Initial Postoperative Imaging Research Articles

Assessment of Ulnar Carpal Translocation and Carpal Alignment After Volar Plate Fixation With Vascularized Bone Graft for Scaphoid Waist Fracture Nonunions

Multiple fixation methods with or without vascularized graft have been described to treat scaphoid nonunions. This study aimed to assess the incidence of carpal malalignment and the degree of ulnar carpal translocation after scaphoid volar plate fixation with pedicled vascularized bone graft in scaphoid waist nonunions with humpback deformity. A retrospective cohort study of individuals with recalcitrant scaphoid fracture nonunion treated with volar scaphoid plating and vascularized bone graft was analyzed. All patients had radiographs with the wrist at neutral with clinical follow-up of at least 3 months after surgery. Ulnar subluxation of the carpus was assessed by the change in lunate uncovering and carpal-radial distance before and after surgery. Seventeen patients were included for analysis. Average age was 26 years with an average follow-up interval of 11.0 months. After surgery, 16 patients (94.1%) had fracture union. Between preoperative and initial postoperative imaging, there was an increase in lunate uncovering (mean difference: 8.8%; 95% confidence interval, 4.6% to 13.1%) and carpal-radial distance (mean difference: 3.3% ulnar shift; 95% confidence interval, 1.1% to 5.4%). After surgery, there was minimal change in lunate uncovering and carpal-radial distance from immediately after surgery to final follow-up. Preoperative lunate uncovering was lower than normal values, suggesting an abnormal radial shift of the carpus with a collapsed scaphoid. Postoperative lunate uncovering was similar to normal values, reflecting an ulnar shift of the carpus after operative intervention. Therapeutic IV.

Radiologic evaluation of the kidney transplant donor and recipient.

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

Adoption and clinical outcomes of fenestrated endovascular aneurysm repair in a regional, multistate community hospital system

ObjectiveComplex endovascular abdominal aortic aneurysm (AAA) repair techniques have evolved over the last decade, yet patterns of physician and hospital system adoption of fenestrated endovascular aneurysm repair (FEVAR) remain poorly defined. We investigated clinical outcomes, use trends, and surgeon and hospital experience for FEVAR in a large community hospital system. MethodsWe conducted a retrospective cohort study of all FEVAR procedures within our 5-state hospital system between April 2012 and June 2021. AAA repair volumes (open, EVAR, and FEVAR) were captured at the hospital and surgeon levels using Current Procedural Terminology and International Classification of Diseases codes. Clinical and outcomes data were collected for FEVAR patients. To consider if surgeon or hospital experience influenced outcomes, sequential case number was used to divide patients into surgeon experience and hospital experience groups. Inverse probability weighted and generalized linear mixed models, adjusted for demographics and comorbidities, were built to examine risk-adjusted outcomes for surgeon and hospital experience groups. ResultsOf 3850 patients treated with AAA procedures of any kind between 2012 and 2021, 160 (4.2%) underwent FEVAR. FEVAR procedures were performed by 34 different surgeons at 12 hospitals, with intraoperative complications and unplanned adjunctive procedures occurring in 18.8% (n = 30) and 19.4% (n = 31) of patients, respectively. Among FEVAR patients, in-hospital mortality was 1.3% (n = 2) and postoperative morbidity was 16.9% (n = 27). Renal function decline occurred postoperatively in 5.1% of patients. Early (<30 day) postoperative endoleaks occurred in 15.3% of patients (n = 21). Target vessel patency was 95.6% on initial postoperative imaging. Surgeon and hospital experience had a small positive impact on outcomes after the first one to three cases. Significant decreases in operative time, fluoroscopy time, and estimated blood loss were observed with increased surgeon experience, relative to a surgeon's first case (P < .05). There were lower odds of intraoperative complications after a surgeon's first case (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03-0.77, for cases 2-3) or after a hospital's first one to three cases (OR, 0.19; 95% CI, 0.04-0.89, for cases 4-8; OR, 0.12; 95% CI, 0.03-0.55 for cases 9-49). ConclusionsClinical outcomes of FEVAR across our hospital system compare favorably with previously published reports. Although system-wide FEVAR adoption increased 3-fold over the last decade, FEVAR continued to be performed by a minority of hospitals in our system. The results from this cohort demonstrate low rates of adverse events, high rates of technical efficiency, and a small impact of surgeon and hospital experience, thereby supporting this advanced endovascular technology as a safe, efficacious, and generalizable treatment alternative to open repair for patients with complex aortic anatomy.

Cerebellar mutism is linked to midbrain volatility and desynchronization from speech cortices.

Cerebellar mutism syndrome is a disorder of speech, movement and affect that can occur after tumour removal from the posterior fossa. Projections from the fastigial nuclei to the periaqueductal grey area were recently implicated in its pathogenesis, but the functional consequences of damaging these projections remain poorly understood. Here, we examine functional MRI data from patients treated for medulloblastoma to identify functional changes in key brain areas that comprise the motor system for speech, which occur along the timeline of acute speech impairment in cerebellar mutism syndrome. One hundred and twenty-four participants, all with medulloblastoma, contributed to the study: 45 with cerebellar mutism syndrome, 11 patients with severe postoperative deficits other than mutism, and 68 without either (asymptomatic). We first performed a data-driven parcellation to spatially define functional nodes relevant to the cohort that align with brain regions critical for the motor control of speech. We then estimated functional connectivity between these nodes during the initial postoperative imaging sessions to identify functional deficits associated with the acute phase of the disorder. We further analysed how functional connectivity changed over time within a subset of participants that had suitable imaging acquired over the course of recovery. Signal dispersion was also measured in the periaqueductal grey area and red nuclei to estimate activity in midbrain regions considered key targets of the cerebellum with suspected involvement in cerebellar mutism pathogenesis. We found evidence of periaqueductal grey dysfunction in the acute phase of the disorder, with abnormal volatility and desynchronization with neocortical language nodes. Functional connectivity with periaqueductal grey was restored in imaging sessions that occurred after speech recovery and was further shown to be increased with left dorsolateral prefrontal cortex. The amygdalae were also broadly hyperconnected with neocortical nodes in the acute phase. Stable connectivity differences between groups were broadly present throughout the cerebrum, and one of the most substantial differences-between Broca's area and the supplementary motor area-was found to be inversely related to cerebellar outflow pathway damage in the mutism group. These results reveal systemic changes in the speech motor system of patients with mutism, centred on limbic areas tasked with the control of phonation. These findings provide further support for the hypothesis that periaqueductal grey dysfunction (following cerebellar surgical injury) contributes to the transient postoperative non-verbal episode commonly observed in cerebellar mutism syndrome but highlights a potential role of intact cerebellocortical projections in chronic features of the disorder.

The Utility of Radiologic and Symptomatic Surveillance After Minimally-invasive Adult Pyeloplasty

To evaluate different types of failure after minimally-invasive pyeloplasty (MIP) when stratified by initial radiologic study and symptoms after ureteral stent removal. We retrospectively reviewed adults who underwent MIP (1996-2019) at a single academic center. Patients with at least 11 months of follow-up and patients who had a Mag3 scan as their initial postoperative imaging were included. Postprocedure, patients were categorized as having normal, equivocal, or obstructed imaging based on their initial radiologic test. Patients who were obstructed were excluded. Primary outcome was procedural failure, defined as the need for a procedure to treat recurrent obstruction. Secondary outcomes were radiologic failure and symptomatic failure. Groups were compared to assess for statistical significance (P <.05). Overall, 122 patients met inclusion criteria. On initial postoperative imaging, 108 (89%) patients had no obstruction and 14 (11%) had equivocal findings. The procedural failure rate was 6.5% in the unobstructed group and 28.6% in the equivocal group (P=.023). Seven unobstructed patients (6.5%) and 2 equivocal patients (14.3%) eventually experienced radiologic failure (P=.275). Among patients who had no obstruction on initial imaging and remained asymptomatic, only one (0.9%) required a salvage procedure. Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians' choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be limited.

Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures.

The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.

Muscle mass change using linear measurement analysis after nephrectomy for pT3 and pT4 renal cell carcinoma is associated with mortality

AbstractBackgroundPreoperative skeletal muscle deficiency is an established risk factor for poor survival outcomes in patients with renal cell carcinoma (RCC). However, given the dynamic nature of skeletal muscle associated with malignancy, there is a need to evaluate the prognostic benefit of muscle area change from the preoperative to postoperative period. We hypothesize that an improvement in muscle area following nephrectomy, measured by linear segmentation of L3 psoas and paraspinal musculature, is associated with improvement in overall survival (OS) and cancer specific survival (CSS) for patients with pT3 and pT4 RCC.MethodsWe retrospectively analysed 270 pT3 and pT4 RCC patients who underwent nephrectomy from March 2004 to February 2020 with available preoperative and postoperative axial CT or MRI studies segmented at the L3 vertebrae. The majority were N0 (79%) and M0 (68%). Psoas and paraspinal muscles were measured bilaterally using a validated digital ruler tool. Total muscle area (TMA) was calculated by aggregating the area of all four muscles and total muscle area index (TMI) by dividing the TMA by height squared (m2). The prognostic value of postoperative muscle improvement, defined as any increase in muscle area index, was analysed using Kaplan–Meier and Cox proportional stepwise hazard models.ResultsMedian time between preoperative scans and surgery was approximately 22 days and between surgery and postoperative scans 172 days. One hundred twenty‐one patients (44.8%) had an increase in total muscle area index post‐nephrectomy (IQR = 33.4; P ≤ 0.0001). On Kaplan–Meier analysis, postoperative improvement in TMI was associated with decreased odds of mortality (P = 0.0024) with a median follow‐up of 38.6 months. In a multivariable Cox regression analysis, improvement of TMI was associated with increased OS (HR = 0.52, 95% CI 0.35–0.78, P &lt; 0.001) and increased CSS (HR = 0.55, 95% CI 0.32–0.94, P = 0.030). A 5% or more improvement in TMI was also associated with increased OS (HR = 0.53, 95% CI 0.34–0.84, P = 0.006) and increased CSS (HR = 0.46, 95% CI 0.24–0.86, P = 0.015).ConclusionsAny improvement in TMI between preoperative and initial postoperative imaging after nephrectomy was associated with increased OS and CSS in patients with pT3 and pT4 RCC. Perioperative linear segmentation is an efficient tool that may improve current prognostication methods and can be performed on any imaging software platform.

Trends and Healthcare Use Following Different Cholesteatoma Surgery Types in a National Cohort, 2003-2019.

To describe national trends in cholesteatoma management. Retrospective analysis Optum Clinformatics® Database from 2003 to 2019. 16,179 unique adult and pediatric patients who received cholesteatoma surgery. Patients were categorized into three groups by initial surgical modality: canal wall down (CWD), canal wall up (CWU), and tympanoplasty without mastoidectomy (TnoM). Three major comparisons between groups were performed: 1) temporal trends, 2) clinical and sociodemographic determinants, and 3) healthcare use in terms of total costs and incidence of postoperative imaging and subsequent surgery. Overall, 23.2% received initial CWD surgery, 44.3% CWU, and 32.5% TnoM. 1) The incidence of initial CWD surgery decreased (odds ratios [OR] = 0.98, 95% confidence intervals [CI] [0.97,0.99]), while CWU increased (OR = 1.02, 95% CI [1.01,1.03]), and TnoM remained stable over the study period (OR = 0.99, 95% CI [0.98,1.00]). 2) Relative to CWU, TnoM surgery was less likely in adults, patients with prior complications, and non-White patients, while being more likely in patients with higher household income. CWD was more likely than CWU in adults, patients with prior complications, and non-White patients, while income had no effect. 3) Postoperative costs for CWU and CWD were similar. In 2 years following initial surgery, postoperative imaging and/or subsequent surgery was performed in 45.48% of CWD, 57.42% of CWU, and 41.62% of TnoM patients. Incidence of initial CWD surgery decreased and social disparities in cholesteatoma management were observed. Postoperative imaging or second-look surgery were performed in less than 60% of patients with initial CWU surgery and over 40% of patients with initial CWD.

Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study

BackgroundPerforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. MethodsWe conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. ResultsOur analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%–87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). ConclusionRoutine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Duplex Ultrasound Can Successfully Identify Endoleaks and Renovisceral Stent Patency in Patients Undergoing Complex Endovascular Aneurysm Repair.

Efficacy of duplex ultrasound (DU) surveillance of complex EVAR such as FEVAR and ChEVAR has not been studied. All patients undergoing FEVAR or ChEVAR at a single multihospital institution were retrospectively reviewed. Postoperative surveillance included DU at 1 month and CTA at 3 months. 82 patients met inclusion criteria including 39 (47.6%) ChEVAR and 43 (52.4%) FEVAR cases. DU identified endoleak with aneurysm sac enlargement in 3 cases requiring reintervention. CTA at 3 months detected 2 new endoleaks without growth and 1 renal artery stent occlusion. Replacement of initial postoperative imaging with DU did not result in any missed endoleaks, deaths, ruptures, or branch occlusions.

Relevance of asymmetric extension gap on initial post-operative and weight-bearing x-rays after total knee replacement

Introduction Asymmetric gap between the femoral and tibial component after primary total knee replacement (TKR) is a known cause of post-operative pain. This study investigates whether significant asymmetric extension gaps seen on initial post-operative non-weight-bearing (NWB) radiographs persist on follow-up weight-bearing (WB) radiographs. Method 203 consecutive patients who underwent primary TKR, and had adequate radiographic follow-up during a four-year period, were included. The distance between the tibial tray and femoral condyle on the medial and lateral sides was measured on initial NWB and follow-up WB radiographs, to identify significant asymmetric extension gaps. Previous studies showed medial extension gaps of ≥1.5mm may be associated with increased pain post-operatively. Therefore, we defined a significant gap as ≥1.5mm. The results were examined to determine whether initial post-operative gaps remain appreciable on follow-up x-rays. Results Of the 203 radiographs reviewed, 29 (14.3%) patients had an extension gap mismatch of ≥1.5mm on initial post-operative imaging. 13 (44.8%) patients had a medial opening gap whilst 16 (55.2%) had a lateral opening. Only 4 (13.8%) of these patients showed no significant change in the asymmetrical extension gap (remained ≥1.5mm) on WB x-rays. In the remaining patients, the gap was no longer appreciable. Conclusion The study showed that if patients present with post-TKR pain, which could be related to a medial opening extension gap, clinicians should use initial NWB x-rays to investigate as the gap mismatch may not be detectable on follow-up WB radiographs.

PD41-09 THE UTILITY OF RADIOLOGIC AND SYMPTOMATIC SURVEILLANCE AFTER PYELOPLASTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (PD41)1 Apr 2020PD41-09 THE UTILITY OF RADIOLOGIC AND SYMPTOMATIC SURVEILLANCE AFTER PYELOPLASTY Peris Castaneda*, Henry Valora Tapia, J. Stuart Wolf, Paholo Barboglio-Romo, Bahaa Malaeb, John Stoffel, Yooni Yi, and Sapan Ambani Peris Castaneda*Peris Castaneda* More articles by this author , Henry Valora TapiaHenry Valora Tapia More articles by this author , J. Stuart WolfJ. Stuart Wolf More articles by this author , Paholo Barboglio-RomoPaholo Barboglio-Romo More articles by this author , Bahaa MalaebBahaa Malaeb More articles by this author , John StoffelJohn Stoffel More articles by this author , Yooni YiYooni Yi More articles by this author , and Sapan AmbaniSapan Ambani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000921.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A combination of symptom assessment and imaging is used to assess for obstruction after pyeloplasty (PY), however current evidence does not support whether these are useful tools to predict PY failure. We sought to evaluate failure after PY when stratified by initial radiologic study and symptoms after ureteral stent removal. METHODS: We performed a retrospective review of adult patients who underwent minimally-invasive PY from 1996 to 2019 at a single academic center. Patients lost to follow up were excluded. Post-procedure, following stent removal, patients were categorized as normal, equivocal, or obstructed based on their initial radiologic test and asymptomatic, mild, or severe based on symptoms. Primary outcome was procedural failure (PF) as defined as the need for a procedure to treat recurrent obstruction. Secondary outcome was radiologic failure. Groups were compared to assess for statistical significance (p<0.05). RESULTS: We identified 299 patients who met inclusion criteria. On initial post-operative imaging, 226 (76%) patients had no obstruction, 30 (10%) had equivocal findings, and 43 (14%) had obstruction (Table 1). Figure 1 demonstrates PF based on radiologic (A) and symptomatic (B) groups. PF occurred in 4% (normal), 13% (equivocal), and 49% (obstructed) of patients. The majority of equivocal (86%) and obstructed (67%) patients managed with surveillance developed improved imaging. PF developed in 0.6% of asymptomatic patients and 2.8% of minimally symptomatic patients with an initial normal radiologic study. Radiologic failure developed in 10 (4%) normal and 2 (7%) equivocal group patients (p=0.59). CONCLUSIONS: Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians’ choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be low. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e824-e825 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peris Castaneda* More articles by this author Henry Valora Tapia More articles by this author J. Stuart Wolf More articles by this author Paholo Barboglio-Romo More articles by this author Bahaa Malaeb More articles by this author John Stoffel More articles by this author Yooni Yi More articles by this author Sapan Ambani More articles by this author Expand All Advertisement PDF downloadLoading ...

Postoperative surveillance and long-term outcome after endovascular aortic aneurysm repair in the Netherlands: study protocol for the retrospective ODYSSEUS study

IntroductionStrict imaging surveillance protocols to detect complications following endovascular aneurysm repair (EVAR) are common practice. However, controversy exists as to whether all EVAR patients need intense surveillance. The 2019 European...

Relevance of Asymmetric Extension Gap on Initial Post-Operative and Weight-Bearing X-Rays After Total Knee Replacement

Introduction Asymmetric gap between the femoral and tibial component after primary total knee replacement (TKR) is a known cause of post-operative pain. This study investigates whether significant asymmetric extension gaps seen on initial post-operative non-weight-bearing (NWB) radiographs persist on follow-up weight-bearing (WB) radiographs. Method 203 consecutive patients who underwent primary TKR, and had adequate radiographic follow-up during a four-year period, were included. The distance between the tibial tray and femoral condyle on the medial and lateral sides was measured on initial NWB and follow-up WB radiographs, to identify significant asymmetric extension gaps. Previous studies showed medial extension gaps of ≥1.5mm may be associated with increased pain post-operatively. Therefore, we defined a significant gap as ≥1.5mm. The results were examined to determine whether initial post-operative gaps remain appreciable on follow-up x-rays. Results Of the 203 radiographs reviewed, 29 (14.3%) patients had an extension gap mismatch of ≥1.5mm on initial post-operative imaging. 13 (44.8%) patients had a medial opening gap whilst 16 (55.2%) had a lateral opening. Only 4 (13.8%) of these patients showed no significant change in the asymmetrical extension gap (remained ≥1.5mm) on WB x-rays. In the remaining patients, the gap was no longer appreciable. Conclusion The study showed that if patients present with post-TKR pain, which could be related to a medial opening extension gap, clinicians should use initial NWB x-rays to investigate as the gap mismatch may not be detectable on follow-up WB radiographs.

Plasmacytoid urothelial carcinoma: a rapid autopsy case report with unique clinicopathologic and genomic profile

BackgroundRapid (“warm”) autopsies of patients with advanced metastatic cancer provide important insight into the natural history, pathobiology and histomorphology of disease in treatment-resistant tumors. Plasmacytoid urothelial carcinoma (PUC) is a rare variant of urothelial carcinoma characterized by neoplastic cells morphologically resembling plasma cells. PUC is typically aggressive, high-stage at presentation, and associated with poor outcomes. Recurrence is common in PUC, with the majority of recurrences occurring in the peritoneum.Case presentationHere, we report rapid autopsy findings from a patient with recurrent PUC. The patient had persistent pain after cystoprostatectomy, although initial post-operative imaging showed no evidence of disease. Imaging obtained shortly before his death showed only subtle growth along vascular tissue planes; however, extensive disease was seen on autopsy. Plasmacytoid tumor cells formed sheets involving many serosal surfaces. Molecular interrogation confirmed a mutation in CDH1 exon 12 leading to early truncation of the CDH1 protein in the tumor cells.ConclusionsThe sheet-like growth pattern of PUC makes early phases of disease spread much more difficult to capture on cross-sectional imaging. Alternative forms of surveillance may be required for detection of recurrent PUC, and providers may need to treat based on symptoms and clinical suspicion.

Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously

ObjectiveThe Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood. MethodsWe performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging. ResultsFifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up. ConclusionsWhereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.

Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients

BackgroundAortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents. MethodsAll TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival. ResultsTwenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate-LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow-up). The 30-day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4-9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up (median follow-up, 9 [interquartile range, 1-23] months). The 1-year and 3-year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively. ConclusionsTEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-up is needed.

Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair

ObjectiveAlternative endovascular strategies using parallel or snorkel/chimney (chimney endovascular aneurysm repair [ch-EVAR]) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and midterm patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR. MethodsReview of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak. ResultsSixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 superior mesenteric artery, 2 celiac). A mean of 1.9 ± 0.6 snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n = 18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 44.3%, 65.2%, and 88.4% of patients at 6, 12, and 18 months postprocedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.9 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (−6.1 ± 10.0 mm vs −4.9 ± 11.5 mm; P = .23). ConclusionsGutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to midterm follow-up. Given that few ch-EVAR patients require reintervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected.

Findings and Impact of Early Imaging After Partial Nephrectomy.

American Urological Association guidelines for surveillance of renal-cell carcinoma after partial nephrectomy recommend imaging within 3-12 months of surgery. Imaging following partial nephrectomy may be difficult to interpret due to the surgical defect, the use of surgical material, and normal postoperative fluid collections. Our primary objective was to evaluate the frequency of indeterminate postoperative imaging results and how those radiographic findings altered patient management. Retrospective chart review from 2006 to 2013 of patients who had undergone open, laparoscopic, and robotic partial nephrectomy at our institution was completed. There was a minimum of 2 years of follow-up imaging. Radiology reports were reviewed from follow-up imaging and were categorized as "normal" or "abnormal." We identified 180 patients with 127 (70.5%) considered to have normal findings on initial follow-up imaging, and 53 (29.5%) with abnormal findings. Median time to initial postoperative imaging for normal findings was 6.8 months compared with 4.4 months for patients with abnormal postoperative scans (p = 0.02). On subsequent imaging, 60% of abnormal studies were downgraded to normal. The median time to receive a second postoperative image from surgery in the normal and abnormal groups was 13.2 and 10.2 months, respectively. The median time interval to the second imaging study was 6.3 months for normal initial scans compared with 5.2 months for initially abnormal scans (p ≤ 0.01). Early postoperative imaging after partial nephrectomy frequently results in "abnormal" findings and more subsequent radiology exams even though the findings rarely represent cancer recurrences. Based on our results, and pending further validation from other centers, we believe postoperative CT or MRI surveillance after partial nephrectomy can be safely deferred until 1 year after surgery.

Cortical Strut Allograft Support of Modular Femoral Junctions During Revision Total Hip Arthroplasty

BackgroundThere is risk of junction failure when using modular femoral stems for revision total hip arthroplasty (THA), especially with loss of bone stock in the proximal femur. Using a cortical strut allograft may provide additional support of a modular femoral construct in revision THA. MethodsWe reviewed prospectively gathered clinical and radiographic data for 28 revision THAs performed from 2004 to 2014 using cementless modular femoral components with cortical strut allograft applied to supplement proximal femoral bone loss: 5 (18%) were fluted taper designs and 23 (82%) were porous cylindrical designs All the patients had a Paprosky grade IIIA or greater femoral defect. The mean follow-up was 5.4 ± 3.9 years. ResultsThe Harris Hip Scores improved from 26 ± 10 points preoperatively to 71 ± 10 points at final follow-up (P < .001). The Western Ontario McMaster Universities Osteoarthritis Index scores improved from 45 ± 12 points preoperatively to 76 ± 12 points at final follow-up (P < .001). Eighty-nine percent (25 hips) of all revision or conversion THAs were in place at final follow-up. Three (11%) patients underwent reoperations, 2 for infection and 1 for periprosthetic fracture. There was no statistical significant change in femoral component alignment (P = .161) at final follow-up. Mean subsidence was 1.8 ± 1.3 mm at final follow-up. Femoral diameter increased from initial postoperative imaging to final follow-up imaging by a mean of 9.1 ± 5.1 mm (P < .001) and cortical width increased by a mean of 4.5 ± 2.2 mm (P < .001). Twenty-seven hips (96%) achieved union between the cortical strut allograft and the host femur. ConclusionThe use of a modular femoral stem in a compromised femur with a supplementary cortical strut allgraft is safe and provides satisfactory clinical and radiological outcomes.