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Persistent air leak (PAL) is a common and challenging condition associated with increased morbidity and mortality, intensive care unit admission, and prolonged hospital stay. Multiple medical and surgical approaches have been developed to manage PAL. Depending on the etiology of PAL, surgical management may be effective and usually performed using video-assisted thoracoscopic surgery (VATS). Medical management is less invasive and consists of pleural or bronchoscopic methods. The non-surgical techniques for the management of PAL have not been investigated in large prospective studies, and so their use is mostly guided by observational data. Specifically, the role of intrabronchial valve (IBV) placement for PAL has been the subject of an ever-increasing number of case reports and series documenting successful deployment of IBVs for both surgical and medical PAL. In this case-based discussion, we describe three patients with non-surgical PAL who were managed using multiple modalities, including both surgical and medical approaches. These cases illustrate the challenges in identifying the location of the air leak and in the application of various therapeutic options.

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Introduction Visceral artery injuries are rare but lethal entities that pose significant management challenges in a patient who presents with blunt trauma. There is a paucity of specific guidelines both in the trauma and vascular literature regarding the management of blunt intra-abdominal vascular injuries. The midterm outcomes of two cases of blunt traumatic visceral artery injuries managed successfully with endovascular interventions are presented. Report An 18 year old male victim of a motor vehicle accident was found to have infrarenal aortic, coeliac artery (CA), and superior mesenteric artery (SMA) injuries. The second patient was a 15 year old male who presented with traumatic occlusion of the CA after an all terrain vehicle collision. Both patients had other associated abdominal and bony injuries. All vascular injuries were addressed endovascularly, which was followed by repair of other associated injuries. In the first case, a self expanding non-covered nitinol stent was used in the injured but tortuous CA; for repair of the SMA, a covered balloon expandable stent was used. In the second patient, a balloon expandable non-covered stent was used to repair the CA occlusion. In both cases, the 12 month post-operative follow up showed that all stents were patent and the patients were asymptomatic. Discussion Endovascular repair of the mesenteric arteries following traumatic injury can be achieved safely, with good midterm outcomes. More data are needed to define the indications for and long term safety and patency of stents used in traumatic visceral artery injuries.

in 68% (34/50) of patients, with respiratory failure being the most common (n ¼ 20 [40%]). No patient experienced stroke or upper extremity ischemia. There were 14 (28%) vascular complications, which included 2 (4%) early aorta-related reinterventions secondary to device compression; these devices were implanted outside the instructions for use. The mean follow-up was 52.4 months (range, 1 month-14.9 years). During the late follow-up period, there were two device-related complications, both repaired with Palmaz stenting. One patient required an axillofemoral bypass for device compression and subsequent Palmaz stenting at 5.5 months. In the other case, the patient originally had an attempt at open repair at another institution. The aorta was wrapped with felt to prevent bleeding, and the patient was transferred for TEVAR. The stenosis occurred in the region of the wrapping at 4 years and was treated with a Palmaz stent. Two patients died (at 8.5 and 43 months, respectively) of non-aorta-related causes (Fig). There were no endoleaks or device fracture or migration.Conclusions: Assessment of long-term outcomes demonstrated few device-related complications that were associated with early off-label device use. Therefore, it may be reasonable to decrease routine surveillance after device implantation, especially in young patients who are at increased risk from radiation exposure. Larger studies with current device iterations will be helpful in determining the optimal surveillance protocol.