Bilateral External Iliac Research Articles

A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery

A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery

Quantitative Abdominal Arterial Calcification Correlates with Kidney Transplant Waitlist Mortality

Introduction: The scarcity of available organs for kidney transplantation has resulted in a substantial waiting time for patients with end-stage kidney disease. This prolonged wait contributes to an increased risk of cardiovascular mortality. Calcification of large arteries is a high-risk factor in the development of cardiovascular diseases, and it is common among candidates for kidney transplant. The aim of this study was to correlate abdominal arterial calcification (AAC) score value with mortality on the waitlist. Methods: We modified the coronary calcium score and used it to quantitate the AAC. We conducted a retrospective clinical study of all adult patients who were listed for kidney transplant, between 2005 and 2015, and had abdominal computed tomography scan. Patients were divided into two groups: those who died on the waiting list group and those who survived on the waiting list group. Results: Each 1,000 increase in the AAC score value of the sum score of the abdominal aorta, bilateral common iliac, bilateral external iliac, and bilateral internal iliac was associated with increased risk of death (HR 1.034, 95% CI: 1.013, 1.055) (p = 0.001). This association remained significant even after adjusting for various patient characteristics, including age, tobacco use, diabetes, coronary artery disease, and dialysis status. Conclusion: The study highlights the potential value of the AAC score as a noninvasive imaging biomarker for kidney transplant waitlist patients. Incorporating the AAC scoring system into routine imaging reports could facilitate improved risk assessment and personalized care for kidney transplant candidates.

A Case of Lymphorrhea after Radical Cystectomy Treated by Ultrasound-Guided Inguinal Intranodal Lymphangiography

A 76-year-old woman was diagnosed with invasive bladder cancer and underwent cystectomy, bilateral external iliac, internal iliac and obturator lymph node dissection, and bilateral cutaneous ureterostomy. Pathological findings showed no lymph node metastasis ; however, the patient had lower abdominal pain and fever from the 14th postoperative day, and computed tomography (CT) revealed fluid retention in the pelvis. Retrograde pyelography showed no leakage from the urinary tract, and a drain was placed after percutaneous puncture of the pelvic cavity. There was copious drainage fluid and its nature and composition suggested lymphorrhea. Ultrasound-guided intranodal lymphangiography revealed contrast material leakage from the bilateral lymph node dissection sites. After lymphangiography, drainage from the drain decreased. Despite the drainage being minimal yet persistent, sclerotherapy was performed, the drain was removed and the patient was discharged. After discharge, there was leakage from the site of urethral extraction, and CT revealed recurrent lymph leakage. The patient was readmitted, and a second lymphangiography was performed. The leakage from the site of urethral extraction gradually decreased, and the patient was discharged on the 59th postoperative day. CT after discharge confirmed that the lymphorrhea had shrunk in size, and there has been no recurrence since then. Lymphangiography is a promising treatment option for lymphorrhea after pelvic surgery.

18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and 68Ga-prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Imaging in the Evaluation of Rare Entity Adult Embryonal Rhabdomyosarcoma of Prostate.

A 21-year-old male with embryonal rhabdomyosarcoma of the prostate was referred for 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and 68Ga-prostate-specific membrane antigen (PSMA) PET/CT for initial disease staging. The PET scans revealed hypermetabolic and PSMA expressing lobulated mass involving both lobes of the prostate and weakly metabolic and PSMA expressing few bilateral pararectal and external iliac nodes, multiple bilateral lung nodules scattered over the lung parenchyma and multiple bone marrow lesions in both axial and appendicular skeleton. Magnetic resonance imaging prostate showed gross prostatomegaly with large lobulated T2 hyperintense heterogeneously enhancing mass lesion showing restricted diffusion, involving both lobes of the prostate with extraprostatic spread along anterior, posterior, and left lateral margins with evidence of lymph nodal and osseous metastases. The demonstration of increased uptake of 18F-FDG and 68Ga-PSMA in the primary as well as bilateral pararectal and external iliac nodes, multiple bilateral lung nodules, and multiple bone marrow lesions in both axial and appendicular skeleton indicates a potential role of 18F-FDG PET/CT and 68Ga-PSMA PET/CT in disease staging in this rare aggressive tumor of the prostate.

SAT140 A Rare Case Of Asymptomatic Severe Refractory Hypoglycemia Due To Hyper-Warburgism In A Young Patient With T-cell Acute Lymphoblastic Leukemia (ALL)

Abstract Disclosure: S. Choe: None. Background: Hyper-Warburgism, exaggerated Warburg effect, is a rare but serious paraneoplastic syndrome caused by excess glucose consumption by cancer cells through glycolytic pathway leading to lactic acidosis and treatment refractory hypoglycemia. Neuroglycopenic symptoms are absent in these patients hence patients do not meet Whipple triad. Clinical Case: A 33yo African American male with past medical history of recently diagnosed cardiomyopathy and atrial fibrillation was initially admitted to outside institution for cardiac ablation then subsequently transferred to our institution for escalation of care in the setting of post-procedural persistent hypoglycemia. He reported symptoms of fatigue and poor appetite. He noted an unintentional weight loss of 30lb over the past 2 weeks. However, he denied fever, night sweats, classic signs and symptoms of hypoglycemia. Vital signs and physical examination were unremarkable. Clinical manifestation of neuroglycopenia was absent despite serum glucose as low as 46 while serum lactate of 23.8 mmol/L (0.5-2 mmol/L). Initial laboratory test notable for lactic acid of 24.2 mmol/L, glucose of 57 mg/dL, bicarbonate of 12 mEq/L, anionic gap of 39 mEq/L, beta hydroxybutyrate of 5.3 mmol/L, IGF-1 of 192 ng/mL (75–212 ng/ml), IGF-II of 570 ng/mL (288–736 ng/ml), AM cortisol of 14.3 μg/dl, ACTH of 41.6 pg/ml, hemoglobin A1c of 4.8 %, fasting insulin of 1 IU/liter, C-peptide of 0.4 ng/ml, and pro-insulin of 2.9 pg/ml. Given suppression of insulin and proinsulin levels and IGF-II level >275 ng/ml, noninsulin-mediated hypoglycemia was suspected. A CT of chest/abdomen/pelvis revealed a subpleural soft tissue mass involving the posterior mediastinum measuring 4.4 x 3.6 x 3.7 cm, diffuse bilateral renal involvement suspicious for renal lymphoma, adenopathy in the bilateral inguinal, axillary, and external iliac chains. Bone marrow biopsy was performed and result was consistent with T-cell ALL. 20% dextrose infusion was titrated up to keep his BG above 70 mg/dl and high dose steroids was initiated to bridge to chemotherapy. Chemotherapy was initiated soon after confirmation of diagnosis by bone marrow biopsy. The lactic acidosis and hypoglycemia dramatically improved shortly after. PET/CT done 4 weeks after first cycle of chemotherapy failed to identify active disease proving the patient’s good response to chemotherapy. Conclusion: The patient presented with noninsulin-mediated hypoglycemia due to rapid glucose use by cancer cell leading to hyper-Warburgism, evident by severe lactic acidosis, spontaneous hypoglycemia, and large tumor burden on CT scan. Absence of neuroglycopenia presumable due to brain using lactate as fuel and, for this reason, Whipple triad cannot be applied to diagnose hypoglycemia in this case. Chemotherapy must be initiated timely manner as it would resolve metabolic abnormalities dramatically as it was seen in our patient. Presentation: Saturday, June 17, 2023

Clinical Outcomes of Pelvic Lymph Node Dissection Before Versus After Robot-Assisted Laparoscopic Radical Cystectomy.

Objective: The purpose of this study was to compare the clinical outcomes of bladder cancer patients treated with extended pelvic lymph node dissection (ePLND) before or after cystectomy under robotic-assisted radical cystectomy (RARC). Methods: A retrospective study to identify 348 patients with bladder cancer who underwent RARC was performed. Of the patients, 152 (42.8%) underwent ePLND before radical cystectomy (RC) (group A) and 196 (56.3%) underwent ePLND after RC (group B). The clinical, pathological, and overall survival were compared. Results: The total and RC operation time in Group A (total: 130.68 ± 29.25 minutes, RC: 59.45 ± 28.63 minutes) were both shorter than Group B (total: 154.17 ± 38.18 minutes, RC: 94.81 ± 41.21 minutes) (P < .05). However, no significant difference in time of ePLND. The estimate blood loss (EBL) of RC part and total operation (RC+ePLND) in group A was less than group B (both P < .05), while the ePLND part did not show significance. The result of vascular and nerve injury and surgical drain withdrawal time were similar in two groups. The total number of lymph nodes in group A was fewer than group B (16 versus 26; P < .05). Moreover, the number of bilateral internal iliac and presacral lymph nodes of group A was fewer than group B significantly, whereas the number of bilateral external iliac, common iliac, and obturator lymph nodes was similar in two groups. The lymph node density of group A was significantly lower than group B. The median follow-up of all patients was 33.0 months. Importantly, the survival of group B was better than group A (hazard ratio: 1.412; 95% confidence interval: 1.004-1.987; P = .048). Conclusions: Performing ePLND before RC reveals better result on operation time and EBL, while, when ePLND after RC, the total number of lymph nodes dissected is more and the survival is better. It recommended ePLND be performed before RC, and it is necessary to recheck the internal iliac and presacral area after cystectomy.

Percutaneous access of an intraoperatively recanalized mid-superficial femoral artery for distal lower limb revascularization.

A 61-year-old male patient presented with rest pain and ulceration in his left leg 1 week after a hybrid procedure with bilateral external iliac stenting, common femoral artery thromboendarterectomy, and left-sided femoral popliteal bypass with an in situ saphenous vein. The bypass had been stented intraoperatively but had again become occluded directly after surgery. In the present report, we demonstrate the usefulness of direct percutaneous access to the mid-superficial femoral artery that had been intraoperatively recanalized via brachial artery access during the same procedure. This innovative combination of approaches allows for proximal and distal lower limb revascularization with stenting when avoidance of femoral artery access is considered appropriate.

A rare case of KILT syndrome in Ireland: A case report

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality. Congenital absence of the inferior vena cava (IVC) is reported in current literature as a rare risk factor for DVT. The presence of kidney and IVC abnormalities on computed tomography together with lower limb thrombosis is collectively referred to as KILT syndrome (Kidney and IVC Abnormalities with Leg Thrombosis), an extremely rare cause of extensive bilateral lower limb DVT.We present a case of KILT syndrome, diagnosed for the first time after the age of 60 years and the first case reported in the Irish population. The patient presented to the emergency department with unilateral limb pain with a prior history of provoked DVT. Clinical gestalt, a high Wells Score, and raised D-Dimer strongly supported a diagnosis of DVT. Lower limb duplex ultrasound confirmed bilateral external iliac and femoral vein thrombus, with computed tomography venography revealing an absent infrarenal IVC and atrophy of the left kidney. The medical team subsequently admitted the patient for therapeutic anticoagulation and investigation. After review by haematology, the patient was discharged on an indefinite duration of anticoagulation with follow-up with our coagulation services. In any patient with bilateral lower limb DVT, comprehensive assessment and investigation, with particular emphasis on imaging, is imperative to exclude rare associated conditions.

ODP645 A Rare Case of Extrapulmonary Sarcoidosis with Hypercalcemia as the Initial Presentation: A Diagnostic Conundrum

Abstract Introduction Sarcoidosis is a multi-system chronic granulomatous disease of unknown etiology with a wide array of manifestations. It most commonly affects the lungs. About 30% of the patients present with extra pulmonary sarcoidosis along with lung involvement and approximately 8% present with disease at extrapulmonary site without lung involvement. Here we present a case of asymptomatic extrapulmonary sarcoidosis that presented with hypercalcemia, later confirmed with an axillary node biopsy showing non-caseating granuloma. Case Presentation A 56-year-old male with a past medical history of renal insufficiency presented with an elevated Calcium (Ca) of 11mg/dL, asymptomatic otherwise. Further lab testing revealed a suppressed Parathyroid hormone (PTH) level of 2 pg/ml, Parathyroid hormone related protein (PTHrP) of 14pmol/L, normal 25-Hydroxy Vitamin D (27ng/ml), markedly elevated calcitriol (106 pg/ml) and 24-hour urinary Calcium (961mg/day). Patient also had renal insufficiency with a creatinine of 1.58mg/dL and glomerular filtration rate of 49ml/min/1.73m2. Angiotensin-converting enzyme (ACE) was also found to b elevated at 125units/L. Computed Tomography (CT)) chest showed scattered pulmonary nodules measuring as large as 7.9 mm, CT scan of abdomen revealed splenomegaly and bilateral non-obstructing renal calculi. A subsequent NM bone scan and X-ray bone survey were unremarkable. Patient's calcium levels progressively increased to a maximum of 13.3. A flow cytometry showed no immunophenotypic evidence of a lymphoproliferative disorder. Due to concern for malignancy, a PET scan was done which revealed small scattered hypermetabolic lymph nodes in bilateral external iliac chain and upper retroperitoneum. A solitary hypermetabolic 10mm right axillary lymph node was seen which was then biopsied. Biopsy report showed epitheloid non-necrotizing granuloma and fibrosis, thus confirming diagnosis of sarcoidosis. Patient was started on prednisone 10mg daily empirically before the biopsy results and repeat calcium in 2 months came back at 9.6mg/dl. He was then switched to a maintenance dose of 5 mg. Case Discussion Hypercalcemia is a common clinical laboratory abnormality with 90% of cases attributed to PTH-dependent hyperparathyroidism and malignancy. Although rare, chronic granulomatous diseases can cause a PTH-independent hypercalcemia through enhanced conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D. Sarcoidosis makes up only 1% of cases of hypercalcemia, making it very challenging to diagnose it as an etiology of hypercalcemia. Furthermore, hypercalcemia is rarely the initial presentation as it happened in our case. All cases of hypercalcemia must be thoroughly evaluated with PTH, 1,25-hydroxyvitamin D, and PTHrP to rule out common etiologies. Corticosteroids are the main stay of treatment of hypercalcemia in sarcoidosis. This case aims to shed light on sarcoidosis as an etiology of hypercalcemia, even though rare, for prompt diagnosis and management. Presentation: No date and time listed

A Rare Finding of Thrombosed Bilateral Giant External Iliac Vein Aneurysms

A 70 year old man presented with severe left lower limb oedema and pain. He had a history of bilateral deep vein thrombosis 20 years ago. (A) Computed tomography phlebography revealed previously unknown bilateral thrombosed external iliac vein aneurysms (arrows), 45 mm and 63 mm on the right and left, respectively. The thrombus extended to both femoral veins being occlusive on the left side. (B) Transpopliteal catheter directed thrombolysis was performed on the symptomatic left side. Although venous aneurysm recanalisation was not achieved, the patient improved due to femoral vein and venous collateral blood clot lysis (arrowheads).Image 1

V11-08 SINGLE-PORT ROBOTIC ANTEGRADE BILATERAL INGUINAL LYMPH NODE DISSECTION

You have accessJournal of UrologyCME1 May 2022V11-08 SINGLE-PORT ROBOTIC ANTEGRADE BILATERAL INGUINAL LYMPH NODE DISSECTION Nathan Cheng, Christopher Wright, Nizar Bou Diab, Mubashir Billah, and Mutahar Ahmed Nathan ChengNathan Cheng More articles by this author , Christopher WrightChristopher Wright More articles by this author , Nizar Bou DiabNizar Bou Diab More articles by this author , Mubashir BillahMubashir Billah More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002632.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: High risk penile cancer following penectomy is often treated with inguinal lymph node dissection. Classically, inguinal lymph node dissections were performed by opening both inguinal regions, with risk of wound complications including skin break down, flap necrosis, and lymphatic complications such as lymphedema or lymphoceles. With the popularization of the single-port robotic system, novel surgeries have taken advantage of its ability to work in tight spaces. Here, bilateral inguinal lymph node dissection is performed through a single suprapubic incision using the single-port robot. The goals are to minimize wound complications associated with open inguinal lymph node dissections while maintaining safety and oncologic outcomes. METHODS: An 82-year-old male with T3 penile squamous cell carcinoma 4 months after recovery from a total penectomy with perineal urethrostomy was offered a single-port robotic antegrade bilateral inguinal lymph node dissection. The SP port was placed midline over the suprapubic region into the Space of Retzius similar to that of an extraperitoneal SP radical prostatectomy. Bilateral external iliac vessels were isolated and the spermatic cord was followed along its lateral edge distally until the inguinal ligament was seen. The external oblique aponeurosis was split anterior to the inguinal ligament, revealing the superficial compartment, where lymph nodes packets were retrieved. The deep compartment was then accessed by dissecting through fascia lata posteriorly and skeletonizing the femoral vessels. After completion of the deep inguinal lymph node dissection, bilateral 15 French drains were placed into both surgical sites. The abdominal wall fascial incision was closed with interrupted figure-of-8 absorbable sutures. RESULTS: Operative time was 3 hours and 16 minutes, with estimated blood loss 20 mL. The patient was discharged to home on post-op day 1 with both drains, which were then removed in 2 weeks. There was a total nodal yield of 15, all of which were negative for metastatic disease. There were no 30-day complications for this patient. CONCLUSIONS: An antegrade approach through a single suprapubic incision using the single-port robot gives excellent access to bilateral inguinal spaces that would be otherwise difficult with a multi-port robot. Larger case series should be performed, but its potential advantages include lower risk of wound complications, decreased risk of lymphatic complications, and access to pelvic lymph node dissection when appropriate. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e923 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Cheng More articles by this author Christopher Wright More articles by this author Nizar Bou Diab More articles by this author Mubashir Billah More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF DownloadLoading ...

Laparoscopic Resection of a High Grade Serous Ovarian Cancer that Recurred at the Vaginal Stump with Extensive Pelvic Adhesions after Complete Surgical Staging

To show laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging. Stepwise demonstration of the procedure with narrated video footage. University hospital. We reported a case of a 62-year-old woman with a history of complete surgical staging of high grade serous ovarian cancer staged IIB, which consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy, about 18 months before this admission. She received 6 courses of carboplatin/paclitaxel combination therapy after complete surgical staging and achieved complete remission. About 12 months after the last course of chemotherapy, she visited the local clinic because of irregular vaginal bleeding. Physical examination revealed a 3×3×2 cm3 mass at the vaginal vault. Biopsy of the mass was performed under colposcopy, and pathological reports showed recurrent high grade serous cancer. Her serum cancer antigen 125 level was in normal range. Positron emission tomographic/computed tomographic imaging (PET/CT) showed no evidence of disease dissemination. A diagnosis of recurrent high grade serous ovarian cancer was made. After the biopsy of the recurrent mass, there were no visible lesions, which made us believe that laparoscopy management would not contribute to intraperitoneal spread of the tumors. Therefore, laparoscopic resection of the vaginal stump was scheduled. The key steps of the procedure were summarized as follows. First, the bowels were released from the side abdominal wall to expose bilateral external iliac vessels. Second, bilateral ureters were identified and mobilized to avoid incidental ureter injuries. Third, we opened the rectovaginal space and detached the rectum from the posterior vaginal wall. Fourth, the posterior vesical wall was separated from the vaginal stump. After exposure of the key anatomic landmarks, laparoscopic resection of the vaginal stump was performed safely. Final pathologic report showed recurrent high grade serous ovarian cancer. The patient received 6 courses of carboplatin/paclitaxel combination therapy, and maintenance therapy with olaparib was suggested, but the patient refused to accept this suggestion. She is still in complete remission 8 months after surgery. Laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging was achieved successfully in a logical way. The critical point of the procedure is to expose the key anatomic landmarks of the pelvis to avoid incidental injuries [1].

Apocrine Carcinoma of the Perineal Region with Bilateral External Iliac Lymph Node Metastases

Apocrine Carcinoma of the Perineal Region with Bilateral External Iliac Lymph Node Metastases

Two Cases of Anti-PIT-1 Hypophysitis Exhibited as a Form of Paraneoplastic Syndrome

Abstract Background: Anti-pituitary-specific transcription factor 1 (PIT-1) hypophysitis (anti-PIT-1 antibody syndrome) is a newly defined clinical entity, demonstrating an adult-onset hypopituitarism, and is a thymoma-associated autoimmune disease characterized by acquired GH, PRL, and TSH deficiencies due to autoimmunity against PIT-1 (1, 2). This disease is defined by an acquired specific GH, PRL, and TSH deficiencies and the presence of circulating anti-PIT-1 antibody and/or PIT-1-specific T cells (2). As the etiology, ectopic expression of PIT-1 in thymoma plays a causal role in the development of the disease (3); however, it is unknown whether this disease is involved in other conditions. Here, we report two PIT-1 hypophysitis cases, exhibiting as a form of paraneoplastic syndrome with malignancies other than thymoma. Clinical Case: A 79-year-old woman (case 1) and an 86-year-old man (case 2) were referred to us on suspicion of anti-PIT-1 hypophysitis because of acquired GH, PRL, and TSH deficiencies. In both patients, the endocrinological evaluation revealed extremely low basal levels and blunted responses of GH, PRL, and TSH to the provocative stimuli. In contrast, the secretion of HPA and HPG axis were preserved in both patients. Magnetic resonance imaging of the pituitary gland showed slight atrophy in case 1 and normal size in case 2. Interestingly, computed tomography imaging revealed no evidence for thymomas in both patients. On the other hand, case 1 was complicated with diffuse large B-cell lymphoma (DLBCL) of the bladder with multiple bilateral cervicals, axillary, para-aorta, and internal and external peri iliac lymphadenopathies. Case 2 was diagnosed with malignancy with multiple metastases of unknown origin with para-aortic and para-gastric lymphadenopathies, and vertebral body infiltrates. Because circulating anti-PIT-1 antibody was detected, both patients were diagnosed with anti-PIT-1 hypophysitis. Circulating PIT-1-reactive T cells were detected in case 1 using Enzyme-Linked Immunospot assay. Interestingly, the PIT-1 protein was ectopically expressed in the DLBCL tissue of case 1, while DLBCL tissues derived from control patients without anti-PIT-1 hypophysitis were negative for PIT-1. In case 2, the materials were not available because of the situation of the best supportive care. Conclusion: These data show that anti-PIT-1 hypophysitis is associated not only with thymoma but also with other malignancies. Additionally, the ectopic expression of PIT-1 in the DLBCL tissues and presence of PIT-1- reactive T cells suggested that the underlying mechanisms were similar to those observed in thymoma (3). Thus, anti-PIT-1 hypophysitis is defined as a form of paraneoplastic syndrome. Reference: (1) J Clin Invest. 2011;121(1):113-119., (2) Endocr Rev. 2020;41(2)., (3) Sci Rep. 2017;7:43060.

Postoperative Pharmacologic Anticoagulation following Temporal Lobe Resection of a Gliosarcoma in a Hypercoagulable Patient

Gliosarcomas are a rare subtype of glioblastomas associated with high rates of malignancy-associated venous thromboembolism (VTE). VTE risk is further increased in hypercoagulable patients upon discontinuing pharmacologic anticoagulation for surgery. We present a 60-year old obese male with history of hypercoagulability on apixaban who developed extensive thrombosis following resection of a gliosarcoma. Prior to temporal lobe resection, apixaban was discontinued and an IVC filter placed. On postoperative day 4, imaging revealed thrombosis above the IVC filter extending to the bilateral common, internal and external iliac, and femoral veins, requiring immediate anticoagulation and suction thrombectomy. Clinicians must balance the risk of VTE and intracerebral hemorrhage following neurosurgical. While withholding pharmacologic VTE is standard, hypercoagulable patients may benefit from pharmacologic prophylaxis postoperatively. Patients with multiple risk factors including malignancies with high rates VTE, like gliosarcomas, medical and hematological conditions, including idiopathic erythrocytosis, and history of VTE may benefit from earlier pharmacologic prophylaxis.

Infrarenal inferior vena cava agenesis

We introduce the case of a 28-year-old male patient, who was admitted to the Vascular Department with a diagnosis of infrarenal inferior vena cava agenesis and secondary deep vein thrombosis (DVT) in the lower limbs (LL). A 28-year-old male patient who came to the hospital’s Emergency Department due to non-specific abdominal discomfort described as "bloated feeling", dull pain in the mesogastrium and oedema in the LL during a month, for which he had consulted his primary care facility on several occasions. Upon arrival at the Emergency Department, the physical examination revealed mild bilateral bimalleolar oedema, with no other significant findings. A complete blood test was performed, showing a D-dimer of 5,600 IU/l. In view of the suspicion of DVT in the LL, a Doppler echocardiography was performed, which reported filling defects inside the common femoral vein and both bilateral external and internal iliac veins. Due to these findings, he was admitted to the Vascular Department to complete the study. During admission, an abdominal/pelvic CT scan was performed, showing the following results: absence of inferior vena cava at the infrarenal level, large amount of collateral circulation – especially paravertebral lumbar, multiple pelvic varicose veins and filling defects in the common bilateral external and internal iliac veins (Figure 1). Given the aforementioned findings, treatment with low-molecular-weight heparins and subsequent anticoagulation therapy was started after hospital discharge.

Reconstruction of the inferior vena cava: different strategies

Purpose: Resection and reconstruction of the inferior vena cava (IVC) is an unusual and challenging procedure. Malignant disease invading or obstructing IVC is the most frequent entity, while nonmalignant is rare and differential diagnostic is difficult. Methods: We report two cases required resection and reconstruction of IVC. Results: A 31-year-old man with left lower extremity paresthesias. His work-up revealed a large (9x3 cm) mass at the right renal hilum involving the IVC and right renal vein (RV) with complete thrombosis of bilateral external and common iliac veins (CIV), as well as the infrarenal IVC. The tumor contacted the aorta in greater than 90 degrees, as well as the third portion of the duodenum. Surgical intervention: through a midline laparotomy, we attained complete control of the IVC (above and below) as well as left RV and bilateral CIV. The IVC was transected at its origin. After thrombectomy of both iliac veins, no relevant venous flow was observed, therefore we sutured the lower IVC stump. We then divided the left RV and the IVC above the RV level, extracting the tumor en-bloc with the IVC and the right kidney. Finally, we anastomosed the left RV to a “cone” cavoplasty of the remaining IVC stump. Histologically, it was a large (11x4.5 cm) benign mesenchymal tumor involving the right renal hilum, with the diagnosis of calcifying fibrous tumor, a rare benign tumor. During follow-up after 6 years patient develops post-thrombotic syndrome of the lower limbs and subcutaneous venous collateral circulation, but without any evidence of tumor recurrence. On the other hand, we present a 39-years-old male with history of left nephrectomy after inferior vena cava and left RV thrombosis when he was one month old. He came for outpatient consultation due to recurrent deep vein thrombosis and thrombophlebitis. CT scan revealed absence of the infrarenal IVC with prominent collateral veins in multiple pathways. Due to unfavorable response to medical treatment, a surgical approach was offered. IVC reconstruction was performed with cadaveric vein graft, from the remaining iliac veins to the junction of the IVC with the right RV. At 2 years of follow up, the patient presented partial clinical improvement, nevertheless, an MRI scan showed thrombosis of the graft. Conclusion: Transplant and Hepato-Pancreato-Biliary surgeons are familiarized with IVC approach, but surgical treatment is usually difficult and may require a major vascular reconstruction.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB). A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism. Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55±7 years and 58±6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30±5 vs. 26±6, P=0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4±25.2 and 52.9±35.4months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues. Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

3:36 PM Abstract No. 86 Predictors of iliocaval in-stent restenosis

Chronic venous disease (CVD) occurs in 1-5% of adults. Iliocaval obstructive lesions play a significant role in the development of CVD. Iliocaval stenting is a mainstay treatment for CVD. However, in-stent restenosis (ISR) occurs in 5-23% and is related to recurrence of symptoms and possible decreased patency. We sought to evaluate risk factors associated with ISR. Patients who underwent successful iliocaval stenting were compiled from a departmental database of all lower extremity venous stents from 1996-2018. In total, 760 iliocaval stents were placed in 160 patients (47.5% female, 52.5% male), mean age 48.7 years. Median follow-up was 332 days (range, 0-5627 days). ISR was defined as >50% reduction in luminal diameter. Risk factors examined for ISR included age, gender, type of stent (Wallstent, Boston Scientific, Natick MA) vs. SMART stent (Cordis, Santa Clara, CA), diameter and length of stent, and diameter of angioplasty balloon. Veins included were the inferior vena cava (IVC), bilateral common iliac veins (CIV), and bilateral external iliac veins (EIV). Median and mean time to ISR was 177 and 422 days respectively (range, 11-3985 days). Neither age nor gender were significantly associated with ISR. Location of stent was not associated with increased risk of ISR. ISR occurred in 15.1% of IVC stents, 15.2% of CIV stents, and 18.4% of EIV stents. In both the CIV and EIV, Wallstents had a decreased risk of restenosis when compared to SMART stents (CIV: HR -3.0, P <0.005; EIV: HR -2.4, P = 0.02). Stent brand was not a risk factor for IVC ISR. Angioplasty balloon diameter following stent deployment was a significant risk factor for ISR as increased balloon diameter was associated with a decreased risk of IVC ISR (HR -2.7, P = 0.01). Balloon diameter did not affect ISR for CIV or EIV stents. Our study had clinically acceptable and similar rates of ISR for the IVC, CIV and EIV. Wallstents may decrease ISR in iliac veins but are similar to SMART stents when placed in the IVC. Some literature suggests that over dilation of stents may help long-term patency (4); however, we found that use of larger balloons decrease ISR in IVC stents only.

SS16. A Novel Technique for Iliocaval Extravascular Reconstruction and Associated Outcomes in Patients With Inferior Vena Cava Agenesis

Congenital absence of the inferior vena cava is a rare deep venous malformation associated with venous stasis ulceration. Endovascular recanalization is limited as patients lack normal anatomic pathways required for endovascular repair. The purpose of this study was to report outcomes of a novel retroperitoneal technique for iliocaval extravascular reconstruction (TIER) using re-entry techniques for the treatment of C5 to C6 disease in patients with iliocaval agenesis. A prospectively maintained single-institution database was used to observe patients who underwent TIER for management of C5 to C6 venous disease. Reconstruction was performed by sharply exiting the deep venous system and entering the retroperitoneum at or above the renal confluence and the bilateral external iliac veins. Cone beam computed tomography was used to exclude potential injury to adjacent structures during retroperitoneal transcatheter dissection. Reconstruction was performed using self-expanding Elgiloy stents. The Villalta clinical scoring system for post-thrombotic syndrome was used to assess symptomatic improvement preoperatively and postoperatively. Postoperatively, patients with C6 venous disease underwent continued compression therapy and were monitored for wound healing. Twelve patients underwent TIER for complete absence of the inferior vena cava resulting in C5 to C6 disease during the study period (Fig 1). Technical success was 100%, with primary patency achieved in all patients (Fig 2). There were no significant intraoperative complications, and the 30-day mortality was 0%. Mean contrast agent volume used was 87 mL, mean fluoroscopy time was 143 minutes, and mean reference air kerma was 6239 mGy. A minimum of six stents were used in all cases. At follow-up intervals of 1, 3, and 6 months, primary patency was 100%. Symptomatic and sustained improvement was seen in all patients with an average decrease in Villalta score of 13. Nine patients had C6 venous disease with ulcers on 15 limbs due to the presence of bilateral disease. Thirteen limbs had complete ulcer resolution during the follow-up period. The remaining limbs demonstrated >75% ulceration size reduction. Iliocaval extravascular reconstruction using novel re-entry techniques appears to be a safe and effective endovascular approach for the treatment of symptomatic congenital absence of the inferior vena cava. The TIER procedure can be performed with excellent patency, minimal morbidity, improved Villalta scores, and improved healing.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)