Long-segment Stenosis Research Articles

Dynamic Computed Tomography Angiography: Role in the Evaluation of Popliteal Artery Entrapment Syndrome

This study reviews our experience with dynamic computed tomographic angiography (CTA) as an imaging modality in the evaluation of popliteal artery entrapment syndrome (PAES). Eight patients with surgically proven PAES were included in this study. Dynamic CTA studies performed with the feet in neutral and plantar flexed positions were reviewed for the detailed anatomy of the region and to define the location and extent of the stenosis, occlusions and collateral circulation. These findings were compared with intraoperative observations. CTA provided adequate angiographic and anatomic information required to arrive at the diagnosis and make a surgical decision. Thirteen limbs were affected in eight patients. There was popliteal artery occlusion in four limbs, stenosis at rest that was accentuated on stress imaging in two limbs, and patent popliteal artery with marked stenosis on stress imaging in seven limbs. Long-segment stenosis was seen in functional entrapment compared to short-segment stenosis in anatomic PAES. Anteroposterior compression of the popliteal artery in anatomic PAES unlike the side-to-side compression in functional PAES was a unique observation in this study. The CTA and surgical characterisation and classification of PAES matched in all the patients, except for misinterpretation of compressing fibrous bands as accessory slips of muscles in three limbs. In conclusion, dynamic CTA is a robust diagnostic tool that provides clinically relevant information and serves as a rapidly performed and easily available "one-stop-shop" imaging modality in the management of PAES.

Current Concepts in the Management of Chronic Mesenteric Ischemia

Treatment of chronic mesenteric ischemia has evolved during the past two decades. Endovascular treatment has emerged as an alternative to bypass in elderly and higher-risk patients and is now the primary treatment modality for most patients with suitable lesions, independent of their surgical risk. Open surgical revascularization still has an important role for patients with more extensive disease, including those with long-segment stenosis or occlusions, small vessel diameter, multiple tandem lesions, or severe calcification. This article summarizes current concepts in the epidemiology, natural history, treatment selection, and outcomes of open and endovascular mesenteric reconstruction for chronic mesenteric ischemia.

Cricotracheal Resection With Hilar Release for Pediatric Airway Stenosis

To determine the effectiveness of cricotracheal resection and hilar release for high-grade, long-segment airway stenosis. We identified 16 patients who underwent cricotracheal resection and hilar release, performed from January 1, 2004, through December 31, 2008, and conducted a retrospective review, emphasizing preoperative findings, operative technique, postoperative course, and results. Complete data sets were available for all patients. Tertiary care children's hospital. The study population comprised 16 patients younger than 18 years who underwent cricotracheal resection and hilar release performed by a thoracic airway team. All patients had high-grade, long-segment subglottic stenosis or severe, long-segment tracheomalacia. Cricotracheal resection with hilar release. Decannulation rate and dehiscence rate. Of the 16 patients, 15 were successfully decannulated. The one patient who was not decannulated remained ventilator dependent and has regained speech. There were no incidents of anastomotic dehiscence. Cricotracheal resection with hilar release is a novel and effective way to approach the problem of severe airway stenosis.

Tubular Duplication of the Esophagus - A Rare Cause of Dysphagia in the Adult

Purpose: Duplication of the esophagus is a rare congenital malformation caused by an error in early embryogenesis. The Dutch anatomist Gerhard Blaes first described this anomaly in the eighteenth century. The incidence is about 1 in 8200. While the cystic form is more commonly observed the tubular type of esophageal duplication seems to be extremely rare - with about 5-10% of these cases. Most of the patients suffering from esophageal duplication (70-90%) become symptomatic in childhood and are diagnosed before 2 years of age. To our knowledge, only few case reports exist with tubular esophageal duplication, incidentally discovered in adulthood. Methods: A 48-year-old male Caucasian was referred to our department, suffering from progressive dysphagia since 2 years. The findings leading to the diagnosis: “tubular duplication of the esophagus” will be presented. Results: Upper GI endoscopy revealed a stenosis of unknown origin at 25 cm from the incisors, which could not be passed with a conventional endoscope (Ø 8.8 mm). The stenosis was marked by two lumina separated by a bridge of intact mucosal epithelium. Using a filling catheter, both lumina could be explored by fluoroscopy showing that both tubular structures eventually lead into the stomach. CT scans showed extensive thickening of the esophageal wall, probably due to scarring, with formation of a septum in the esophageal lumen. After dilation therapy, upper GI endoscopy was again performed with a pediatric endoscope (Ø 5.9 ). The stenosis at 25 cm from the incisors could be passed and a normal gastro-esophageal junction was seen at 42 cm. At 38 cm from the incisors, a septum of intact mucosa was found similar to that in the proximal esophagus. Again, two lumina could be observed, however, only the larger lumen could be intubated. A guide-wire, introduced at 25cm showed communication of the two esophageal ducts at 35cm. Miniprobe endosonography revealed normal layers of the esophageal wall as well as within the septum. Kinematography showed a long-segment stenosis of the upper esophagus and an additional filiform, blind-ending lumen ventral of the esophageal main lumen. Conclusion: With regard to the present literature, surgery is the first-line treatment of tubular esophageal duplication. Esophagectomy and gastric interposition should also prevent malignant transformation, which may occur. Following this extensive operation, numerous adjustments in daily life have to be managed by the patients. PPI therapy is thought to relieve symptoms of dysphagia. In our case, dilation therapy and PPI medication have led to slight clinical improvement with satisfactory relief of the patients complaints. At the time being, the patient refuses surgery.

Treatment of Congenital Tracheal Stenosis

Congenital tracheal surgery is uncommon and few centers have enough experience to make meaningful conclusions about treatment. Short-segment congenital tracheal stenosis is treated by tracheal resection, whereas long-segment stenosis is treated by slide tracheoplasty. Tracheomalacia is treated most commonly by aortopexy if due to simple vascular compression, division of an offending vascular ring if due to a compressing or encircling ring, or by careful observation if not associated with vascular compression.

Clínica, diagnóstico y tratamiento de las estenosis traqueales

Introduction New surgical techniques have been developed for treatment of tracheal stenosis (TS) over the last few years. The aim of the present study is to examine the clinical, therapeutic characteristics and progress of the cases of TS diagnosed in our hospital from January 2004 to August 2007. Methods We have reviewed the clinical history, focusing on age at diagnosis, clinical signs and symptoms, baseline pathology, previous history of mechanical ventilation, degree of stenosis, diagnostic technique, treatment and progress. Results A total of 16 cases were found, (2 congenital and 14 acquired). Mean age at diagnosis was 8.8 months (23 days-2.5 years). Of these, 14 patients had been intubated (3–44 days). Clinical suspicion was prompted by inspiratory stridor (44%), difficulty to be extubated or intubated (28%) and recurrent laryngotracheitis (39%). Three patients received CO 2 laser therapy and suffered a high number of restenosis and required re-interventions. Three patients underwent costal cartilage tracheoplasty and tracheal-cricoid split, showing a good prognosis and one patient underwent a slide tracheoplasty. Five patients with only a few clinical signs and mild stenosis, were managed on a wait and see basis. One patient with tracheal membrane underwent resection of the stenosed portion and end-to-end anastomosis with favourable progres. Another patient had a partial cricotracheal resection but suffered three restenoses. Two patients underwent surgical correction of the vascular ring. Conclusions Asymptomatic patients may receive conservative therapy. In the case of short-segment stenosis, resection and end-to-end anastomosis is the therapy of choice and the long-segment stenosis has obtained good results by means of slide tracheoplasty, which involved no deaths and a very low morbidity.

Surgical management of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is a rare but life-threatening disorder, particularly in neonates and infants. The stenotic lesions are commonly composed of complete rings of cartilage varying in length, location, and severity. A definitive diagnosis of CTS may be delayed because of the rarity of this disorder and thus its unfamiliarity among physicians, its variable onset time, its various clinical symptoms, and the diversity of associated clinical conditions due to the cardiovascular disorders that may accompany it. More than half of the patients who manifest clinical symptoms during early infancy show a long-segment stenosis. Long-segment CTS is problematic and challenging to manage. Over the last two decades several surgical techniques for long-segment CTS have been devised and developed, but no definitively advantageous surgical procedure has been established because of insufficient experience and the lack of large-scale studies. Although rib cartilage tracheoplasty and pericardial patch tracheoplasty have provided limited early to midterm success for infants with long-segment CTS, these procedures are associated with early and late complications, including granulation tissue formation, patch collapse, and restenosis necessitating reintervention. By contrast, slide tracheoplasty has given rise to better surgical outcomes. This procedure enables reconstruction of the stenotic trachea using native tracheal walls with preserved blood supply. The trachea is foreshortened by only one-half of the original stenosis, resulting in reduced tension on the anastomosis. Consequently, the technique has several advantages, including less formation of granulation tissue, satisfactory subsequent growth, and infrequent reoperation for restenosis. Slide tracheoplasty is currently recognized as the preferred technique for long-segment CTS.

Surgical Approaches in Left Anterior Descending Artery In-Stent Stenosis

In-stent stenosis remains the major disadvantage of coronary interventions. Extensive applications of the intracardiac devices especially involving long segments of coronary arteries have resulted in an increase in the number of cases of in-stent stenosis. That may require aggressive surgical approaches. Between June 2006 and October 2007, 7 patients with long-segment left anterior descending artery in-stent stenosis were operated on in our institution. Two of the operations were off pump with minimally invasive techniques, whereas the latter 5 patients were operated on through cardiopulmonary bypass. All patients were male, except for the last patient; their ages were between 43 and 71 years (59.67 +/- 12.36). They all had received an intracoronary stent for the left anterior descending artery (3 to 11 months before surgery). The first 2 operations were minimally invasive off-pump procedures; however, the latter 5 were with cardiopulmonary bypass. Mean follow-up was 6.33 +/- 4.13 months, and a postoperative coronary angiogram was performed on all the patients. Although long-segment in-stent stenosis complicates subsequent coronary artery bypass grafting operations, stent removal with coronary endarterectomy seems to be the technique of choice because it is effective and safe.

Salvage of a Failing Dialysis Graft by Percutaneous Creation of a Jump Bypass Graft

Percutaneous salvage of failing arteriovenous grafts with diffuse disease or occlusion in the venous outflow remains an issue with no ideal solution. The present report describes a method of percutaneous creation of vascular bypasses in a patient with a failing graft. The patient had a long-segment stenosis in the venous outflow of a brachial-cephalic dialysis graft, and the graft was salvaged by conversion to a brachial-basilic graft. Notably, this method allowed the bypass to safely traverse a long distance (20 cm), and at 8 months, the graft remained functional and free of complications. In principle, this approach can be applied to different situations in which superficial bypass conduits are desired.

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Perioperative extracorporeal membrane oxygenation support for critical pediatric airway surgery

Extracorporeal membrane oxygenation (ECMO) has been used for cardiopulmonary support in neonates, infants, and adults. We report the application of ECMO for critical airway surgery when mechanical ventilation cannot provide adequate gas exchange. Three pediatric patients underwent emergency ECMO establishment because of hypercapnia that could not be managed by conventional mechanical ventilation. The pathology included: (1) left pulmonary artery sling with long-segment tracheal stenosis; (2) absence of the right intermediate bronchus and abnormal origin of the right lower bronchus arising from the left main bronchus; (3) right-lung agenesis with long-segment tracheobronchial stenosis. Venoarterial ECMO was established. Before ECMO, the arterial pH values were 7.28, 7.0, and 7.08, and the PaCO2 values were 111.8, 112.0, and 208.7 mmHg for each patient, respectively. After ECMO support, respiratory acidosis was reversed. The patients then underwent surgical intervention. The surgical procedures included: (1) slide tracheoplasty and reimplantation of the left pulmonary artery; (2) resection of the stenotic tracheal segment and reconstruction of the bronchial tree; (3) tracheal dilatation and stent implantation. The ECMO durations were 11, 5, and 16 h, respectively. All patients were successfully weaned off ECMO without complications. In conclusion, ECMO provided adequate ventilation support for patients undergoing critical tracheobronchial reconstruction when conventional mechanical ventilation could not maintain adequate gas exchange.

Feasibility of Angioplasty and Stenting for Abdominal Aortic Lesions Adjacent to Previously Stented Visceral Artery Lesions in Patients with Takayasu Arteritis

Two young female patients with Takayasu arteritis presented with symptomatic long-segment abdominal aortic stenosis in the vicinity of previously deployed celiac and renal artery stents that projected markedly into the narrowed aortic lumen. Crushing or distortion of the visceral artery stents during aortic angioplasty was avoided by performing simultaneous or alternating balloon dilatations in the aorta and in the visceral artery stents. Consequently, the visceral artery stents remained patent and shortened longitudinally, allowing unhindered deployment of Wallstents in the adjacent aorta and abolition of a pressure gradient across the aortic lesions. Access to side branches covered by the Wallstent was obtained without difficulty, enabling the performance of balloon dilatation in multiple side branches and ostial stent deployment in a renal artery. These techniques could increase the scope of endovascular therapy in the treatment of patients with Takayasu arteritis.

Variations in the Technique of Slide Tracheoplasty to Repair Complex Forms of Long-Segment Congenital Tracheal Stenoses

Slide tracheoplasty has become the preferred technique for repair of long-segment congenital tracheal stenosis with complete tracheal rings. Complex morphological subtypes require technical modifications, which we present as follows.

Management of congenital tracheal stenosis in infancy☆

Congenital tracheal stenosis (CTS) is a very infrequent malformation. Till recently, the outlook for these patients was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. We review the short- and long-term outcomes of a single institution experience in the management of children with CTS, comparing different treatment modalities. Between 1991 and 2004, 19 cases of CTS have been managed in our Unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy was performed for diagnostic purposes in all cases; other imaging techniques (computed tomography (CT), magnetic resonance imaging (MRI), bronchography, angiography, doppler-ultrasound) were performed on an individual basis. According to clinical and endoscopical features, patients were classified into three groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomical type, associated anomalies, treatment modality, complications, outcome and time of follow-up. Ten boys and nine girls have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 4 months) and 84% of cases showed associated anomalies. Five patients presented mild or no symptoms and have been managed expectantly. The other 14 cases were operated on because of persistent or severe clinical symptoms. The following procedures were performed: slide tracheoplasty (n = 7), costal cartilage tracheoplasty (n = 5), tracheal resection and reconstruction (n = 3), endoscopical dilatation (n = 3), stent placement (n = 1), and laser resection (n = 1). Three patients required two or more procedures and surgical survival rate is 78%. Overall mortality in the series is 21% and all survivors (15 patients) are asymptomatic or show mild symptoms with respiratory infections only. Follow-up is complete, ranging from 8 months to 12.3 years (mean, 5 years). Bronchoscopy is our preferred diagnostic tool. Selection of the type of treatment depends on the patient's clinical status and the anatomical pattern of the stenosis. In symptomatic cases with short-segment stenosis (<30% of total tracheal length), we prefer tracheal resection with end-to-end anastomosis; for long-segment stenosis (>30%), slide tracheoplasty is our procedure of choice.

Techniques for large sheath insertion during endovascular thoracic aortic aneurysm repair

Despite improvements in operative technique and perioperative management, conventional open repair of descending thoracic aortic aneurysms (DTAs) continues to be associated with significant morbidity and a perioperative mortality between 4.8% and 20%, which may be even more pronounced in the acute setting. Since the first description of the endovascular repair of a thoracic aortic aneurysm by Dake et al, several studies have shown the safety of this approach, as well as possible decreases in perioperative mortality and complications, most notably paraplegia. Because of the less invasive nature and likely improved perioperative outcomes of endovascular repair of DTA, this is rapidly becoming the favored approach for management in these patients. Many patients, however, continue to be ineligible because of suboptimal vascular access, aortic arch angulation, and landing zone inadequacies. Although industry has been working to solve the last two issues, vascular access continues to be of major concern because delivery systems remain excessively large. In the United States, the currently available endografts for thoracic aorta aneurysms require delivery sheaths ranging from 20F to 25F, depending on the size of the graft and the manufacturer (Table). Despite these challenges, with the recent approval by the US Food and Drug Administration of the Gore Thoracic Aortic Graft endoprosthesis (W.L. Gore and Associates, Inc, Flagstaff, Ariz) and the ongoing evaluation of the Talent (Medtronic, Santa Rosa, Calif) and Zenith TX1 and TX2 (Cook Inc, Bloomington, Ind) endografts, it is clear that this technology is moving forward. With more widespread use and continued innovation, industry should be able to overcome the difficulties currently encountered with vascular access for the introduction of thoracic aortic endografts. Until that time, however, one should be knowledgeable of and comfortable with the implementation of several adjunctive maneuvers that may allow graft placement in otherwise ineligible patients. Furthermore, a thorough knowl-

Perforation of the esophagus after dilation treatment for dysphagia in a patient with eosinophilic esophagitis

A 17-year-old girl presented with progressive dysphagia. Congenital esophageal stenosis had been diagnosed 8 years previously on the basis of similar symptoms. After repeated esophageal dilation at that time, she had remained asymptomatic for several years. Achalasia was excluded by manometry, which documented complete lower esophageal sphincter relaxation and uncoordinated contractions. A barium swallow examination showed a long-segment stenosis of the esophagus (Figure [1]). Endoscopy revealed a long-segment stenosis, which was dilated to a diameter of 11 mm to allow multiple biopsies to be taken. Minor bleeding and mucosal tears were observed after the dilation. A check-up gastroscopy showed signs of esophagitis and white pin-point plaques (Figure [2]), and multiple biopsies were taken. Computed tomography showed that there was air in the paraesophageal space, and perforation of the esophagus was assumed (Figure [3]). Four weeks later, no further extramural air was detected, and the patient remained clinically stable.

Homozygosity for the CARD15 frameshift mutation 1007fs is predictive of early onset of Crohn's disease with ileal stenosis, entero-enteral fistulas, and frequent need for surgical intervention with high risk of re-stenosis

Objective. The identification of CARD15 as a susceptibility gene for Crohn's disease (CD) offers new possibilities for patient classification and risk assessment. The purpose of this study was to carry out a CARD15 sequence analysis in a large single-center IBD cohort and to investigate the impact of different genotypes on disease phenotypes. Material and methods. A total of 445 unrelated patients with IBD (68.1% CD, 28.5% ulcerative colitis (UC), 3.4% indeterminate colitis (IC)) were included in the study. Clinical data were recorded by detailed questionnaire and analysis of the charts. CARD15 variants (R702W, G908R, 1007fs (frameshift)) were identified by DNA sequence analysis. Results. CARD15 variants were found in 142 inflammatory bowel disease (IBD) patients (31.9%) including 120 CD patients (39.6%). In CD, the presence of two CARD15 variants was associated with ileal disease (p=0.008 versus wild-type (wt); OR 4.04; 95% CI 1.36–11.96) and a fibrostenotic phenotype (p=0.002 versus wt; OR 5.47; 95% CI 1.61–18.58). Subgroup analysis of 19 patients (4.3%) homozygous for the CARD15 variant 1007fs (3020ins C) revealed an association with onset of CD at an early age (p=0.014 versus wt), ileal involvement (p=0.001), and intestinal stenoses in all patients (p=0.001) frequently requiring surgery (73.7%; p=0.093). Of these patients 78.6% developed re-stenoses after surgical resection; 52.6% of the homozygotes were diagnosed as having entero-enteral fistulas. Conclusions. Patients homozygous for the 1007fs mutation had an early disease onset with long-segment ileal stenoses and entero-enteral fistulas. They frequently needed surgical intervention and had a high risk of re-stenosis. Genotyping therefore appears to be an important diagnostic tool in identifying severely affected patients requiring individualized treatment strategies at an early stage of the disease.

Primary Sclerosing Cholangitis: The Role of Endoscopic Therapy

Primary sclerosing cholangitis is characterized by progressive fibrosing inflammation of the bile ducts leading to their obliteration, resulting in cholestasis, and finally, cirrhosis of the liver. The majority of patients with advanced disease with time develop dominant stenoses of major bile ducts. Such dominant stenoses may be recognized by magnetic resonance cholangiopancreatography with good specificity and sensitivity, but for definite diagnosis and especially for therapeutic decisions, endoscopic retrograde cholangiography still represents the gold standard. Ursodeoxycholic acid treatment does not prevent the development of such stenoses. Endoscopic measures allow the opening of short- and long-segment stenoses of the common bile duct. Short- but not long-segment stenoses of the hepatic ducts near to the bifurcation also may be treated endoscopically. Repeated balloon dilatations over years appear to be the treatment of choice. In patients treated by early endoscopic dilatation of dominant stenoses, survival may be significantly improved compared with the predicted survival.

Electrocautery therapy for refractory anastomotic strictures of the esophagus

Anastomotic esophageal stenoses after esophageal resection are common and sometimes are refractory to Savary bougie dilation. The efficacy of electrocautery needle-knife treatment in these patients is described. Twenty patients with a refractory anastomotic stricture of the esophagus were treated with electrocautery and were followed for 12 months. All patients had recurrence of dysphagia despite repeated bougienage. All 12 patients with a stricture shorter than 1 cm remained without dysphagia after a single treatment. In all 8 patients with a long-segment stenosis of 1.5 to 5 cm, dysphagia recurred, and a mean of 3 treatments were necessary. The interval between electrocautery treatments was significantly longer compared with bougienage. There were no complications. The body weight of all patients increased. Electrocautery seems to be a good single-treatment modality for refractory short-segment anastomotic strictures, whereas longer-segment stenoses appear to require repeated treatment sessions before similar results are obtained.

Endoscopic Treatment of Dominant Stenoses in Patients With Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is characterized by progressive fibrosing inflammation of the bile ducts, leading to their obliteration, which results in cholestasis and, finally, cirrhosis of the liver. Over time, the majority of patients with advanced disease develop dominant stenoses of major bile ducts. Ursodeoxycholic acid (UDCA) treatment does not prevent the development of such stenoses. Endoscopic measures allow the opening of short- and long-segment stenoses of the common bile duct and also of short segment stenoses of the hepatic ducts. Inpatients treated by early endoscopic dilatation of dominant stenoses, as well as with UDCA,survival may be significantly improved (compared with the predicted survival).