Complete Obliteration Research Articles

Giant Pediatric Dural Arteriovenous Fistula Management Using a Combined Operative Approach in a Hybrid Neuroendovascular Surgery Suite: Technical Nuances and Review of Literature.

Pediatric intracranial dural arteriovenous fistulas (dAVFs) are rare, complex entities usually presenting with macrocephaly from increased intracranial pressures at a young age. In the setting of a symptomatic intracranial dAVF that has undergone multiple endovascular treatments with subsequent recurrence or failed embolization attempts, the intracranial venous system can become inaccessible by traditional transvenous and transarterial routes. Direct puncture of the venous sinus for endovascular access after surgical exposure is a viable option. To describe the technical nuances and available literature for direct puncture of the venous sinus for endovascular access in a pediatric patient with dAVF. The clinical characteristics were reviewed and reported for a patient who underwent direct puncture of the venous sinus for endovascular access. In addition, a literature review was conducted for relevant literature pertaining to this technique and its associated indications, outcomes, and complications. Only 2 other reports of direct puncture of venous sinus for endovascular access after surgical exposure were found in the literature. Our patient achieved a favorable outcome with complete dAVF obliteration. Direct puncture of the venous sinus for endovascular access after surgical exposure for complex dAVFs that are inaccessible by transvenous or transarterial routes is a practical and safe approach to intracranial venous access that should be part of the vascular neurosurgeon's arsenal.

Short-Term Results of Plug-Assisted Retrograde Transvenous Obliteration for Portal Steal from Complicated Portosystemic Shunts in Living-Donor Liver Transplantation

PurposeTo investigate the effectiveness of plug-assisted retrograde transvenous obliteration (PARTO) for portal steal from complicated portosystemic shunts (PSSs) in living-donor liver transplantation (LDLT). Materials and MethodsThis retrospective study included consecutive patients who underwent LDLT and intraoperative or postoperative PARTO for complicated PSS between January 2020 and December 2021. PARTO was performed when hepatofugal portal flow steal was identified during intraoperative cineportography, and afferent vein embolization was difficult because of multiple afferent veins or incomplete afferent vein embolization. Liver volume, complete obliteration of PSS, technical success, adverse events, and follow-up clinical and laboratory data were evaluated. ResultsThirty-seven patients were included, and the technical success rate was 100% with no major adverse events. During the median follow-up of 20.0 months, all patients recovered well with suitable regeneration of the liver without graft dysfunction related to a portal steal. The liver volume significantly increased within 1 month (median, 956 vs 1,198 mL; P < .001). Complete obliteration of a PSS occurred in 36 of 37 (97.3%) patients, and there was no recurrence during follow-up. The Child-Pugh score, serum albumin and total bilirubin levels, and prothrombin time showed significant improvement over serial follow-up. Compared with preprocedural values (14.9 cm/s), follow-up portal flow (median) peaked on the first day (71.2 cm/s, P < .001) and then remained significantly high at 1 week (60.3 cm/s, P < .001) and 1 month (53.1 cm/s, P < .001), in accordance with the graft regeneration. ConclusionsPARTO is an effective procedure for the treatment of complicated PSS in LDLT.

MORPHOLOGICAL AND IMMUNOHISTOCHEMICAL FEATURES OF PLACENTA AND PLACENTAL FACTOR IN WOMEN WITH ISOLATED CONGENITAL HEART DEFECTS IN NEWBORN

Introduction. Congenital heart defects (CHD) in fetus can affect the course of pregnancy, cause changes in the functioning of the pregnant woman's systems and metabolic and hemodynamic disorders. The relevance of the problems CHD is primarily due to their high frequency in newborns (5-9 per 1,000 live births) depending on geographical differences and the significant share among multiple congenital malformations and the need for surgical treatment in the neonatal period. Placenta, as one of the least studied human organs, plays not only a crucial role in the process of organogenesis, but also in the "programming" of human health after fetal and newborn periods. For today, it’s important to determine the association between the CHD and placental abnormalities, the nature and consequences of which need further study.Objective. To study morphological and immunohistochemical features of placental structures in parturients with isolated congenital heart defects in the newborn.Material and methods. Over the period 2020-2021, 90 pregnant women aged 17 to 39 years (mean age 28.36±5.08) who gave birth at 37-41 weeks, and their placents, of which 30 had different forms of CHD in the newborn, were examined on a hospital-based sample. Patients were divided into two groups: the study - women with CHD in the newborn, and control - somatically healthy motherswith healthy children. Given the different etiologies of cardiovascular defects in fetus, as well as the presence of different risk factorsfor their occurrence, in order to minimize their impact on the emergence of isolated CHD, considered appropriate selection criteria for pregnant women with non-syndromic forms of cardiovascular defects, as the presence of genetic syndrome can affect intrauterine fetaldevelopment, which makes it impossible to determine a single effect of CHD development. The selection criteria in this study included:somatically healthy woman, unburdened pregnancy, natural insemination (without using of reproductive technologies), the presence of isolated heart disease in the fetus, confirmed by a cardiologist using echocardiography. Organometric, macroscopic, general histological and immunohistochemical methods were used to study placental morphology and placental factors.Results. Analyzing the data on the morphological features of placentas from women with CHD in the newborn, we should note the presence of circulatory disorders in 60% of cases, namely multiple infarcts, complete or partial obliteration of arteries and arterioles with perivascular fibrosis (in the stem villi – 15%, intermediate – 10%, terminal - 10%), reduced number of fetal vessels in the terminal villiand syncytiocapillary membranes, abrupt vasodilation of intermediate villi. Complete or partial replacement of villous epithelium by fibrinoid masses in 20% was also detected. Immunohistochemical study of placental growth factor showed less pronounced expression in syncytia, decidual sheath and stromal cells (1-2 points) compared with control (2-3 points).Conclusions. The revealed morphological and immunohistochemical changes in the placental barrier at different levels refer to the damage of maternal and fetal placenta structures of parturients with isolated neonatal heart disease, which lead to impaired stromalvascular processes with reduced perfusion. This confirms the world data on the presence of placental-cardiac axis and can be a predictor of CHD at the early stages of placental structure study, as well as in further prediction of the child's health.

Ultrashort Echo Time Magnetic Resonance Angiography as an Alternative Tool to Digital Subtraction Angiography in the Follow-up of Stent-Assisted Coil Embolization Outcomes.

Follow-up of aneurysms treated with stent-assisted coil embolization has been performed using digital subtraction angiography (DSA) because in time-of-flight magnetic resonance angiography, metal artifacts from the stent often affect visualization. To confirm whether ultrashort echo time (TE) MRA may be an alternative for DSA during follow-up. Patients with unruptured aneurysms initially treated with stent-assisted coil embolization between April 2019 and March 2021 were enrolled. After 3 months of treatment, follow-up DSA and ultrashort TE MRA were performed. All images were independently reviewed by neurosurgeons to evaluate in-stent flow and rated from 1 (not visible) to 4 (excellent). Aneurysmal embolization status was assessed as complete obliteration, residual neck, or residual aneurysm. Ultrashort TE MRA findings were classified as evaluative or nonevaluative state based on the presence of metal artifacts. We investigated the types of aneurysms that were evaluative and the agreement between ultrashort TE and DSA. Overall, 89 aneurysms were examined, of which 74% (n = 66) were classified as evaluative on ultrashort TE. Significant differences were observed in size and stent type. Evaluative cases had an aneurysm size of <7 mm ( P = .0007) and a higher rate of Neuroform Atlas ( P = .0006). The rate of agreement between ultrashort TE with evaluative state and DSA was 95%. Ultrashort TE MRA could evaluate an embolization status treated with stenting, and the findings are in excellent agreement with those of DSA. Aneurysms measuring <7 mm and treated with Neuroform Atlas are evaluative on ultrashort TE, and DSA might not be necessary.

Dural arteriovenous fistula of the craniocervical junction along the first cervical nerve: A single-center experience and review of the literature

BackgroundDural arteriovenous fistulas (DAVFs) of the craniocervical junction (CCJ) are relative rare lesions. Most studies of DAVFs of the CCJ included the fistulas at the foramen magnum, first cervical (C1), and second cervical (C2) level. DAVFs of the CCJ along C1 spinal nerve are rare vascular lesions with distinctive features. Our aim is to review cases of DAVFs of the CCJ along C1 spinal nerve at our institution. MethodsFrom June 2008 and December 2021. We reviewed a consecutive series of intracranial and spinal DAVFs at our institution and collected all patients harboring DAVFs of the CCJ along C1 spinal nerve. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, treatment methods, and neurological outcome and complications after treatment. All image studies, including cranial computed tomography (CT) scan, cervical magnetic resonance imaging, CT angiography, and digital subtraction angiography (DSA) with rotational CT angiography were analyzed by experienced neuroradiologists. The authors also review of the literature of DAVFs of the C1 spinal nerve. ResultsThe authors identified 7 patients, including 5 men (71.4 %) and 2 women (28.6 %) with median age 54 years, range 48–72 years. Subarachnoid hemorrhage (SAH) occurred in 5 (71.4 %) patients, and progressive myelopathy in 2 (28.6 %). All fistulas except one received blood supply from the radiculomeningeal branch of the VA at C1 level. Venous aneurysms, being the source of bleeding, were detected in all fistulas with SAH. All patients except one were treated by surgical management. One fistula was treated by balloon-assisted Onyx embolization. Most patients had good neurological outcome following surgery. Complete obliteration of all fistulas treated by surgery was confirmed by follow-up DSA obtained 1 week after surgery. Two patients developed temporary pain and spasm of the trapezius muscle after the surgery. One patient resulted in poor neurological outcome and died due to sepsis and acute upper gastrointestinal bleeding one month after failed embolization. For patients with SAH, only one patient required ventriculoperitoneal shunt. ConclusionsDAVFs of the CCJ along the first spinal nerve are rare and a unique subtype of DAVFs at the CCJ. These fistulas account for 1.74 % of all intracranial and spinal DAVFs in the present study. SAH is the major manifestation of DAVFs at C1 spinal nerve that may be overlooked on routine initial DSA. Rotational CT angiography is useful for clarification of the angioarchitecture of these fistulas, including small feeding artery and venous varix. Surgical treatment by interruption of the intradural draining vein should be the treatment of choice for C1 spinal nerve DAVF

Chronic thromboembolic pulmonary hypertension resulting in decompensated right heart failure

Chronic thromboembolic pulmonary hypertension is a notoriously underdiagnosed cause of severe pulmonary hypertension. It is a form of precapillary pulmonary hypertension (PH) that results from intraluminal thrombus organization and fibrous formation which ultimately results in the complete obliteration of pulmonary arteries, resulting in increased pulmonary vascular resistance which leads to the development of pulmonary hypertension and as a result right heart failure. The mechanism involves the narrowing of the pulmonary artery which increases blood pressure within the lungs and impairs blood flow which increases the workload of the right side of the heart ultimately causing right heart failure. Pulmonary hypertension can also cause arrhythmias, blood clots, and bleeding in the lungs. Even though CTEPH is a deadly condition, among all forms of pulmonary hypertension, CTEPH is the only curable form. Echocardiography is the initial assessment tool for suspected PH. A right heart catheterization may be performed to confirm the presence of pulmonary hypertension. Confirmation of CTEPH requires a V/Q scan. Although ventilation/perfusion scintigraphy has a major role in the evaluation of patients with suspected CTEPH, nowadays CTA chest is being used widely as it produces much better-quality images compared to V/Q scan. Without treatment, the prognosis is very poor. Out of three treatment modalities such as; pulmonary endarterectomy (PEA) surgery, balloon pulmonary angioplasty (BPA), and medical therapy, surgery is the gold standard. The physician must be familiar with the disease entity, early diagnosis, and appropriate treatment to improve survival. Here we present a literature review on this topic.

Letter: Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Systematic Review and Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines.

To the Editor: We read with interest the article by Singh et al1 synthesizing the modern literature around the use of stereotactic radiosurgery (SRS) in the treatment of cranial dural arteriovenous fistulas (DAVFs). Neurointervention has disrupted the established treatment paradigm for many neurosurgical conditions. From intracranial aneurysms and large vessel occlusions to hydrocephalus, neuroendovascular surgery favorably altered the natural history and reduced the treatment-related morbidity of these and other disease processes. This has changed the mindset of clinicians who treat patients with cerebrovascular disease. For instance, a patient with an unruptured wide-necked aneurysm may be better served with an endovascular treatment that leaves a small neck remnant than with clip reconstruction that affords complete occlusion but requires a considerably more invasive surgical approach. Endovascular therapy has, in a generally safe and minimally invasive fashion, lowered the clinical risk of many pathologies without affording complete cure. In light of the available literature, a similar shift in mindset may be warranted regarding SRS for the treatment of cranial DAVFs. Just as SRS met with initial skepticism regarding its efficacy for vestibular schwannomas,2 neurointerventionalists and cerebrovascular surgeons have been slow to embrace its utility for DAVFs.3 In recent years, mounting evidence has emerged to support the efficacy of SRS as more than just a salvage therapy after failed endovascular embolization of DAVFs.4,5 In light of this, a recent systematic review and meta-analysis by Singh et al1 on behalf of the International Stereotactic Radiosurgery Society has summarized the DAVF SRS outcomes and provided some practice guidelines. In their analysis of 705 SRS-treated patients with DAVF in 21 studies, the authors reported complete occlusion and symptomatic cure rates of nearly 70% and 80%, respectively.1 In comparison, a recent meta-analysis of transarterial DAVF embolization using ethylene vinyl alcohol copolymer (Onyx; Medtronic Neurovascular) reported a complete occlusion rate of 82%.6 A multicenter retrospective analysis of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database reported a complete obliteration rate of 55% after initial Onyx embolization.7 In this CONDOR study, the final obliteration rate with Onyx was less than 70%, even after all treatments. Surgical DAVF series typically report a higher obliteration rates than endovascular series, but many of these surgical cases have failed endovascular therapy, and operative morbidity and mortality rates up to 17% have been reported.3,8,9 The rates of post-SRS hemorrhage and permanent neurological deficits reported by Singh et al1 in their meta-analysis were 1.1% and 1.3%, respectively. By comparison, the risk of permanent neurological deficit after DAVF embolization was 4% in the meta-analysis by Sadeh-Gonike et al6 and 16.1% in the CONDOR database.7 In a separate analysis of unruptured high-grade DAVFs from CONDOR, post-treatment hemorrhage rates in the observation, endovascular, surgical, and SRS groups were 6.9%. 1.6%, 2.3%, and 0%, respectively.4 Although there were relatively few patients in the SRS group (n = 19), the risk of post-treatment hemorrhage seems to be similar among the various therapeutic modalities for unruptured DAVFs. DAVFs can be rewarding lesions to address for neurointerventionalists, as they provide a satisfying combination of technical skill, anatomic knowledge, and innovative approaches (ie, transvenous, direct puncture, combined surgical and endovascular). However, these cases can require hours of radiation exposure for the patient over potentially multiple embolization sessions, and there is a modest risk of DAVF recurrence even after initial angiographic cure. Based on analyses of the CONDOR database, obliteration of a low-grade DAVF after a single embolization session was achieved in <40% of cases,10 and the rate of recurrent arteriovenous shunting after angiographic cure (which required a mean of >2 embolization sessions) was 7%.11 Based on these findings, SRS may warrant consideration as a first-line treatment for unruptured DAVFs.1 If patients understand the potential risks associated with the latency period between treatment and efficacy, SRS should be discussed with unruptured patients with DAVF as a viable and reasonable alternative to embolization and surgical ligation. Definitive evidence from randomized comparative trials among the various treatment strategies for DAVFs is unlikely to be forthcoming for such a rare condition. Therefore, we will continue to rely on large multicenter databases, such as CONDOR, for our best available evidence regarding management outcomes and complications in contemporary neurovascular practice. The practice guidelines put forth by the ISRS underscore the favorable risk to benefit profile of SRS for appropriately selected DAVFs.

Vessel wall imaging features of Moyamoya disease in a North American population: patterns of negative remodelling, contrast enhancement, wall thickening, and stenosis

BackgroundThis study characterized vessel wall imaging (VWI) features of Moyamoya disease (MMD) in a predominantly adult population at a North American center.MethodsConsecutive patients with VWI were included. Twelve arterial segments were analyzed for wall thickening, degree and pattern of contrast enhancement, and remodeling.ResultsOverall, 286 segments were evaluated in 24 patients (mean age = 36.0 years [range = 1–58]). Of 172 affected segments, 163 (95%) demonstrated negative remodeling. Complete vessel wall obliteration was most frequent in the proximal M1 (17/48, 35%). Affected segments enhanced in 72/172 (42%) (n = 15 for grade II; n = 54 for concentric and n = 18 for eccentric); 20 of 24 (83%) patients had at least one enhancing segment. Both enhancing and non-enhancing segments were present in 19/20 (95%) patients. Vessel wall enhancement was most common in the proximal segments and correlated to the degree of stenosis (p < 0.001), and outer wall diameter (p < 0.001), but not disease duration (p = 0.922) or Suzuki score (p = 0.477). Wall thickening was present in 82/172 (48%) affected segments and was associated with contrast enhancement (p < 0.001), degree of stenosis (p < 0.001), and smaller outer wall diameter (p = 0.004).ConclusionThis study presents VWI findings in North American patients with MMD. Negative remodeling was the most common finding. Most patients had both enhancing and non-enhancing abnormal segments. Vessel wall enhancement was most common in proximal segments, variable in pattern or degree and was correlated to the degree of stenosis and smaller outer wall diameter.

In Reply: Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Systematic Review and Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines.

To the Editor: We appreciate the insights regarding our systematic review and meta-analysis and practice guidelines from the International Stereotactic Radiosurgery Society (ISRS) on stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in a recent Letter to the Editor by Raper et al.1,2 As noted, our analysis found that SRS was estimated to result in complete obliteration (CO) rates of approximately 70% with very favorable symptom improvement and symptom cure rates of roughly 97% and 79%, respectively. CO rates after SRS compare quite favorably with those with Onyx embolization only per the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) of approximately 55%.3 Of note, multimodality therapy with prior embolization was also noted to be associated with improved symptom cure rates in our analysis, suggesting a potential benefit in the therapeutic ratio for patients with poor prognostic factors for achievement of CO after either SRS or embolization alone. Treatment-related morbidity was also found to be quite limited with incidences of either permanent neurological deficits or hemorrhage after SRS both estimated to be roughly 1%. In our guidelines analysis, we were unable to report on favorable outcomes (as was performed in CONDOR and defined as achievement of CO without hemorrhage) because of lack of patient-level data. As noted, the risk of permanent neurological deficits after SRS compares favorably with embolization with estimates ranging from 4% to 16.1%.3,4 Previous analyses have noted similar rates of hemorrhage after embolization of 1.6%, quite similar to those observed in our analysis after SRS.3 We also noted in our analysis that previous hemorrhage was associated with a higher risk of hemorrhage after SRS similar to findings from CONDOR noting patients with prior hemorrhage had lower rates of favorable outcomes. The favorable risk profile and outcomes of SRS highlighted by our meta-analysis suggest it is an excellent therapeutic option for management of appropriately selected patients with dAVFs. Of note, limitations regarding both our analysis and CONDOR are inclusion of data from experienced and high volume sites that may not be reflective of sites with less experience in management of dAVFs. In the absence of prospective randomized data in part secondary to the rarity of dAVFs, prospective registries are key to further characterize both efficacy and toxicity of SRS for treatment of dAVFs. The prospectively maintained NeuroPoint Alliance SRS registry allows an avenue for analysis of patient-level data and further characterization of the impact of patient, lesion, and treatment characteristics on clinical outcomes after SRS for dAVFs.5 In addition, the International Radiosurgery Research Foundation (IRRF) has a long-standing history of conducting and publishing multi-institutional outcomes on SRS for a variety of indications. On the topic of SRS for dAVFs, the IRRF has published CO rates without hemorrhage ranging from 37% to 80% for 120 patients dependent on the presence of corticovenous reflux (CVR), prior hemorrhage, and noncavernous sinus (NCS) location.6 These findings are similar to our analysis where prior hemorrhage was associated with higher risk of hemorrhage after SRS and NCS dAVF associated with poorer CO and symptom control rates. Another analysis by the IRRF of 131 patients noted inferior CO rates in patients with NCS dAVFs as compared with cavernous sinus (CS) dAVFs with an association with CO and symptom improvement among NCS dAVFs but not among CS dAVFs.7 These findings in combination with those of our analysis suggest a need for improved CO rates, potentially through multimodality approaches for NCS dAVFs. The latency period for dAVFs, similar to arteriovenous malformations treated with SRS, has been characterized through work by the IRRF with similar rates of hemorrhage noted before and after SRS before CO being achieved.8 As noted by Raper et al, counseling on the risk of hemorrhage after SRS during the latency period is key as is patient selection given the association of prior hemorrhage and risk of hemorrhage during the latency period after SRS. Through these successful multi-institutional initiatives through the IRRF, robust clinical evidence has demonstrated the efficacy and safety of SRS for dAVFs. Further studies examining the potential role of multimodality approaches for patients at risk of unfavorable outcomes (particularly those with prior hemorrhages or NCS dAVFs) are warranted.

Results of Double Low-Profile Visualized Intraluminal Support Blue Stenting for the Treatment of Fusiform Cerebral Aneurysms

The flow diversion technique is increasingly used for reconstructive endovascular treatment of fusiform cerebral aneurysms. Double stenting with the Low-profile Visualized Intraluminal Support (LVIS) Blue stent is one of the flow diversion techniques. The aim of this study was to analyze the clinical and angiographic outcomes of LVIS Blue double stenting for fusiform cerebral aneurysms. Between March 2016 and July 2020, double LVIS Blue stenting was attempted in 25 fusiform cerebral aneurysms. Patient medical records and radiological images were carefully reviewed. The technical success rate was 100% (25/25). Six aneurysms (24.0%) were located in the anterior circulation and 19 aneurysms (76.0%) were located in the posterior circulation. Intraprocedural thromboembolic complications occurred in 1 patient (4.0%). During the follow-up period (30.8±14.2months), there were no deaths or delayed complications. The mean angiographic follow-up duration was 28.2±12.8months. Follow-up angiography revealed complete obliteration (O'Kelly-Marotta D) in 21 (84.0%) patients and near-complete obliteration (O'Kelly-Marotta C+ 2 matched with Kamran-Byrne grade 3) in 2 (8.0%) patients. Two patients (8.0%) showed worsening of obliteration grades. One (4.0%) patient required retreatment. There was no significant in-stent stenosis or branch occlusion covered by stents. Double stenting using LVIS Blue stents for the treatment of fusiform cerebral aneurysms is effective and safe.

Peri-procedure efficacy and safety of one-stop hybrid surgery for the treatment of brain arteriovenous malformations: A single-center preliminary experience.

Some deficiencies and shortcomings in treatment strategies of brain arteriovenous malformation (bAVM) remain. It is worth exploring whether the one-stop hybrid surgical platform can play a positive role in the treatment of bAVM. This study investigated short clinical and angiographic results of one-stop hybrid surgery for the treatment of bAVM. All patients with bAVM treated with one-stop hybrid surgery were reviewed from February 2017 to December 2021. Data including demographic information, clinical conditions, characteristics of AVM, procedure details, and clinical and angiographic results were collected. In total, 150 cerebral bAVM patients received one-stop hybrid surgery; among them, 122 received surgical resection assisted by intraoperative DSA, and 28 were treated with combination surgical resection and endovascular embolization. Complete angiographic obliteration of the AVM was achieved in 136 patients (90.7%), and procedure-related death and neurological deficit rates were 7.3%. Of all relevant variables, logistic regression analysis showed that the Spetzler & Martin (S&M) score was the only factor related to the cure rate (P < 0.001) and endpoint complication rate (P = 0.007). In our preliminary experience, one-stop hybrid surgery for the treatment of brain AVMs achieves a high angiographic total occlusion rate, with acceptable peri-procedure morbidity and mortality. For S&M 4 and 5 lesions, more cases and further study are needed to investigate the effects and safety of hybrid surgery.

An Audit of Management of Male Urethral Stricture and its Outcome: A Retrospective Review

Background: Urethral stricture leads to obstructive voiding dysfunction. We report an audit of surgical management of urethral stricture in adult males. Methods: The records of all patients diagnosed with urethral stricture from December 2017 to March 2019 at B. P. Koirala Institute of Health Sciences, Nepal were retrieved. Preoperative, surgical, and postoperative follows-up data were evaluated. The American Urological Association International Prostatic Symptom Score (AUA-IPSS) and Uroflowmetry (voided volume and peak urinary flow rate (Qmax)) were used to assess the outcome of the surgery. Results: Among 50 patients, the majority (46%) belonged to 40 - 59 years. Twenty-five patients (78.1%) with traumatic anterior urethral stricture underwent excision and primary end to end anastomotic (EPA) urethroplasty; seven patients (21.9%) with pelvic fracture urethral injury (PFUI) underwent progressive perineal urethroplasty (PPU) with EPA; eight patients with inflammatory urethral stricture underwent Kulkarni urethroplasty; four patients with iatrogenic urethral stricture underwent EPA; six patients with idiopathic urethral stricture underwent Barbagli dorsal onlay urethroplasty. All patients had preoperative voided volume &lt; 150ml, Qmax &lt; 15ml/s. Thirty patients had complete obliteration; the remaining patients had severe storage and voiding symptoms (AUA-IPSS ≥ 20) before surgery. Except for two patients who underwent redo surgery, outcome of urethroplasty was successful in terms of storage and voiding symptoms (AUA-IPSS &lt; 7) and uroflometry findings (voided volume &gt; 150ml and Qmax &gt;15ml/s). Conclusion: Urethreal stricture was most common in the age group of 40 - 59 years and traumatic stricture was the most common cause.

Stent-alone treatment of unruptured vertebral artery fusiform aneurysms: A comparison of flow diverter and conventional stents.

Treatment of vertebral artery fusiform aneurysms (VAFAs) is complex and controversial. This study aimed to compare the safety and efficacy between flow diverter and conventional stents in patients with VAFAs undergoing endovascular stent-alone treatment (SAT). Thirty-six patients with 36 VAFAs who underwent SAT between January 2014 and December 2018 were retrospectively analyzed. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical outcomes were compared between flow diverter stent patients (n = 22) and conventional stent patients (n = 14). More branches covered with stent were found in the conventional stent group (88.9 vs. 33.3%; p = 0.008). The number of stents placed was significantly higher in the conventional stent group (1.57 ± 0.76 vs. 1.09 ± 0.29; p = 0.016). The proportion of patients with significant or moderate stasis within the aneurysm immediately after stent placement was higher in the flow diverter stent group (95.5 vs. 57.1%; p = 0.004). The proportion of patients with complete obliteration or only a residual neck on follow-up angiography was significantly higher in the flow diverter stent group (86.3 vs 50.0%; p = 0.047). However, the incidence of parent artery stenosis or occlusion was also higher in the flow diverter stent group (27.3% vs. zero; p = 0.032). The rate of complications did not significantly differ between the groups. SAT was safe and effective in patients with VAFAs. Flow diverter stents are associated with a significantly better complete occlusion rate than conventional stents; however, they are also associated with an increased risk of parent artery stenosis.

Utility of manual venous compression during transvenous Onyx injection for a scalp arteriovenous fistula: illustrative case.

When performing transvenous liquid embolization for scalp arteriovenous fistulas, multiple networks of venous drainage could limit effective retrograde penetration of embolic agents into feeding arteries, resulting in incomplete obliteration. A salvage technique to achieve effective Onyx penetration with manual venous compression during transvenous embolization is demonstrated. A 43-year-old man presented with a progressively enlarging mass on his left temporal scalp that was first noticed approximately 20 years earlier. External carotid artery injection showed two scalp arteriovenous fistulas (AVFs). The patient received endovascular embolization. After successful transarterial obliteration of one AVF, transvenous Onyx embolization was performed for another AVF located in the subcutaneous layer. To avoid unnecessary Onyx migration into multiple venous networks, several coils were put in a venous pouch as a scaffold for the Onyx, and feeding arteries were temporarily occluded. Despite these adjunctive techniques, the Onyx migrated into multiple veins and even toward the orbit without complete fistula obliteration. Thereafter, Onyx was injected under manual compression of venous outlets from the pouch, resulting in complete obliteration. Manual compression of venous outlets can be used as a salvage procedure during transvenous Onyx embolization for a scalp AVF. A surgeon's radiation exposure can be reduced by step-by-step adjunctive procedures.

New aneurysm formation and regrowth associated with rebleeding of residual pediatric ruptured arteriovenous malformation: patient series.

If complete obliteration of ruptured pediatric arteriovenous malformation (AVM) cannot be achieved, the appropriate follow-up duration and predictors of rebleeding remain unknown. Pediatric patients with ruptured AVMs admitted to the authors' hospital within the past 30 years were evaluated. Rebleeding was confirmed in two patients. The first patient was a 5-year-old boy who experienced right thalamic hemorrhage. AVM was found in the bilateral thalamus and treated with stereotactic radiosurgery (SRS). New aneurysm formation and residual AVM regrowth were confirmed 21 years after the SRS. Eight months later, rebleeding occurred. The second patient was a 5-year-old boy who underwent removal of a left cerebellar hemorrhage and AVM. The residual AVM was treated with SRS. Residual AVM regrowth was detected at 6 years 7 months after SRS. Five months later, new aneurysm formation was confirmed. Two additional days later, rebleeding occurred. New aneurysm formation and residual AVM regrowth may predict rebleeding and can occur >20 years after the initial rupture and treatment. If AVM obliteration is not achieved, long-term follow-up is needed, even in adulthood, with attention to new aneurysm formation and residual AVM regrowth. Further treatment is recommended if these findings are confirmed.

Transvenous embolization of vein of galen aneurysmal malformations with coils as a final procedure for cure: A single-institution experience of 18 years.

Staged, transarterial embolization (TAE) is currently considered the gold standard for the treatment of vein of Galen aneurysmal malformation (VGAM); however, as transarterial access becomes restricted, further staged TAE may become ineffective or carry an increased risk of hemorrhagic or ischemic stroke when attempting complete obliteration. To describe the first consecutive, retrospective series of VGAM treated with transvenous embolization (TVE) with coils alone, as the final treatment in staged endovascular therapy, at a single institution between January 2004 and September 2021. A total of 10 patients with a median age of 5.5 (IQR: 9.25) years were treated with coiling TVE. Patients were treated with a median number of 5 (IQR: 2.75) TAEs prior to the final TVE treatment. Complete or near-complete immediate angiographic obliteration was achieved in eight patients. Immediate post-procedural (within 48 h) hemorrhagic complications were noted in two patients (20%), one of whom passed away while the second suffered from hemiparesis. Stereotactic radiosurgery was performed in two patients with incomplete obliteration after TVE. The median follow-up time after TVE was 17 (IQR: 9) months. At long-term follow up (17 months) for the remaining nine patients, all VGAMs were completely obliterated. Long-term clinical deterioration compared to pre-TVE was noticed in one case. Transvenous coil embolization is a technically feasible but risky option, as a final-stage treatment for cure of VGAMs with restricted trans-arterial access. Although TVE with coils remains an effective therapeutic modality, we recommend continuing investigation of safer TVE techniques to achieve cure.

Flow diversion of a dissecting PICA aneurysm

A 47-year-old female with a history of a ruptured left posterior inferior cerebellar artery (PICA) aneurysm, status post coil embolization and retreatment for recurrence, presented with evidence of a recurrent dissecting PICA aneurysm. Given that these aneurysms are considered high risk and have a greater propensity for rupture than anterior circulation aneurysms, retreatment was recommended. With the patient's strong preference for endovascular therapy, flow diversion with a Silk Vista Baby was performed. Given the low-profile design of the device, a radial artery approach and coaxial technique were used to deploy the flow diverter. The device was successfully placed, with complete obliteration of the aneurysm after 1 year. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2247.

LOBAR TORSION FOLLOWING DOUBLE LUNG TRANSPLANTATION: A SURGICAL EMERGENCY

LOBAR TORSION FOLLOWING DOUBLE LUNG TRANSPLANTATION: A SURGICAL EMERGENCY

A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

Percutaneous endoscopic creation of a neoinfundibulum for a calyceal diverticulum: A case report and review of the literature

IntroductionCalyceal diverticula (CD) are cystic structures within the renal parenchyma that likely result from inappropriate interaction between the ureteric bud and metanephric blastema during development and, if obstructed, may cause problems that include flank pain, urinary tract infections, gross hematuria, or nephrolithiasis. Herein, we present the results of percutaneous management of an obstructed calyceal diverticulum causing recurrent flank pain and infections in a 17-year-old girl.Case summaryThe patient initially presented with febrile pyelonephritis, at which time an ultrasound was concerned about an abscess versus an infected cyst. She underwent percutaneous drain placement with IV antibiotics and improved. Three years later, she re-presented with similar symptoms. After a similar treatment course, a sinogram revealed communication of the cystic-appearing lesion with the proximal ureter, confirming a diagnosis of a calyceal diverticulum. The patient opted for endoscopic management. An initial attempt at ureteroscopy was unsuccessful due to both the small ureteral caliber as well as the stenotic infundibular os. A repeat attempt at percutaneous management revealed a stenotic infundibulum that could not accommodate a wire. A holmium laser fiber was used to create a neoinfundibulum from the diverticulum to the renal pelvis adjacent to the stenotic infundibular os. Follow-up retrograde pyelography and ultrasonography confirmed an interval decrease in size of the infundibulum, and the patient’s infectious symptoms and pain resolved.DiscussionCD is a rare anomaly and is infrequently reported in the pediatric population. Percutaneous management of CD in adults has been well described in the literature. Direct percutaneous management of CD involves access to the CD and ablation of the CD cavity to prevent re-accumulation of urine. Previous studies done in adults have suggested that stone-free rates from this management range from about 80% to 100%. Diverticular obliteration, as measured by postoperative CT scans, also appears to be feasible in a percutaneous, antegrade approach, with complete diverticular obliteration rates ranging from 60% to 100%. Our case demonstrated a successful decrease in size from the original diverticulum (9 cm) to a smaller size (2 cm). Future studies with longer follow-ups will need to ascertain if percutaneous management of symptomatic CD is effective in the pediatric population.