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Arterio-esophageal fistula (AEF), whether congenital or acquired, is a rare condition which can lead to fatal upper gastrointestinal bleeding. We report here a young man who developed a subclavian-esophageal fistula (SEF) secondary to chicken bone impaction in the upper esophagus. The diagnosis was reached by urgent upper endoscopy and Computed Tomography of the chest which showed pseudo-aneurysmal changes at left subclavian artery with leaked contrast through the fistula towered the esophagus. Urgent endo-vascular angiography confirmed the subclavian arterio-esophageal fistula that was managed uneventfully using covered 6mm Viban stent-graft. The patient survived this serious condition and was discharged home in good condition.
Background: Thoracic endovascular aortic repair (TEVAR) is superior to open techniques, as it is a minimally invasive procedure with low morbidity and mortality rates. The aortic isthmus is usually the rupture site in aortic thoracic injuries. Therefore, the distance from the left subclavian artery (LSA) usually allows proximal stent graft fixation. The main challenge is the intentional coverage of the LSA without revascularization, which is necessary to expand the proximal landing zone and to achieve an adequate seal. Acute arm ischemia, claudication, stroke, and/or left subclavian steal syndrome may occur during intentional occlusion of the LSA without revascularization when performing thoracic aorta lesion endovascular repair. The present study was conducted to analyze the safety of coverage of the LSA without revascularization during the endovascular treatment of traumatic thoracic aorta injuries. Methods: A retrospectively collected data set from two trauma centers in Saudi Arabia was reviewed between April 2007 and January 2018 to analyze the safety of LSA coverage during TEVAR performed for traumatic thoracic aorta transection. In this data set, 69 patients presented with descending thoracic aortic injuries. All were treated urgently with TEVAR with intentional LSA occlusion without revascularization during aortic injury endovascular repair. Those who underwent thoracotomy and pre-TEVAR patients who died were excluded from this study. Results: A total of 69 patients underwent intentional left subclavian artery (LSA) coverage without revascularization during the procedure; the primary technical success reached 94.2% for patients who underwent TEVAR for traumatic aortic transection. The clinical success rate was 98.6%. Only 1 of 69 patients with LSA coverage developed a localized ischemic stroke (1.4%). The 30-day mortality rate was 4.3% due to multiple organ failure. Conclusion: Revascularization of LSA is not mandatory with TEVAR for treating traumatic thoracic aortic injury with an inadequate proximal landing zone. Extending the landing zone to zone 2 and coverage of LSA is considered safe and non-time-consuming, especially in urgent situations. It provides better fixation and a good sealing zone. Highlights:
linked, porcine pericardial patch (dCELL, Tissue Regenix, UK).Methods: Informed consent was obtained. Elective FEA with dCELL patch closure was performed using standard technique. Postoperative examination and Doppler ultrasound was performed at 1, 3, 6, and 12 months.Results: 21 patients participated; all were examined at 6 months and 18 were followed at 12 months (86%). 64% were active smokers; 27% had diabetes; 55% had previous vascular procedures. Mean time to hemostasis was 3.5 Ϯ 2.1 min. Handling characteristics were considered excellent. There was one wound hemorrhage requiring reoperation, not due to the patch. There was one superficial wound infection not related to the patch. There was one early asymptomatic occlusion (22 d) associated with an occluded profunda. In mid-term followup, 4 patients developed non-flow-limiting neointimal hyperplasia Ͼ2mm; mean neointima was 0.78mm. Mean mid-patch PSV was 93.3 cm/s at 12 months which was similar to 90.18 cm/s at 1 month; there was no change in mid-patch neointima at 1 and 6 months (diameter 9.22 Ϯ 0.22 mm vs. 8.99 Ϯ 1.31 mm, pϭ0.583). No aneurysmal dilation occurred (mean internal diameter 8.12 cm vs. 8.39 cm proximal, pϭ0.71). In 56% it was impossible to distinguish the patch wall due to remodelling. There were no pseudoaneurysms.Conclusions: dCELL porcine pericardial patches are safe and effective for patch angioplasty, with minimal restenosis and excellent tissue incorporation. dCELL patches may be a platform for next-generation tissue-engineered closure devices.
Background Endovascular stent grafting has emerged as an option to treat traumatic aorta injuries with reported significantly low mortality and morbidity. Stent collapse is one of the complications that can occur in this type of treatment. The aim of this article is to analyze the expected cause of stent collapse and to draw attention to the importance of the surveillance follow-up, as this phenomenon may occur late postdeployment. Methods A retrospectively collected dataset from the two highest volume trauma centers in Saudi Arabia was analyzed between April 2007 and October 2012. A total of 66 patients received stent grafts for traumatic aortic injury and were included in the study. We apply Ishimaru's anatomical aortic arch zones and Benjamin's aortic injury grading systems. There were 35 patients with aortic injury at zone 2, 26 patients in zone 3, and 5 patients in zone 4. About 96% (63) of the injuries were grades 2 and 3, including large intimal flap or aortic wall pseudoaneurysm with change in wall contour. The technical success rate, as defined by complete exclusion of lesions without leaks, stroke, arm ischemia or stent-related complications, was 90%. Results Proximal stent collapse occurred in 4.5% of patients (3 of 66 inserted stents) during follow-up of 4 to 8 years (mean, 6 years). Patients with stent collapse tended to have an acute aortic arch angle with long-intraluminal stent lip, when compared with patients with noncollapsed stents. Intraluminal lip protrusion more than 10-mm increased collapse (p < 0.001). Stent-grafts sizes larger than 28 mm also demonstrated a higher collapse rate (p < 0.001). Conclusions The risk of stent collapse appears related to poor apposition of the stent due to severe aortic arch angulation in young patients and to large stent sizes (>28 mm). Such age groups may have more anatomical and aortic size changes during the growth. Clinical and radiological surveillance is essential in follow-up after stent-graft treatment for traumatic aortic injury.
Objective: The arteriovenous fistula (AVF) is the preferred access type for hemodialysis, owing to its better patency rates and fewer complications. This study aimed to evaluate the outcome of percutaneous transluminal angioplasty in a failing arteriovenous fistula and arteriovenous graft in hemodialysis patients. Methods: Clinical data of patients who underwent percutaneous transluminal angioplasty in the vascular department of Aseer Central Hospitals, KSA, from January 2017 to May 2018 and with follow-up of >12 months were analyzed in retrospective cohort study. Results: Angioplasties were performed in 55 patients with fistulae, of which 18 patients had venous hypertension on dialysis and the remaining patients had weak or poor flow. Conclusions: Percutaneous transluminal angioplasty is an efficacious method for the correction of stenosis of arteriovenous fistulae for patients on hemodialysis, prolonging the patency of the fistula and enabling new interventions. Highlights:
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