Higher entry (50.51±22.7º Vs 21.71±30.6º, p=0.001) and exit (45.26±27.8º Vs 16.92±23.5º, p=0.000) angulations of the stent in the sagittal plane were also associated with higher endoleak rates. Accordingly, a higher HBF in the sagittal plane (34.65x10-4±38.2x10-4N Vs 14.53x10-4±30.7x10-4N, p=0.001) was also related to endoleak. The rate of branch thrombosis was 7.1% (n=8). All cases were renal arteries (Figure 2). Neither the number of stents per branch (p=0.461) nor the type of branch (p=0.430) were associated with thrombosis. A higher rate of thrombosis was observed in smaller arteries (5.00±1.3mm Vs 7.07±1.8mm, p=0.001) and with higher stent oversize (36.9±26.6% Vs 5.63±15.6%, p=0.001) but not with the stents length (p=0.647). Further, an oversize inferior to 15% has a negative predictive value (NPV) of 100% (p=0.001). Higher entry (68.63±6.2º Vs 30.07±33.6º, p=0.012) and exit (70.86±60.7º Vs 16.18±22.3º, p=0.005) angulations of the stent in the coronal plane were also associated with higher rates of thrombosis. Accordingly, a higher HBF in the coronal plane (39.72x10-4±42.6x10-4N Vs 16.71x10-4±23.2x10-4N, p=0.013) was also related to thrombosis. When analyzing exclusively the renal arteries a higher exit angle of the stent in the transversal plane (91.87±24.6º Vs 62.13±52.1º, p=0.041) was related with thrombosis. Moreover, an exit angle of the stent in the coronal plane under 61º has a NPV of 100% (p=0.001). The rate free from type III endoleak and thrombosis at 24 months were 87% and 91%, respectively. Conclusion: Type III endoleak is mostly associated with visceral arteries, while branch thrombosis is related to renal arteries. To avoid thrombosis, the stent oversize should fall behind 15% and the transversal exit angle of the stent should not exceed 61º. Longer stents should be considered rather than using more than one, to avoid endoleak.Figure 2Kaplan-Meier curve comparing time free from thrombosis between visceral & renal arteries.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose