External Iliac Research Articles

A rare presentation site for osteochondroma scapula and pelvis, intramembranous ossifying bones of axial skeleton: case series

Osteochondroma is the most common primary bone tumour comprising over 33% of benign bone tumours. The formation of osteochondroma occurs because of exophytic protuberance on the surface of growing bones. The most common sites for osteochondroma are the distal femur, proximal tibia, and proximal humerus. We are presenting a case series of three patients with rare presentation sites of osteochondroma, scapula and pelvis. Osteochondroma is primarily disease of appendicular skeleton but we are reporting it in axial skeleton. Radiographic findings include fluffy cartilaginous outgrowth arising from the external surface of a long tubular bone that may be pedunculated or sessile. Osteochondromas usually develop in bones that develop by enchondral ossification and rarely develop in bones developing by intramembranous ossification like pelvis. These tumours are usually asymptomatic but can cause pubic visceral compression or neurovascular compromise by compressing external and internal iliac vessels and lumbosacral pluxes. Scapular osteochondroma can cause compression or neurovascular compromise in thoracic cavity and axillary vessels and brachial pluxes. Treatment with surgical excision gives consistent results and relief of pain.

A case of chronic limb threatening ischemia with kinking of the external iliac artery due to downward deviation of abdominal aortic stent graft.

A case of chronic limb threatening ischemia with kinking of the external iliac artery due to downward deviation of abdominal aortic stent graft.

A case of hip joint disconnection caused by iatrogenic external iliac artery injury

A case of hip joint disconnection caused by iatrogenic external iliac artery injury

An ultrasound imaging and computational fluid dynamics protocol to assess hemodynamics in iliac vein compression syndrome

ObjectiveElevated shear rates are known to play a role in arterial thrombosis; however, shear rates have not been thoroughly investigated in patients with iliac vein compression syndrome (IVCS) owing to imaging limitations and assumptions on the low shear nature of venous flows. This study was undertaken to develop a standardized protocol that quantifies IVCS shear rates and can aid in the diagnosis and treatment of patients with moderate yet symptomatic compression. MethodsStudy patients with and without IVCS had their iliac vein hemodynamics measured via duplex ultrasound (US) at two of the following three vessel locations: infrarenal inferior vena cava (IVC), right common iliac vein, and left common iliac vein, in addition to acquiring data at the right and left external iliac veins. US velocity spectra were multiplied by a weighted cross-sectional area calculated from US and computed tomography (CT) data to create flow waveforms. Flow waveforms were then scaled to enforce conservation of flow across the IVC and common iliac veins. A three-dimensional (3D), patient-specific model of the iliac vein anatomy was constructed from CT and US examination. Flow waveforms and the 3D model were used as a basis to run a computational fluid dynamics (CFD) simulation. Owing to collateral vessel flow and discrepancies between CT and US area measurements, flows in internal iliac veins and cross-sectional areas of the common iliac veins were calibrated iteratively against target common iliac flow. Simulation results on mean velocity were validated against US data at measurement locations. Simulation results were postprocessed to derive spatial and temporal values of quantities such as velocity and shear rate. ResultsUsing our modeling protocol, we were able to build CFD models of the iliac veins that matched common iliac flow splits within 2% and measured US velocities within 10%. Proof-of-concept analyses (1 subject, 1 control) have revealed that patients with IVCS may experience elevated shear rates in the compressed left common iliac vein, more typical of the arterial rather than the venous circulation. These results encourage us to extend this protocol to a larger group of patients with IVCS and controls. ConclusionsWe developed a protocol that obtains hemodynamic measurements of the IVC and iliac veins from US, creates patient-specific 3D reconstructions of the venous anatomy using CT and US examinations, and computes shear rates using calibrated CFD methods. Proof-of-concept results have indicated that patients with IVCS may experience elevated shear rates in the compressed left common iliac vein. Larger cohorts are needed to assess the relationship between venous compression and shear rates in patients with IVCS as compared with controls with noncompressed iliac veins. Further studies using this protocol may also give promising insights into whether or not to treat patients with moderate, yet symptomatic compression.

Ureteral compression syndrome due to right external iliac artery aneurysm

Ureteral compression syndrome due to right external iliac artery aneurysm

Kidney Transplantation in Nigeria: A Single Centre’s Early Surgical Experience and Outcomes

With the rise in the population of patients with End-stage Renal Disease (ESRD) in Nigeria, there is an increased demand for Renal Replacement Therapy (RRT) including kidney transplantation (KT). We present our initial surgical experience and early outcomes with KT at a Nigerian transplant center over 2 years. A 2-year retrospective review of patients who underwent KT was done. Data of both kidney donors and recipients were recorded in designed proformas. Extracted information included demographic characteristics, side of open donor nephrectomy (ODN), recipient anatomy, surgical techniques and postoperative outcomes. Data were analyzed using SPSS version 21. A total of 210 patients had KT during the period under review<em>. </em>Donors had an age range of 19 to 53 years with a mean of 30.8 3 ± 8.43 years while recipients aged between 9 and 73 years with a mean of 45.97 ± 13.71 years. There were 190 (90.5%) male and 20 (9.5%) female donors. One hundred fifty-four recipients were males (73.3%) and 56 (26.7%) were females. Left ODN was performed in 152 (72.4%) of cases and the commonest indication for right ODN was multiple left renal arteries. The allograft was placed in the right iliac fossa in 187 (89.0%) recipients with the external iliac artery preferred for anastomosis with the allograft renal artery in end-to-side fashion in 182 (86.7%) cases. The internal iliac artery was used in end-to-end fashion anastomosis in 28 (13.3%) of cases. Ureteroneocystostomy using the Modified Lich-Gregoir technique over a double-J stent was performed in all but 5 patients who had uretero-ureterostomies. Significant peri-operative hemorrhage necessitating blood transfusion was experienced in 9 donors and 26 recipients. There was a low complication rate in kidney donors. Allograft renal artery thrombosis, venous thrombosis, and arterial pseudo-aneurysms were encountered in 3, 2 and 4 recipients respectively. Kidney transplantation can be safely and routinely carried out in Nigeria. The early surgical outlook of both kidney donors and recipients was found to be excellent in this study.

Validation of single-photon emission computed tomography with computed tomography and lymphoscintigraphy for sentinel lymph node identification in cervical cancer.

To compare single-photon emission computed tomography with computed tomography (SPECT/CT) and lymphoscintigraphy (LSG) for the detection of sentinel lymph nodes (SLNs) in patients with early-stage cervical cancer. This hospital-based, single-center, retrospective study included 128 patients with cervical cancer (aged >18 years) treated between 2014 and 2022. Injection of 99 m Technetium-labeled phytate into the uterine cervix was used to detect pelvic SLNs. SNL identification rates and locations were analyzed for preoperative LSG and SPECT/CT. Median age and body mass index of patients were 40 years (range, 20-78 years) and 21.7 kg/m2 (range, 16-40 kg/m2 ), respectively. There was no significant difference in overall identification rates (identification of at least one SLN) of SLNs between SPECT/CT (91%) and LSG (88%). There was no significant difference in bilateral SLN identification rates between SPECT/CT (66%) and LSG (65%). A total of 219 pelvic SLNs (110 right and 109 left hemipelvis) were identified by SPECT/CT; the most frequent locations were the obturator (122 SLNs, 56%) and external iliac (67 SLNs, 30%). SPECT/CT and LSG showed high SLN identification rates in patients with cervical cancer, and there was no significant difference in overall or bilateral SLN identification rates between the two techniques.

True Non-Contrast Phase versus Virtual-Non Contrast: “Lights and Shadows” of Dual Energy CT Angiography in Peripheral Arterial Disease

(1) Background: The value of dual-energy CT angiography (DE-CTA) in the detection of peripheral arterial disease (PAD) has been widely recognized. We aim to evaluate the diagnostic accuracy of virtual non-contrast (VNC) imaging of DE-CTA compared to true non-contrast phase (TNC). (2) Methods: Our Internal Review Board (IRB) approved prospective study enrolled 40 patients (28 men, 12 women; median age 69 y, range 41–93 y) who underwent lower extremity DE-CTA for symptomatic PAD. Mean attenuation values of TNC and VNC were obtained by placing circular regions of interest (ROI) at five levels from the aortic to the popliteal arterial lumen, reported in Hounsfield units (HU), and compared using a two-sample t-test. The subjective quality of VNC images was assessed by two independent radiologists with 10 and 4 years of CTA-imaging experience according to a 4-point scale and verified by the intra-class correlation coefficient (ICC). Dose Length Product (DLP) values of each DE-CTA examination were also considered. (3) Results: Except for the external iliac artery, VNC attenuation values were significantly lower than the corresponding TNC values at all levels, with a mean difference ranging from 14.1 and 8.7 HU. At qualitative analysis, VNC images were considered excellent to diagnose in 40%, good in 50%, and sufficient in 10% of cases. No cases of non-diagnostic VNC imaging were reported. Avoiding the TNC phase, a mean reduction in DLP of 54% for each DE-CTA was estimated. (4) Conclusions: TNC and VNC images showed comparable reliability and diagnostic accuracy in the detection of PAD. VNC may be considered a promising substitute for TNC from the perspectives of dose reduction and workflow optimization.

Robotic management of isolated endometriosis of sciatic nerve: a reproducible approach that can guide through the labyrinth of pelvic neuroanatomy

To present the robotic, standardized, and reproducible surgical technique we routinely use in our center to manage isolated endometriosis of the sciatic nerve. Surgical video article. Tertiary referral center. A 36-year-old woman suffering from left-sided sciatica pain was diagnosed with an isolated endometriotic nodule of the left sciatic nerve at preoperative assessment. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. Complete removal of the isolated endometriotic nodule of the sciatic nerve may be performed through a stepwise robotic approach. The surgery starts laterally with the opening of the iliolumbar space between the external iliac vessels and the psoas muscle, as well as the identification of the genitofemoral and obturator nerves. The lumbosacral trunk and emergence of the sciatic nerve were then identified medially and caudally to the obturator nerve. The surgery moves medially with the anterograde dissection of both the internal iliac artery and vein, which allows a safe approach to the posterior and medial limits of the nodule. Ligation of branches of internal iliac vessels directed toward the nodule may be necessary during this step. Isolation and ligation of obturator vessels are frequently required to obtain a bloodless dissection of the lateral limit of the nodule from the lateral pelvic wall. The complete removal of the nodule was then achieved using an alternating approach to all limits of the nodule previously identified, with subsequent release of the sciatic nerve. Description of the relevant pelvic neuroanatomy and the evaluation of robotic routes in the field of pelvic neurosurgery. The use of standardized techniques together with the advantages of a robotic route can make the radical excision of isolated endometriosis of the sciatic nerve reproducible, feasible, and safe. Because of the complexity of neuroanatomy and the risk of severe complications, this surgery remains challenging, and patients affected by deep infiltrating endometriosis involving retroperitoneal neural structures should be referred to multidisciplinary management in expert centers.

Surgical External Iliac Artery Access for Transcatheter Aortic Valve Replacement Is a Safe, Suitable Alternative to Common Femoral Artery Access.

Background Many patients undergoing transcatheter aortic valve replacement (TAVR) have peripheral artery disease necessitating surgical access. This study reviews the preoperative risk factors, procedural characteristics, and outcomes in patients undergoing surgical common femoral artery (CFA) and external iliac artery (EIA) access through a retro-inguinal groin incision for TAVR. Methods A single-center TAVR database was retrospectively analyzed for patients undergoing surgical cutdown (January 1, 2016 - December 31, 2020). Access sites were evaluated on preoperative imaging. Data on demographics, imaging, procedural characteristics, and outcomes were collected. The vascular surgeon selected the cutdown site. Results A hundred and thirty TAVR patients had surgical cutdown. The choice of access site was either the common femoral artery (82 patients, 63%) or the iliac artery (48 patients, 37%). There was no difference in age, BMI, or medical risk factors. There was no difference in iliac diameter or circumferential iliac calcium. In the iliac group, there was a smaller mean CFA size and a higher incidence of circumferential CFA calcium. In the femoral group, there was: a lower mean sheath-to-CFA ratio, a trend toward increased unplanned endarterectomy, and a higher incidence of 30-day readmission. There was no difference in adjunct procedure use. Conclusion EIA surgical access had similar complication rates and length of stay with a reduced tendency for unplanned endarterectomy when compared to CFA access. The EIA is a suitable access site for TAVR in select patients.

Extended versus standard pelvic lymph node dissection yields no difference in 3-year biochemical recurrence rates.

extended pelvic lymph node dissection (ePLND) increases the detection rate of lymph node positive prostate cancer compared to a standard pelvic lymph node dissection (sPLND). However, improvement of patient outcomes remains questionable. Here we report and compare 3-year postoperative PSA recurrence rates between patients that underwent sPLND versus ePLND at the time of prostatectomy. 162 patients received a sPLND (which involvedremoval of periprostatic, external iliac, and obturator lymph nodes bilaterally), and 142 patients received an ePLND (which involved removal of periprostatic, external iliac, obturator, hypogastric, and common iliac nodes bilaterally). Decision to undergo ePLND versus sPLND at our institution was changed in 2016 based on the National Comprehensive Cancer Network guideline. The median follow-up time was 7 and 3years for sPLND and ePLND patients, respectively. All node-positive patients were offered adjuvant radiotherapy. Kaplan-Meier analysis was carried out to assess the impact of a PLND on early postoperative PSA progression-free survival. Subgroup analyses were done for node-negative and node-positive patients, as well as Gleason score. Gleason score and T stage were not significantly different between patients who received an ePLND and sPLND. The pN1 rate for ePLND and sPLND were 20% (28/142) and 6% (10/162), respectively. There was no difference in the use of adjuvant treatments in the pN0 patients. Significantly, more ePLND pN1 patients received adjuvant androgen deprivation therapy (25/28 vs. 5/10 P=0.012) and radiation (27/28 vs. 4/10 P=0.002). Yet, no difference in biochemical recurrence between ePLND and sPLND was observed (P=0.44). This remained true in subgroup analyses of node-positive (P=0.26), node-negative (P=0.78), Gleason Score 6-7 (P=0.51), and Gleason Score 8-10 (P=0.77). PLND provided no additional therapeutic benefit, even though ePLND patients were significantly more likely to have node-positive disease and undergo adjuvant treatment, compared to a sPLND.

SWOG S1011: A phase III surgical trial to evaluate the benefit of a standard versus an extended lymphadenectomy performed at time of radical cystectomy for muscle invasive urothelial cancer.

4508 Background: S1011 tested the hypothesis that an extended lymphadenectomy (ELND) is associated with improved disease-free and overall survival (DFS, OS) compared to standard (S) LND in patients with localized muscle invasive bladder cancer (MIBC) undergoing radical cystectomy (RC)(NCT01224665). Methods: Eligible patients with cT2-4a N0-2 were stratified by receipt and type of neoadjuvant chemotherapy (NAC), T2 vs T3-4a and PS 0-1 vs 2. Patients were randomized 1:1 after intraoperative exploration determined they did not have disease outside the pelvis. All patients then underwent a standard bilateral pelvic LND including external and internal iliac and obturator LNs. If randomized to the experimental arm additional ELND up to at least the aortic bifurcation including common iliac (CI), pre-sciatic, and pre-sacral nodes was performed. We hypothesized that patients in the ELND arm would have a 10% improvement in 3-year DFS compared to an estimated 55% for patients in the SLND arm (HR = 0.72). Assuming a 1-sided a=0.025 and 85% power, 564 eligible randomized patients were required. Final analysis was to occur at 184 DFS events in the SLND arm or after max follow-up (6 yrs) using a stratified logrank(LR) test with a=0.022 to account for interim testing. Hazard ratios from Cox model are adjusted for strat factors. Secondary endpoints included OS and safety. Results: 36 surgeons at 27 sites in US and Canada were credentialed prior to enrolling patients, 658 were registered from 8/11-2/17, and 618 eligible patients were randomized to ELND (n=292) or SLND (n=300). Median f/up was 6.1 years in both arms. Median age was 69, 21% female, and 9% non-White. Clinical stage was balanced in both arms: T2 (71%) and T3-4a (29%). NAC was given to 57% in both. Pathologic T stage was <T2 in 39% in S and 37% in E and ³ T2 in 61% and 63%, respectively. Median lymph nodes removed was higher in ELND compared to SLND (41 vs 25), but there was no difference in node metastasis with 26% vs 24%, respectively. More ELND patients had N2 or N3 disease. ELND was associated with increased G3-4 AEs compared to SLND: 16% vs 8%. Deaths within 90 days of RC occurred in 26 (4.4%) patients, including 16 in ELND vs 9 in SLND. There was no difference in DFS between E vs S arms (HR 1.10; 95% CI 0.87, 1.42), 1-sided LR p=0.82. OS results were similar (HR 1.15 95% CI 0.89, 1.48), 1-sided LR p=0.87. Conclusions: Patients with MIBC undergoing RC and ELND had increased node yield and higher pathologic N stage, but no significant DFS or OS benefit compared to patients undergoing SLND. ELND was also associated with greater morbidity and higher peri-operative mortality. Clinical trial information: NCT01224665 . [Table: see text]

PREVALENCE AND DISEASE SPECTRUM OF FIBROMUSCULAR DYSPLASIA IN PATIENTS WITH SPONTANEOUS CEREBROVASCULAR ARTERY DISSECTION

Objective: Spontaneous cervical artery dissection (sCeAD) is the most frequent cause of ischemic stroke in young adults and has been associated to various arteriopathies, such as fibromuscular dysplasia (FMD). The aim of this study was to assess the prevalence of both cervical and extra-cervical FMD in patients with a diagnosis of CeAD. Design and method: All patients discharged from the Stroke Unit of A.O.U. Città della Salute e della Scienza of Turin from 2016 to 2020 with a diagnosis of CeAD underwent a contrast-enhanced CTA from chest to pelvis to look for FMD-related lesions (multifocal stenosis, aneurysms, dissections, arterial tortuosity). FMD diagnosis was assessed in the presence of at least a multifocal stenosis in one of the vascular beds explored. Results: Among 56 patients with spontaneous CeAD, 72.7% were male of middle age (52±8.5 y.o.). According to radiological findings, 43.2% of patients showed extra-cervical arterial lesions, with a prevalence of overall FMD (defined as the presence of at least a multifocal stenosis) reaching 47.3% of the studied sample and affecting carotid (36.4%), renal (18.9%), visceral (16.2%), iliac (22.2%) and coronary arteries (2.7%) respectively. Renal involvement included multifocal renal stenosis (13.5%) and arterial aneurysms (5.4%). Visceral involvement included multifocal stenosis (13.5%), visceral aneurysms (2.7%) and silent mesenteric artery dissection (5.4%). Iliac involvement included multifocal stenosis (2.7%), silent artery dissection (2.7%) and tortuosity (16.7%). Furthermore, two spontaneous dissections, one of the left external iliac artery and the other of the coeliac trunk, clinically asymptomatic, were reported in two males with no multifocal stenosis. Two women suffered also from SCAD. Multivascular extra-cervical involvement was observed in almost one third of the patients (27.0%) with sever lesions (multifocal high degree stenosis and/or arterial dissections) affecting 13.5% of the population. Conclusions: According to our results, we demonstrated that FMD is frequently associated to CeAD and that silent FMD-related lesions, even severe as arterial dissections, may coexist in such patients. Therefore, FMD should always be taken in consideration in the differential diagnosis of spontaneous arterial dissection, especially in young subjects without major cardiovascular risk factors.

Right axillopopliteal artery bypass using a combined transiliac and lateral popliteal approach for groin infection and lymph fistula.

Wound infection in the groin is a serious complication after vascular bypass surgery. The combined treatment of critical limb ischemia and recurrent infection presents challenges for vascular surgery(1Lounes Y. Ozdemir B. Alric P. Canaud L. Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report.EJVES Short Reports. 2019; 42: 31-33https://doi.org/10.1016/j.ejvssr.2019.01.002Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Multon S. Jayet J. Javerliat I. Coscas R. Coggia M. Aortic–tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.J Vasc Surg Cases, Innov Tech. 2022; 8: 201https://doi.org/10.1016/j.jvscit.2022.02.008Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 3Engin C, Posacioglu H, Ayik F, Apaydin A . Management of vascular infection in the groin. Texas Hear Inst J (2005) 32:529–534.Google Scholar). In this case, we successfully managed the wound infection in the groin after axillofemoral artery bypass grafting, using a combination of trans-iliac bypass and lateral popliteal approach(4Enzmann F.K. Nierlich P. Eder S. Aspalter M. Dabernig W. Aschacher T. et al.Trans-Iliac Bypass Grafting for Vascular Groin Complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935https://doi.org/10.1016/j.ejvs.2018.11.003Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Benzing C. Fellmer P. Lateral Approach to the Distal Femoral Artery in Femoro-Anterior-Tibial Bypass Surgery.Eur J Vasc Endovasc Surg. 2016; 52: 267https://doi.org/10.1016/j.ejvs.2016.04.024Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). A 74-year-old man, having Buerger's disease and arteriosclerosis obliterans, presented with extensive lymphatic fistula and necrosis of the groin (Fig.1) after right axillary artery to the right deep femoral artery bypass, which had been patented for last five years after the several revascularizations of iliac arteries and femoral arteries. Due to the several open surgeries, such as aorto-right external iliac artery bypass, aorto-left popliteal artery bypass, cholecystectomy and resection of gastric cancer, we chose right axillopopliteal artery bypass grafting, through the iliac wing. The skin incision was made along the iliac crest and the external oblique muscle fascia was separated to reach the pelvis, and a longitudinal incision was made anterosuperior to the greater trochanter to create a gluteal pathway to bypass the infected groin. 10-mm hole was made by shaving the bone about 4 cm from the iliac crest, and the graft was passed through the hole. (Fig 2). A lateral popliteal approach was selected for revascularization owing to extensive groin and medial thigh infective wounds. After that the extensive lymphatic fistula and necrosis were controlled with using negative pressure wound therapy.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) The postoperative course was uneventful, and contrast-enhanced computed tomography confirmed proper arrangement of the graft, without bending (Fig 3 and Fig 4). He was discharged from the hospital on the 14th postoperative day. The computed tomography which was taken one year later showed the patency of this graft. The combination of trans - iliac bypass and lateral popliteal approach was shown to be effective in this case of extensive groin and medial compartment infection, and can potentially be applied in similar future cases.Figure 4View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Rotura espontánea de vena ilíaca: una causa infrecuente de abdomen agudo hemorrágico

Spontaneous rupture of the iliac vein is a rare cause of fatal retroperitoneal hemorrhage that is generally associated with trauma and iatrogenic injury during lower abdominal or pelvic surgery. It usually occurs in the left common and external iliac veins. We report a fatal case of spontaneous rupture of the left external iliac vein to emphasize the clinical and imaging characteristics of this rare condition. Treatment is based on open surgical repair or endovascular stenting in selected cases. High level of suspicion is essential for early diagnosis and treatment to improve the associated morbidity and mortality.

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.

The Evaluation of Sentinel Lymph Node Biopsy Using Radiocolloid in First Stage Endometrial Cancer.

Detection of a sentinel lymph node (SLN) in patients with endometrial cancer (EC) reduces the rate of unnecessary systemic lymph dissection. The aim of this study was to assess the SLN detection rate, accuracy of the method using Tc-99m-SENTI-SCINT and the rate of metastatic nodal involvement in patients with preoperative first stage EC. A prospective study of SLN biopsy of 41 patients with stage I EC was conducted after cervical application of 4mCi Tc-99m-SENTI-SCINT. Planar lymphoscintigraphy and single-photon emission computed tomography/computed tomography (SPECT/CT) of the pelvis were performed, followed by site-specific lymphadenectomy in intermediate-risk patients if no SLN was detected per hemipelvis and pelvic lymphadenectomy in all high-risk patients. Pre-operative detection rate of planar lymphoscintigraphy was 80.49 [95% confidence interval (CI): 68.36-92.62] and of SPECT/CT 95.12 (95% CI: 88.52-101.7). The total intraoperative SLN detection rate was 95.12 (95% CI: 88.52-101.7) per patient and 26.83 (95% CI: 19.91-33.75) bilaterally. The average number of SLNs removed was 1.6±0.8. The most common anatomical location of SLN was the right external iliac region. The SLN metastatic rate was 17%. Both sensitivity and negative predictive value regarding metastatic involvement were 100%. The SLN detection rate, sensitivity and negative predictive value using Tc-99m-SENTI-SCINT in patients with EC in our study were high. The application of ultra-staging in the histopathological analysis of SLN increases the detection of nodal metastases and improves the staging in these patients.

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.

Outcomes of Stent Angioplasty Based on Postoperative Antiplatelet Regimen for Isolated Iliac Occlusive Disease

Antiplatelet therapy following stent angioplasty for lower extremity peripheral arterial disease is recommended. To date, however, the ideal number of agents and length of treatment for iliac artery intervention are yet to be determined. The goal of this study is to determine whether single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) is superior and how long this regimen should be administered in the postoperative period. Patients with arterial occlusive disease receiving isolated iliac artery stent angioplasty (including both common iliac artery and/or external iliac artery) registered in the Society for Vascular Surgery Vascular Quality Initiative Peripheral Vascular Intervention module between 2010 and 2021 were included. Patients were stratified into two groups: (1) DAPT (aspirin and P2Y12 inhibitor) and (2) SAPT, to include aspirin or P2Y12 inhibitor. Outcomes were evaluated based on antiplatelet therapy at discharge and at 1-year follow-up. Primary outcome measures of mortality, major adverse limb events, major adverse cardiac events, and need for reintervention were assessed using univariate analysis. A P value of <.05 was set as significance criterion. A total of 5615 patients meeting inclusion criterion were analyzed with 3859 (68.7%) in group 1 (DAPT) and 1756 (31.3%) in group 2 (SAPT). Average age of the population was 65.4 ± 10.7 years with 3200 males (57%) and 2413 females (43%). Patients in the DAPT group were found to have lower mortality at 1 year (3.1% vs SAPT = 11.7%; P < .001) with more patients undergoing minor amputations (DAPT 46.2% vs SAPT 31%; P < .001), but with no significant difference between those requiring major amputations (P = .097). The DAPT group was also found to require more reinterventions (5.5% vs SAPT = 4%, P = .01). There was no significant difference in major adverse cardiac events (P = .217) or in major adverse limb events (P = .10) between the two groups. At the 1-year follow-up, patients receiving isolated iliac artery stent angioplasty for occlusive disease treated with DAPT therapy were found to have lower mortality with an increase in reinterventions. There was no significant difference in major adverse cardiac events or in major adverse limb events between DAPT and SAPT regimens.

Coexisting nephrotic syndromes influences in st elevation myocardial infarction patient and chronic limb-threatening ischemia patient: is there any correlation?

Background: ST elevation myocardial infarction (STEMI) and chronic limb-threatening ischemia (CLTI) were cardiovascular emergencies and require urgent reperfusion treatment. Both diseases shared same traditional cardiovascular risk factors. Nephrotic syndrome (NS) patients were known for risk of thromboembolic complications that may present as STEMI or CLTI, result of hypercoagulable state stemming leading to thrombus formation. Case illustration: Three cases were described in a case series. The first case presented with anterior extensive STEMI, coroangiography revealed total occlusion at proximal left anterior descending artery with high burden thrombus, treated with defered stenting and medical therapy. The second case presented with CLTI, imaging modality showed occlusion with thrombus in infra-renal abdominal aorta until bilateral superficial femoral artery (SFA), the patient refused any interventional treatment, so he was treated with medical therapy only. The third case presented with CLTI on left leg and chronic limb ischemia on right leg, imaging modality showed occlusion at left external iliac artery and 1/3 distal of right SFA with prominent plaque calcification, treated with percutaneous transluminal angioplasty, and medical therapy. All patients achieved significant improvement in the disease. Conclusion: NS is a risk factor for STEMI and CLTI. Even corticosteroids for NS treatment also a risk factor for thromboembolic complications. Controlling the disease severity with precaution of the therapy side effect should be achieved. If thromboembolic complications related to NS happen, the management mainly follows the available guidelines.