ABSTRACT. Introduction: Roux-en-Y bypass (RYGB) is the most commonly bariatric procedure performed. One major post-operative limitation of this procedure is the difficult access to the remnant stomach, often leading to late discovery of gastric lesions and hence delayed treatment. Gastric cancer is the fifth most common cancer in the world and the second cause of death due to cancer. Literature on the occurrence of gastric cancer in the remnant stomach is scarce. We report cases of gastric cancer in the excluded stomach after RYGB with aim to illustrate the difficulty of diagnosis and care of this uncommon condition. Case series: We present four patients who underwent RYBG ten to twenty years before a gastric cancer diagnosis. Their symptoms of gastric cancer are non-specific and include weight loss, anemia, abdominal pain, and ballooning. In all four cases, an explorative laparoscopy was used as last resort in order to find a diagnosis. Unfortunately, due to the late diagnosis, three of the four patients passed away. All deaths occurred within the first year of diagnosis. Discussion: Although the incidence of gastric cancer is rare, these cases illustrate the importance of not underestimating the symptoms. Gastric cancer symptoms are vague and often bear resemblance with symptoms linked to the RYGB. Hence when despite a thorough clinical, biological, and radiological examination no diagnosis can explain the patient’s symptoms, an exploratory laparoscopy should be discussed with the patient. Conclusion: Despite gastric cancers in the remnant stomach are singular, surgeons should be aware of its presence when faced to symptoms with no explainable cause. Further investigations are essential in order not to miss an incipient cancer that could be revealed too late.

ABSTRACT. Backround:

After extended hepatectomy, portal overflow, microvascular damage, hepatocyte hyper-proliferation, and lobular disorganization, are proposed pathophysiological mechanisms for hypoxia and dysfunction of the remnant. As such, clinical studies advocate that triggered mass recovery does not correlate with liver function. Previously, we showed that activation of hypoxia sensors in SFSS-hepatectomy surged early angiogenesis (partially through mobilization of endothelial progenitors (EP)) that preserved the sinusoidal architecture, with a favorable impact on survival. However, it remains unclear whether preserved liver function in hypoxic remnants is entirely due to favorable microvascular remodeling.

Purpose: To assess the impact of early mobilization of EP on vascular remodeling and function of the remnant. To decipher why triggered liver mass recovery is not sufficient to sustain the metabolic homeostasis.

Methods:

Mice with a SFSS-hepatectomy were submitted to systemic hypoxia, normoxia (SFSS-controls) or treated with Granulatory-colony stimulating factor (G-CSF). We used Cdh5-CreERT2xmTmG mice to trace the recruitment of EP. We assessed hepatocyte and liver endothelial cell proliferation, function, hepatocyte differentiation (E-Cadherin staining, and gene expression of HNF4a) and survival.

Results: Hypoxia significantly improved survival in SFSS-hepatectomy. Hypoxia favored the recruitment of EP and angiogenesis, improved the sinusoidal vascular network, and restored lobular perfusion and architecture (Fig.1A). Administration of G-CSF reproduced early recruitment of EP and rescued sinusoidal damage but did not improve liver function and survival in hepatectomized mice. After SFSS-hepatectomy, high hepatocyte proliferation (and liver remnant’s volume recovery) associated to high mortality rates. Compared to hypoxia, Epithelial-to-Mesenchymal transition of the proliferating hepatocytes was significantly higher in normoxia (Fig.1B) and associated with reduced liver function and survival. Conclusions: The recruitment of EP rescues vascular damage but does not sustain liver function after extended hepatectomy. In SFSS, abrupt volume restoration associates with loss of epithelial signature of the highly proliferating hepatocytes, leading to organ failure. Hypoxia limits this phenomenon.

ABSTRACT. Background Bariatric surgery (BS) is an effective treatment for obesity and associated comorbidities, including non-alcoholic fatty liver disease (NAFLD). In recent years, the number of available bariatric procedures has increased, yet their outcome and mechanisms of action have not been compared in detail. We performed vertical sleeve gastrectomy (VSG) and plication (VSP), Roux-en-Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB) with three different biliary limb lengths (25%=Omega1, 50%=Omega2, 75%=Omega3) for comparison. Methods Mice were fed Western diet (WD) for 12 weeks, followed by surgery, and subsequent sacrifice at week 20. Six different types of BS were performed and compared with each other, with a sham and a control group (WD, no surgery). Statistical differences between group mean values were assessed by one-way ANOVA tests with Tukey post-hoc test. Results Notably, the Omega3 procedure resulted in 100% mortality after just three weeks due to severe malnutrition and rapid weight loss. Relative weight loss differed significantly (p<0.0001) amongst the groups (Figure 1). Average food intake was significantly lower in VSG and VSP compared to RYGB (p<0.05), Omega1 (p<0.01), and Omega2 (p<0.001). In RYGB, Omega1, and Omega2, relative visceral adipose tissue weight was significantly lower compared to the sham mice (p<0.0001). RYGB, Omega1, and Omega2 significantly attenuated the elevated serum ALT levels and liver triglyceride content (p<0.01). Histologically, sham-operated mice had developed severe liver steatosis and moderate inflammation after 20 weeks of WD feeding, which was attenuated by BS, especially by Omega1 (p<0.05), and Omega2 (p<0.01). Bacterial translocation in the liver was observed in RYGB, Omega1, and Omega2 (p<0.001). Signs of intestinal inflammation were detected in the terminal ileum of mice that underwent Omega2 (p<0.01). Conclusions BS procedures in mice, especially RYGB, Omega1, and Omega2, improved histological NAFLD. Our models open up the field of research on how the gut and the liver interact following surgery.

ABSTRACT. OBJECTIVE R0 resection (≥ 1-mm margin) is the gold standard in the surgical treatment of colorectal liver metastases (CRLM). Detaching CRLM from blood vessels (R1-vascular) has been described as a possible technique within parenchyma-sparing liver surgery although reports in literature are limited.

METHODS A prospectively kept single-center database including 348 consecutive patients between May 2018 and December 2022 was reviewed. Patients who underwent an R1 vascular resection for CRLM were selected.

RESULTS Twenty-seven patients were included, 24 patients (89%) underwent a technically major liver surgery and 2 were performed laparoscopically. A total of 53 metastases were resected, including 66% (35/53) R1-vascular resections. Sixteen tumors were detached from a hepatic vein and 19 from a portal pedicle. R0 and R1-parenchymal resection rates were 28% (15/53) and 6% (3/53) respectively. Median hospital stay was 5 days (range 2 - 28) with major morbidity in 2 patients (Clavien-Dindo ≥ grade 3) and no 90-day mortality. After a median follow-up of 26 months (range 5-57), per tumor analysis showed local recurrence in 19% of the resection areas (10/53). Local recurrence rates were 20% (3/15) after R0 resection, 17% (6/35) after R1-vascular resection and 33% (1/3) after R1-parenchymal resection. Subsequent hepatectomy after recurrence was performed in 5 patients.

CONCLUSIONS R1-vascular resection allows to expand the surgical possibilities within parenchymal-sparing liver surgery for CRLM and seems to be associated with local recurrence rates comparable to R0 resection.

ABSTRACT. Objective: While outcomes after spleen-preserving distal pancreatectomy (SP-DP) are widely reported, the impact on splenic parenchyma has been poorly studied. This study aimed to assess splenic imaging after SP-DP and to compare postoperative outcomes with versus without splenic vessels removal. Methods: All patients undergoing SP-DP with splenic vessels removal (Warshaw technique, WDP) or preservation (Kimura technique, KDP) between 2010 and 2022 in two tertiary centres were retrospectively analysed. Splenic ischemia and volume at early/late postoperative imaging and postoperative outcomes were reviewed. Prognostic factors of splenic atrophy were evaluated. Results: Ninety-five patients were included, 57 in WDP and 38 in KDP groups. . Patients from WDP group had a higher Charlson Comorbidity Index and more frequently malignant indication than KDP group. Operative time was longer in WDP group than KDP group (p=0.020). Postoperative morbidity was similar between groups according to the Comprehensive Complication Index and the rate of severe complications. There was more splenic ischemia at early imaging in WDP compared to KDP groups (53% vs. 14%, p=0.007), especially severe ischemia (>50% of parenchyma, 22% vs. 0). Splenic partial atrophy was observed in 30% and 0% of WDP and KDP groups, respectively (p<0.001); no complete splenic atrophy appeared. Charlson Comorbidity Index and day-6 platelets levels were prognostic factors of splenic atrophy at multivariate analysis. No episodes of overwhelming post-splenectomy infection or secondary splenectomy were recorded. Conclusions: Splenic ischemia appeared in one half of patients undergoing SP-DP with splenic vessels removal at early imaging, and partial splenic atrophy in 30% at late imaging, without clinical impact neither complete splenic atrophy. No difference was observed in postoperative outcomes after SP-DP with splenic vessels removal versus preservation.

ABSTRACT. Introduction The histological growth pattern (HGP) of liver metastases is a strong predictive factor for the risk of recurrence in patients who underwent surgical resection of colorectal liver metastases (CRLM). The aim of this study is to evaluate if the HGP could also influence the type of recurrence after a first surgery on CRLM.

Patients and Methods A retrospective series of patients who underwent a curative-intent hepatectomy for CRLM was reviewed. In each patient, the HGP of CRLM at first hepatectomy was scored as desmoplastic (dHGP), replacement (rHGP) or non-desmoplastic (non-dHGP). The characteristics of recurrences were evaluated, distinguishing the patients who may undergo a second curative-intent surgery (salvage surgery) and those with diffuse recurrences only amenable to palliative treatments. In patients who underwent repeated hepatectomy for recurrent CRLM, the HGPs were compared between the first and the second resections.

Results In a consecutive series of 268 patients, 174 (65%) recurred after surgery. Non-dHGP was independently associated with the risk of recurrence (HR: 1.58 [95%CI: 1.04-2.40]; p=0.033). Among the patients with recurrence, a lower rate of salvage surgery was observed in patients with non-dHGP as compared to dHGP (57% versus 79%, p=0.03). The dHGP was the only independent factor associated with the possibility of salvage surgery (OR: 0.36 [95% CI:0.14-0.97]; p=0.043). In patients who underwent a second resection for recurrent CRLM, a higher ratio of rHGP was observed compared to the first resection (85% versus 7%, p<0.001).

Conclusions Besides its global predictive value, the HGP of CRLM also predicts the type of postoperative recurrence, as illustrated by its influence on the possibility of salvage surgery. Together with the relative increase in rHGP observed during tumor progression, these data confirm that HGP represents a promising candidate marker of metastatic behavior in patients with CRLM.

ABSTRACT. OBJECTIVE: A growing body of evidence supports the advantages of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) mainly for peritoneal metastases originating from gynecological, colorectal, and gastric tumors. However, data regarding the possible benefits of PIPAC in advanced stage of hepatopancreato-biliary cancer is still scarce. Few small case series have been published showing promising oncological long-term results such as disease regression and improved overall survival without additional morbidity. The purpose of this study is to retrospectively investigate short- and long-term outcomes of hepatopancreato-biliary cancer patients with peritoneal metastasis who underwent PIPAC in our center. METHODS: The prospectively maintained database of our institution was searched to include all patients with peritoneal metastasis originating from hepatopancreato-biliary cancer. Demographic, clinical, surgical, and oncological data of the patients between September 2015 to December 2022 were extracted. The short- and long-term clinical and oncological outcomes were analyzed. RESULTS: A total of 65 PIPAC procedures was performed on 26 patients (18 male, median age: 61.2 (29-80) years old). Among those, 13 patients were diagnosed with pancreas adenocarcinoma, four hepatocellular carcinoma, six cholangiocarcinoma, two duodenal and one gallbladder adenocarcinoma. The median number of PIPAC procedures was 2 (1–6) with a median Peritoneal Cancer Index of 15 (2–39). Median ASA score was 2 (2-4). No major complications (Clavien-Dindo>2) were recorded within 90 days postoperatively. Median hospital stay was one day (1-10). During the follow-up 11 patients died due to tumor progression. Median overall survival from the first PIPAC was 21.0 months (95% CI 7.4-34.6) and 18.6 months (95% CI 5.2-32.0) for hepatobiliary tumors and pancreas adenocarcinoma, respectively (figure 1). CONCLUSION: PIPAC for hepatopancreato-biliary cancer is feasible and safe without additional morbidity. Despite the small heterogeneous data, this is to our knowledge the largest series of PIPAC procedures performed for hepatopancreato-biliary cancer with promising oncological results.

ABSTRACT. OBJECTIVE: The surgical treatment of gallstone disease has greatly evolved following the spread of laparoscopic cholecystectomy, but the concomitant surgical exploration of the common bile duct has not incremented equally. In contrast, among endoscopists the management of common bile duct stone is widely diffused, despite studies show comparable efficacies of surgical exploration. The aim of this study was to analyze our single-center intra-operative and post-operative outcomes after surgical exploration of the common bile duct.

METHODS: The prospectively maintained database of our institution was searched to include all patients that underwent a surgical exploration of the common bile duct. Indications were cholecystolithiasis with concomitant common bile duct stone in both elective and urgent settings. Demographic, clinical, and surgical data of the patients between September 2016 to December 2022 were extracted.

RESULTS: Surgical exploration was performed in 48 patients of which 29 were female (60%). In two patients concomitant liver resection was performed, in one patient concomitant ileostomy closure. Median age was 67.5 (15-87) years old. Seven patients (14.6%) had a previous history of open abdominal surgery, three patients (6%) previously underwent a laparoscopic gastric bypass. No conversion was performed. No intra-operative complications occurred. In 7 patients (14.6%) the common bile duct could not be cleared because of a distal impacted stone, at the level of the ampulla of Vater. Transcystic approach was performed in 38 patients (80%), transcholedochal approach in 10 (21%). Postoperative complications (<90 days) occurred in 3 cases (6.2%) of which 2 (4.2%) were minor complications (Clavien-Dindo <3). 1 (2.1%) was a major complication (Clavien-Dindo>2) but not related to the common bile duct exploration. Median hospital stay was 2 days (0-8).

CONCLUSION: Surgical exploration of the common bile duct is a valid technique to simultaneously treat cholecystolithiasis and common bile duct stones. It seems to be associated with limited morbidity and short hospitalization.

ABSTRACT. Introduction: The liver metastases microarchitecture, or histopathological growth pattern (HGP), has been demonstrated as a prognostic factor in patients operated for colorectal liver metastases (CRLM). Our study has for aim to evaluate the association between the primary colorectal tumor’s pathological characteristics and the CRLM’s HGP.

Methods: A retrospective series of 167 patients with CRLM’s curative-intent resection in whom pathological samples from primary tumor and liver metastases were available, was reviewed. At primary tumor level, KRAS mutational status, differentiation’s grade and tumor budding were assessed. HGP were scored in resected CRLM and classified as desmoplastic (dHGP) or non-desmoplastic (non-dHGP). A binary logistic regression model evaluated associations between primary tumor characteristics and CRLM’s HGP. A Overall- and recurrence-free survival were evaluated using Kaplan-Meier and multivariable Cox regression analysis.

Results: CRLM were classified as dHGP in 36% and as non-dHGP in 64%. No relation was observed between primary tumor location, stage, nodal status, KRAS mutation and CRLM’s HGP. Higher rate of moderately/poorly differentiated primary tumors was observed in the non-dHGP CRLM group, representing 80% against 60% in dHGP group (OR=3.6; (95% CI: 1.6-7.05); p=0.001). Higher rate of tumor budding was observed in the non-dHGP CRLM group, with median tumor budding of 4 against 2.5 in the dHGP group (p=0.042). In the entire serie, the 5-years overall and disease-free survivals were 43% and 32.5%. The CRLM’s non-dHGP was the most significant factor for poor post-hepatectomy survival, with 5-years overall and disease-free survivals of 32.2% and 24.6%, against 60.8% and 45.9% in the dHGP group (p=0.02).

Conclusion: Colorectal tumors with moderate/poor differentiation and high tumor budding are more frequently associated with non-dHGP CRLM. This suggests that primary tumor characteristics of local aggressiveness and migratory capacity could promote the CRLM with infiltrating pattern’s development. These parameters could be considered in new scores for predicting the HGP before the surgery.

ABSTRACT. Objective: To present the technique of a left sided retroperitoneoscopic adrenalectomy Methods: We present a retroperitoneoscopic approach to an en-block adrenalectomy. Using 2 trocars, placed at the level of rib 12, we inflate the posterior renal space and open the fascia of Zuckerkandle. We then place a third trocar more medial and further dissect the renal fat approaching the adrenal gland. The kidney is pushed downward, and the overlying fat is coagulated. The adrenal vein is ligated with clips. The adrenal gland is further fully separated from the surrounding tissues, placed in an endoscopic bag, and removed from the body. After hemostasis, the fascia is closed with vicryl 3/0. The skin with monocryl 3/0. The skin glued shut with dermabond and sealed with opsite spray. Results: This technique offers a more quick, safe and direct approach to perform an adrenalectomy, compared to laparoscopic and open approaches. The retroperitoneal approach provides a direct access to the adrenal gland, without the need of manipulation of surrounding organs. This also results in faster recovery times, with hospital discharge withing 3 days. Patients have virtually no postoperative pain in the immediate postoperative period. Conclusions: With the retroperitoneoscopic adrenalectomy we present a quick and safe approach to adrenalectomy, with improved recovery times compared to other approaches. This technique aligns with the theme of this year’s Belgian Surgical Week, discussing enhanced recovery after surgery.

ABSTRACT. OBJECTIVE Celiac artery compression by the median arcuate ligament comprises a rare surgical entity called median arcuate ligament syndrome. Maintaining a tendency toward a female phenotype, they often follow a long-term clinical course, often manifesting with an upper postprandial abdominal pain mimicking symptoms of foregut ischemia. METHODS We present a rare case of 50-year-old-male patient diagnosed with a median arcuate ligament syndrome. The patient presented with a history of recurrent epigastric abdominal pain, accompanied by vomiting, diarrhea, and malaise. Abdominal computed tomography angiography revealed the characteristic findings of the syndrome; celiac artery stenosis and gastroduodenal artery collateral dilatation. RESULTS A general surgeon, with a vascular surgeon on standby, undertook a robot assisted laparoscopic approach. The celiac artery was identified and the strictures about the median arcuate ligament and surrounding nerve tissue were circumferentially cleared using EndoWrist monopolar curved scissors. The patient had an uneventful postoperative course reporting improvement of preoperative symptoms at the first postoperative visit. CONCLUSIONS Robot-assisted median arcuate ligament release is safe and feasible option in expert hands, resulting to a short hospital stay and minimal morbidity.

ABSTRACT. Objective We want to present an 18-year old female with a hereditary chronic pancreatitis who underwent a full robotic total pancreatectomy with islet autotransplantation (TPIAT). This patient is known with a hereditary chronic pancreatitis treated for years with ductal stenting. She underwent a longitudinal pancreaticojejunostomy in 2016. Now she has been nearly continuously hospitalized because of recurrent attacks of acute pancreatitis. Preoperative oral glucose tolerance test showed a normal glucose status. Exocrine testing revealed an already failing digestive function. Because of the small duct nature of this chronic pancreatitis, all other therapeutic options were exhausted. Additionally, because of the already deteriorating exocrine function with preserved endocrine function, the option of TPIAT was considered.

Methods Robotic spleen-preserving total pancreatectomy was performed. Similar to a donor procedure, vascularization was preserved until just before pancreatectomy. Through an enlarged incision, in the scar of the previous pancreatic surgery, the organ could be exteriorized and was perfused. The day after the procedure, the islet suspension was injected in the liver via the portal vein by the interventional radiologist. The added value of the use of a Da Vinci robot lies in a quicker postoperative recovery because of the minimal invasive technique, and this in combination with a high precision suturing the hepaticojejunostomy (separate 6/0 stitches). For this young woman the smaller incisions (8mm) were of important esthetic value.

Results Further postoperative recovery was uneventful. Restarting normal oral nutrition took some time because of the long period of tube feeding before surgery. Postoperative results at 3 months are satisfying. Her endocrine function is recuperating with a C-peptide of 0.5 nmol/l (normal values 0.37-1.47) for a blood glycaemia of 129 mg/dl. Her HbA1c was 5.7%.

Conclusion This video describes the technique we use for a robotic total pancreatectomy with islet autotransplantation.

ABSTRACT. Introduction

Radical re-resection is the recommended treatment in case of incidental gallbladder cancer (iGBC) stages ≥ pT1b , with similar disease-free survival rates in case of extended cholecystectomy versus segment IVb-V segmentectomy. Given the increased risk of lymph node metastasis, a regional lymphadenectomy of the hepatoduodenal ligament should be associated to the re-resection. The laparoscopic approach increasingly challenges traditional laparotomy, despite some concerns over the quality of lymphadenectomy. Robotic platforms offer an increased degree of instrument freedom, which could overcome the limitations of laparoscopy.

Methods A 68 years old man was referred for iGBC pT2a four weeks after laparoscopic cholecystectomy for cholelithiasis. Three weeks later was realized a radical re-resection with regional lymphadenectomy (stations 5-8-9-12-13) by a robot-assisted minimally invasive approach, with the DaVinci Si surgical system console (Intuitive Surgical, Sunnyvale, CA, USA).

Results The procedure lasted 360 minutes, with selective intermittent pedicle clamping and minimal blood loss. The specimen included 6 nodes and was free from tumor lesion. The length of stay was seven days, and no complications were observed at 90 days. After surgery 6 cycles of adjuvant chemotherapy (Gemcitabine-Oxaliplatin) was administered, with no recurrence after six months of follow-up.

Conclusions Robotic assisted radical surgery (segments IVb-V and regional lymphadenectomy) for iGBC is feasible, reproductible and safe.

ABSTRACT. Aim: The optimal surgical treatment of a parastomal hernia after ileal conduit urinary division has yet to be determined. Data is scarce and reported recurrence rates after different approaches in parastomal hernia repair remain high.

Material & Methods: A 65-year-old male patient, who had a history of a radical cystectomy with an ileal conduit urinary diversion, presented with a recurrent symptomatic parastomal hernia. He had a previous repair of his parastomal hernia via an open retromuscular approach with a unilateral posterior component separation (transversus abdominis release).

Results: A robot assisted repair of the recurrent parastomal hernia was performed using a partial intraperitoneal onlay mesh technique (PIPOM). Intraoperatively, intraluminal Indocyanine green (ICG) was used to identify the ileal conduit loop. A closure of the defect was performed with a barbed suture whereafter the repair was reinforced with a PVDF IPST ‘Chimney’ parastomal mesh. The latter being partially covered by peritoneum. The postoperative course was uneventful, and the patient went home on postoperative day one. The patient had no complications and a well-functioning ileal conduit stoma 6 weeks after surgery.

Conclusions: The repair of a recurrent parastomal hernia after ileal conduit urinary division represents a surgical challenge. After a previous retromuscular approach, a robotic assisted approach using a partial intraperitoneal onlay mesh technique (PIPOM) represents a feasible technique with promising results.

ABSTRACT. Pancreatoduodenectomy (PD) is the surgical procedure of choice for resectable and borderline pancreatic cancer occurring within the head of the gland. Improved outcomes have been associated to high-volume and academic centers, with trained surgeons, and where fellows and resident involvement is the norm. Despite, the full understanding of the different steps of PD might not be easy for junior staff, especially since the reconstructive phase can be achieved with a number of technical variations, in particular for the pancreatic anastomosis. In order to improve residents’ preparedness, the phases of a pancreatojejunostomy are detailed in this educational video. A 50y woman without relevant past medical history presented with of obstructive jaundice and pruritus. The diagnostic workup by contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography revealed common bile duct dilatation due to a periampullary lesion. Endoscopic-ultrasound showed an infiltration of the periampullary region, with the biopsy specimen suggesting adenocarcinoma. Given the localized and resectable nature of the lesion, the dedicated Multidisciplinary Tumor Board advised upfront surgical resection. The patient underwent a full-robotic PD procedure, with DaVinci Xi Surgical System console (Intuitive Surgical, Sunnyvale, CA, USA). The neck of the pancreas was transected with endo-GIA, and given the soft-texture of the pancreatic stump, a modified Blumgart anastomosis with trans-anastomotic Wirsung stenting was performed. Despite the similar oncological outcomes between laparoscopic and robotic PD, the robotic approach offers better vision and an increased freedom of the instruments. These advantages are highlighted in this pedagogic video during each step of the end-to-side, duct-to-mucosa, two layered, pancreatojejunostomy with trans-anastomotic pancreatic stenting. The procedure lasted 480 minutes, with 100 ml of blood loss. The patient postoperatively developed a biochemical leak and was discharged home by day 10. The pathological analysis confirmed an ampullary adenocarcinoma (pT2b N1), and the MDTB advised adjuvant chemotherapy.

ABSTRACT. Solid pseudopapillary tumor (SPT) of a low malignant potential lesion of the pancreas mostly found in young women, for which surgical resection is the treatment of choice. Given the low risk of malignancy based on a low risk of lymph node and vascular invasion, SPT can be resected by parenchyma-sparing pancreatectomy with splenic vessels preservation. A 37-year old woman without significant medical history was referred to our hospital with an incidental 6-cm pancreatic lesion discovered on an abdominal computed tomography for acute appendicitis. Radiological, endoscopic and histological assessment confirmed the diagnosis of SPT, located at the neck-body junction closed to mesentericoportal vein and gastroduodenal artery. In this case video, we performed a laparoscopic central pancreatectomy with splenic vessels preservation, with a pancreatogastric anastomosis on the distal pancreatic remnant. The operating time was 215 min, with 20 ml of blood loss and no transfusion. The postoperative course was initially uneventful, with a hospital stay of 15 days. Then the patient was readmitted for a grade B pancreatic fistula that needed to be drained with a transgastric pigtail. After drainage, the evolution was favorable. At final pathology, the diagnosis of a 6-cm SPT was confirmed (pT3N0), with a R0 resection. At one year of follow-up, the patient was asymptomatic with no tumor recurrence and no pancreatic insufficiency. SPT is a good indication for laparoscopic central pancreatectomy, this tumor being at low risk of malignancy and mostly observed in young female patients. Although the risk of pancreatic fistula is present after such surgery on healthy pancreas, parenchymal sparing has the long-term advantages to prevent from pancreatic endocrine and exocrine insufficiency.

ABSTRACT. We present a 47-year-old male with persistent ureter stenosis who underwent a robotic autotransplantation of the right kidney. The ureter stenosis was due to an extensive history of urolithiasis, treated with external shock wave lithotripsy and eventually ureterorenoscopy. The stenosis was initially treated with a laparoscopic partial ureterectomy but was complicated with anastomosis leakage. Conservative treatment with percutaneous drainage failed. Imaging showed a persistent proximal ureter stenosis of around 10 centimeters. The patient consented to a robotic autotransplantation of the right kidney to restore the ureter.

The video shows the technique which implicates two phases. Firstly the right nephrectomy with sparing of the vascular structures and the proximal part of the ureter. Lastly the reimplantation of the kidney in the right fossa with anastomosis of the renal vein, the renal artery, and the non-stenotic part of the ureter (ureteroureterostomie).

The postoperative course was uneventful, except for a fever of unknown origin for which antibiotics were shortly administered. After six weeks the protective double J-stent was removed and the patient recovered well.

ABSTRACT. Introduction Echinococcosis is a parasitic disease caused by infection with tapeworms of the Echinococcus type. Echinococcosis is classified as either cystic echinococcosis or alveolar echinococcosis. Echinococcus multilocularis is the cause of potentially fatal alveolar hydatid disease. Initially developing in the liver, the disease exhibits a tumor-like growth. This one is endemic in arctic and alpine areas but also in central Europe. Humans are an incidental host and remain asymptomatic for years. Diagnosis involves imaging studies with serologic confirmation. Management requires surgical resection with prolonged anthelminthic therapy.

Materials and methods We present a unique case of abdominal alveolar echinococcosis.

Results A 32 years-old man presented with abdominal discomfort and jaundice. The bilirubin blood test level was high and abdominal computed tomography shown large mass in the right liver infiltrating the hilum with dilation of the left intrahepatic bile ducts, peritoneal nodular lesions and a solid mass beyond the rectal wall. Serology test were positive for Echinococcus multilocularis. The extension work-up was negative. After explorative laparoscopy, we decided to treat the patient by a combination of preoperative and postoperative anthelminthic therapy and several steps surgical resections. First, we performed an extended right hepatectomy include portal vein and common bile duct resection with hepaticojejunal anastomosis, followed by epiploic and partial diaphragmatic resection. In a second time, we resected pelvic localizations by total mesorectal excision with coloanal anastomosis followed by the resection of the right seminal vesicle. The last intervention was the exploration of the entire digestive tract with enucleation of nodules.

Conclusion We successfully treated a 32-year-old man affected by alveolar abdominal echinococcosis with multi-organ involvement by a combination of anthelminthic therapy and several steps surgical resections. Patient is asymptomatic at two-years follow-up. Diagnosis and treatment of alveolar echinococcosis remains a challenge for clinicians.

ABSTRACT. Objective: Abdominal wall defects after multivisceral transplantation pose a major challenge to clinical practice. We aim to share our experience with abdominal wall closure using a non-vascularized donor rectus fascia. Methods: A classic midline sternolaparotomy is performed. The skin and subcutaneous tissues are then mobilized as laterally as possible and the whole anterior fascia of the abdominal wall is exposed. A subcostal incision is made and extended to the lateral edge of the rectus abdominis muscle, entering the peritoneum. Subsequently, a longitudinal incision is made downwards following the lateral edge of the rectus sheath. Ultimately, the inferior epigastric vessels are clamped and ligated, and the fascia is excised. During the bench-table procedure, the lateral flap edges (including the transverse, internal and external oblique muscles) are removed, thereby opening the junction between the anterior and posterior fascia. Next, the rectus abdominis muscle is carefully removed towards the linea alba, creating a non-vascularized rectus fascia. Afterwards, the donor graft is preserved in a standard preservation solution (Institut Georges Lopez 1 (IGL-1)) at 0°C. In the recipient, the abdominal wall defect is assessed and the donor fascia is shaped. The goal is to create a ‘tension-free’ closure. The donor rectus sheath is implanted and sutured to the recipient’s abdominal fascia edges using continuous running 2-0 polypropylene (Prolene®) sutures. Finally, the abdominal skin is closed using sutures and negative pressure vacuum therapy if the skin defect is too wide. Results: Three patients were treated at our center using the above-mentioned technique. Abdominal wall closure was performed either immediately after or in the days following the multivisceral transplantation. Conclusions: The procurement, bench-procedure and transplantation of a non-vascularized rectus fascia is technically feasible and aids in the reconstruction of abdominal wall defects after multivisceral transplantation.

ABSTRACT. OBJECTIVE: Thoracoabdominal aortic aneurysm (TAAA) remains challenging to treat given the complexity of the pathology. Actually, branched endovascular aneurysm repair (BEVAR), as well as fenestrated endovascular aneurysm repair (FEVAR), are emerging technology, less invasive, used in patients at increased risk for conventional repair of extensive TAAAs. We present here, our experience and the technical and clinical outcomes of our patients who have benefited from a BEVAR-type intervention.

METHODS: between November 2021 and December 2022, 10 patients underwent BEVAR procedure for the treatment of complex and extensive TAAAs. In our study, demographic data, perioperative (complication, presence of an endoleak) and post-operatives outcomes (hospital duration, reintervention, aneurysm-related death, all-cause mortality,…) were analyzed.

RESULTS: Concerning our 10 patients, there were 2 females (20%) and 8 males (80%). The mean age was 70 years old (SD +/- 6 years, Max 79 years and Min 58 years). Completion aortography showed 30% patients had a type II or III endoleak. The mean hospital stay was 13 days (SD +/-15 days, Max 49 days and Min 3 days). Perioperative mortality was 0%. Permanent spinal cord ischemia occurred in 1 patient (10 %) and renal failure occurred in 1 patient (10 %). 1 patient (10%) required reintervention for an occlusion of the BEVAR and 2 endoleak repairs ((20%) were performed. The mean follow up was 69 days and at this time freedom from aneurysm-related death was 80%, and freedom from all-cause mortality was 50%.

CONCLUSIONS: the use of this innovative iBEVAR-type technology is a good alternative for the treatment of complex lesions, in patients at risk for whom conventional treatment is considered as life-threatening.

ABSTRACT. Objective Eagle syndrome is a rare and poorly explained phenomenon causing partial or total ossification of the stylohyoid ligament. The clinical presentation is not very specific and is most often related to the compression of the vascular-nervous structures caused by the bony structure during swallowing or head rotation. Eagle syndrome can make surgical management of carotid stenosis complicated.

Methods We will describe the case of a patient with Eagle's syndrome concomitant with a soft atheromatous plaque causing an 80% stenosis of the right internal carotid artery causing paresthesias of the left side of the mouth and the fingers of the left hand as well as vertigo.

Results The patient was initially seen in ENT for vertigo. A Doppler ultrasound of the neck vessels was performed and revealed a moderate carotid stenosis. The patient was then referred to vascular surgery where an angio-scanner of the supra-aortic trunks was requested. The stenosis of the right internal carotid artery was found to be 80%, as well as the complete ossification of the stylohyoid ligaments, which complicated the surgical approach. An endovascular treatment has been considered as well as a drug treatment. Unfortunately, shortly after the workup, the internal carotid artery closed completely and the patient suffered a stroke.

Conclusion In our case, the concomitant presence of Eagle syndrome and severe carotid stenosis complicated the diagnosis and delayed management. Eagle's syndrome made the conventional surgical approach complex and therefore did not allow optimal management in this patient. Here, specific management with resection of the ossified ligament followed by endarterectomy could have been considered.

ABSTRACT. OBJECTIVE In patients with a supra-aortic bypass or hybrid aortic arch repair vascular graft infection is rare, but associated with high morbidity and mortality.

METHODS A 68-year-old male was referred because of an infected subclavian-subclavian bypass with a left carotid interposition graft, conducted after stroke due to left common carotid and left subclavian artery occlusion. The prosthesis was exposed in the right supraclavicular region. Guidelines for treatment of infected vascular grafts recommend systemic antibiotics and complete graft explantation, followed by in situ or ex situ reconstruction. A prevertebral carotid-carotid bypass was carried out using an armed 6mm ePTFE graft (Flowline Jotec). Afterwards the infected vascular grafts were completely removed. The left subclavian anastomosis was primarily closed without a new bypass, but with retaining excellent vascularisation of the left upper limb. When approaching the right subclavian artery a detachment of the graft anastomosis was noticed. The bleeding was controlled by deployment of a covered stent (Covera 10x60mm, BD). This endovascular solution was preferred over open surgery through manubriotomy, as the patient’s medical history contained a CABG-procedure with use of a right internal mammary artery.

RESULTS The postoperative course was uneventful without signs of stroke, limb ischemia or sepsis.

CONCLUSIONS Literature shows only three similar cases each using different approaches, ranging from endovascular to open surgical treatment with autologous material. We can conclude that evidence is scarce and that complete graft explantation with reconstruction can be challenging, but feasible in supra-aortic graft infections.

ABSTRACT. OBJECTIVE Traumatic aortic injury is a life-threatening condition usually followed by blunt trauma with damage at the thoracic aorta. Abdominal aortic injuries are rare and usually seen with seatbelt trauma. Timing and approach of treatment are associated with significant morbidity and mortality.

CASE This case concerns a 66-year-old man with a high impact trauma after a fall from height. Upon presentation in our level two trauma center, he was conscious but hemodynamically unstable. Computer Tomography scan revealed multiple rib, spine and pelvic fractures with bilateral lung contusions warranting a transfer to a level one trauma center. However, an infrarenal aortic dissection with a retroperitoneal rupture and active bleeding necessitated acute surgical intervention. He was treated endovascularly with an off-the-shelf aortic stent graft which is meant for aortic aneurysm repair. Surgery was performed percutaneously under local anesthetic. Other fractures were treated conservatively. Postoperatively, the patient made a swift recovery without any complications in follow-up.

CONCLUSIONS As this case demonstrates, urgent endovascular repair of a traumatic infrarenal aortic injury can be done quickly with a minimally invasive approach with conventional stent graft systems thereby reducing the high morbidity and mortality rates associated with this life-threatening condition.

ABSTRACT. Objective In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest ESVS guidelines on the management of atherosclerotic carotid disease, routine patching is preferred over routine primary closure. However there are no RCT’s evaluating selective patching strategies. Our previous study based on perioperative results showed primary closure to be an equivalent closure technique compared to patch angioplasty when used in selected patients. This follow-up study aimed to assess long-term complication rate and restenosis after CEA with selective patching. Methods Two hundred thirteen consecutive CEAs over a 3-year period were prospectively analysed over 5 years. Patient population consisted of 213 cases. Risk factors such as hypertension, diabetes mellitus, coronary artery disease and smoking were assessed. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after CEA. Results Primary closure was used in 110 operations, patch angioplasty in 103. There were no significant differences among the baseline characteristics at the time of surgery. Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and 5.29% after 5 years (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05). There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P= .006), restenosis (P= .01) and mortality (P= .003). Conclusion After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected patients. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

ABSTRACT. OBJECTIVE: The objective of this case reports is to present two adult patients diagnosed with coarctation of the thoracic aorta with atypical life-threatening complications.

METHODS:

The first patient was de novo diagnosed with coarctation of the thoracic aorta after he presented to the emergency department with a ruptured thoracic poststenotic aneurysmal dilatation, which was treated urgently in a first step by thoracic endovascular aortic repair (TEVAR). In a second time the coarctation was treated with a CP Stent™ (Heart Medical).

The second patient was diagnosed after he was successfully reanimated following cardiac arrest due to severe hypertensive cardiomyopathy. The de novo diagnosed coartation was also treated by implantation of a CP Stent™ (Heart Medical).

RESULTS: The CP stent was successfully deployed in both patients, resulting in immediate improvement in blood flow across the coarctation with no adverse events during the procedure or follow-up. Both patients showed significant improvement in their clinical symptoms and follow-up imaging confirmed resolution of the coarctation.

CONCLUSIONS: This report describes two atypical, rare and life-threatening complications of a previously undiagnosed coarctation, i.e. rupture of a posstenotic aneurysm and an almost catastrophic severe hypertensive cardiomyopathy. This emphasizes the need for early diagnosis and treatment of coarctation to prevent serious complications.

ABSTRACT. Objective Agenesis of the abdominal aorta and iliac arteries is an extremely rare congenital vascular anomaly, associated with various long-term morbidities. The goal of this case is to report a complex type IV thoracoabdominal aortic aneurysm (TAAA) where an endovascular approach was performed with customised stent-graft and trans-apical access.

Methods This case report considered a 49-year-old women which presents a progressive large aneurysm (64 mm) of the type IV thoraco-abdominal aorta. She has an history of bilateral lower extremities that were amputee at 37-year-old in a context of arterial thrombosis on abdominal aortic agenesis.

An unusual custom-made branched thoraco-abdominal aortic stent-graft with three distal branches (coeliac, SMA and right renal) (Cook Medical) was deployed in the thoracic aorta from a transapical left ventricular apex access. Afterward, the catheterization of branched components and stenting of the target vessels were inserted and deployed from right axillary artery puncture.

Results The stent-graft was successfully deployed. The completion angiography peroperative was perfect. Unfortunately, postoperative period was complicated by total thrombosis of the stent-graft, treated by prosthetic bypass between ascending aorta and hepatic, SMA and right renal arteries. The patient died on day 12 after the procedure due to multiorgan failure.

Conclusion There are very few case reports of agenesis of the abdominal aorta and iliac arteries documenting the long-term future of those patients. The development of aneurysm in this type of patient has never been reported.

Currently, the endovascular approach has become a mainstay in the treatment of aortic aneurysms and the transapical left ventricular apex access is considered as a practical and versatile approach extending the number of eligible patients.

Yet, despite the optimism for an endovascular approach, one of the issues with this emerging technology includes the risk of endograft thrombosis.

ABSTRACT. OBJECTIVE Carotid artery stenting (CAS) has proven to be feasible and safe (1), however the use of transradial access seems to be mainly used by interventional colleagues. This approach suggests to be an opportunity to expand carotid artery stenting to patients with a high risk for femoral complications, unfavourable anatomy or need for early mobilisation. This single-centre retrospective study investigated if transradial CAS (TRCAS) can be safely implemented in an experienced transfemoral CAS department.

METHODS Thirty-four patients with high-grade unilateral internal carotid artery (ICA) stenosis were selected for TRCAS after pre-operative workup in collaboration with the neurology stroke unit. Selection criteria: aortic arch anatomy, femoral access problems (PAD or previous surgery) or femoral complication risk (obese patients, coagulation disorders) or COPD patients. Diagnostic modalities included: CTA with aortic arch and supra-aortic imaging, clinical evaluation of upper limb arterial status (pulsations, Allen-test, Duplex ultra sound (DUS)) and negative history of previous transradial interventions. Primary endpoint: Procedure-related major adverse in hospital cardiac and cerebral events. Secondary endpoints: angiographic outcome of the procedure and hospitalisation in days.

RESULTS All patients (N=34) were operated via ultrasound guided radial access with 4fr Micropuncture Access set (Cook), 5fr Destination sheath and Roadsaver stent (Terumo), 85,3% were performed under local anaesthesia and 88,2% was right-sided radial access. Follow-up consisted of outpatient clinic visit after 7 days, 1 month and annual with DUS. Angiographic success was achieved in all 34 patients. The incidence of in-hospital major adverse cardiac and cerebral events was 2,9% (1 pacemaker implantation due to bradycardia). 2 non-procedure-related deaths were reported within 30 days post-operative.

CONCLUSIONS Transradial CAS is a safe and feasible technique. This technique provides an expansion to possible patients treated by CAS, especially beneficial to patient groups with high risk for femoral access problems, difficult aortic arch anatomy or need for early mobilisation

ABSTRACT. Introduction A ‘PROficiency-based StePwise Endovascular Curricular Training’ program (PROSPECT), combining E-learning and simulation has proven its superiority over traditional training in a randomised controlled trial to acquire basic endovascular skills outside theatre, but real-life adherence is low. This study aimed to compare the original distributed training format, where trainees learn at their own pace, with a massed training format, offering the same content within a limited timespan while exempt from clinical duties. Secondly, long-term skills retention was evaluated.

Methods A multicentre prospective study allocated participants to the distributed D-PROSPECT or a massed, compact version C-PROSPECT based on logistics like travel time, participant and instructor availability. A Multiple-Choice Question test (MCQ) (max score 20) tested cognitive skills. Technical skills were assessed using a Global Rating Scale (GRS) (max score 55), Examiner’s checklist (max score 85) and validated simulator metrics. Data were collected pre- and post-program and three, six and twelve months after program completion.

Results Over four years and in two countries, D-PROSPECT was implemented in two centres and C-PROSPECT in three. Twenty-two participants completed D-PROSPECT with a 41% dropout rate and 21 completed C-PROSPECT (0% dropout). All participants showed significant improvement for all performance parameters after program completion: MCQ (median 14.5 vs. 18, p <.001), GRS (median 20 vs. 41, p <.001), Examiner’s Checklist (median 49 vs. 78.5, p <.001) and simulation metrics (p <.001). Scores of C- or D-PROSPECT participants were not significantly different. No significant differences were seen between groups during the retention period.

Conclusion PROSPECT significantly improves the quality of simulated endovascular performances using a massed or distributed training format. A massed training format of PROSPECT may be preferred to decrease dropout during standardized training to obtain basic endovascular skills in surgical curricula.

ABSTRACT. Objective. To assess the impact of diabetes, amputation level, gender and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates. Methods. Nationwide data including individuals undergoing minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals +/- diabetes. Matched amputation-free individuals +/- diabetes served as controls. Time trends were analysed. Results. In total, 41 304 amputations were performed in 26 526 individuals: 13 247 major LEA (7 500 with diabetes, 5 747 without diabetes) and 28 057 minor LEA (19 461 with diabetes, 8 596 without diabetes). Kaplan-Meier survival curves for mortality after LEA are presented (Figure 1). Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA (individuals without diabetes: 45% and 63%). In the first six postoperative months, no differences in mortality rates were found. Later, hazard ratios (HRs) for diabetes (compared to no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p≤0.005). In all time intervals, HRs for diabetes were lower in individuals with LEA compared to controls without LEA. In individuals without diabetes, a significant increase in one-year survival rates was observed after minor and major LEA (minor LEA: p=.020; major LEA: p=.003); in individuals with diabetes, one-year survival rates didn’t change. Conclusions. In the first six postoperative months, mortality rates after minor and major LEA were not different between individuals +/- diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free control individuals, diabetes impacts mortality less in the minor and major amputation-groups compared to the control group without LEA.

ABSTRACT. OBJECTIVE: Vascular ulcers affect a significant fraction of the population. If recalcitrant to standard treatment, they can persist for months and are associated with high costs, pain and morbidity. Leukocyte- and platelet-rich fibrin (L-PRF) is a simple and inexpensive topical autologous wound dressing.

METHODS: This prospective observational cohort study at the department of Vascular Surgery UZ Leuven (Belgium) investigated the efficacy and safety of the L-PRF technique on chronic vascular ulcers refractory to optimal standard treatment for ≥3 months. This abstract presents preliminary results from a larger registry. All patients received weekly application of L-PRF membranes, produced following the method developed by Choukroun and optimized by Pinto et al. Wound area surface and pain scores were registered.

RESULTS: Nineteen patients with chronic ulcers of arterial (58%), venous (16%), lymphatic (5%), and mixed (20%) origin were treated with L-PRF. All wounds showed improvement. Ten wounds (53%) healed completely. Seven of them (37%) healed completely with L-PRF alone. Three (16%) other wounds were treated until significant wound reduction and were then switched back to standard wound care. An average of 6 sessions were necessary to achieve healing. Average time to healing was 5,3 weeks with L-PRF alone and 10 weeks taking in account for those with additional wound care. In the nine patients (47%) who discontinued therapy a decrease in wound size was observed. Nine patients (47%) experienced pain from the ulcer at the start of treatment. Seven of them (37%) were pain free at the last treatment. No adverse events were observed.

CONCLUSIONS: Topical L-PRF treatment for chronic vascular leg ulcers induced wound healing and pain relief in almost all patients. These preliminary results of a larger observational prospective study are very promising. L-PRF is simple to produce, safe and seems a suitable therapy for all recalcitrant vascular ulcers.

ABSTRACT. Objective Antegrade revascularisation of chronic total arterial limb occlusions can be challenging. For infra-inguinal chronic occlusions this approach fails in 10-20%. When antegrade revascularisation is not succesfull, there is a higher risk of amputation and additional morbidity. Therefore, retrograde revascularisation using transpedal or transplantar access can be a valid alternative to avoid major limb amputations. We present a case of a successful retrograde revascularisation trough transpedal puncture for a chronic total arterial occlusion with critical limb ischemia. The amputation level was limited to a transmetatarsal amputation, avoiding a lower leg amputation.

Method and results A 83-year old man presented at our hospital with critical limb ischemia of the left foot. The patient has type 2 diabetes mellitus and an extensive history of coronary and peripheral vascular disease. There was necrotic tissue loss of the left forefoot with resting pain (Rutherford 6/Fontaine IV). An unsuccesful revascularization attempt of the left leg was already performed in Spain, where the patient was residing. Because of the previous unsuccessful attempt, a left lower leg amputation was planned on arrival at our hospital. Beforehand, an angiography was performed to assess the inability of revascularisation. There was a total occlusion of the popliteal artery (P3), the tibiofibular trunk and the proximal anterior tibial artery with distal flow in the anterior tibial artery and fibular artery. An additional antegrade revascularisation attempt was unsuccessful. A transpedal puncture was performed with successful retrograde revascularisation of the popliteal and anterior tibial artery. Since perfusion was restored only a transmetatarsal amputation was needed. Postoperatively there was a good wound healing tendency.

Conclusion Antegrade revascularisation of chronic total arterial limb occlusions can be difficult and failure may lead to major amputation and morbidity. A retrograde approach can be a valid alternative with the ability to restore perfusion and subsequently limb preservation.

ABSTRACT. Objective: A 72-year-old man consulted his general practitioner due to swelling and pain in the left lower limb. Blood sample revealed elevated D-dimers. Due to a suspected deep venous thrombosis of the left leg, treatment with a therapeutic dose of low molecular weight heparins was initiated. Three days later, he was referred with severe swelling and pain in the entire left leg. Clinical examination revealed a haematoma in the left leg, with a distended, tense and painful calf. Haemodynamic parameters remained stable. Relevant history included aneurysm rupture of the right common iliac artery, leading to an arteriovenous fistula. He had anaemia requiring blood transfusion. CT angiography showed an arterial bleeding in a left popliteal aneurysm, with a profuse intramuscular haematoma in the entire leg. Methods: An endovascular repair of the popliteal aneurysm was performed, using two covered stents. A short occlusion in the anterior tibial artery and an occlusion in the fibular artery were treated with balloon angioplasty to maintain a good run-off for the popliteal stents. Control angiography showed an acceptable outflow through the three lower limb arteries. Results: The postoperative course was uneventful. Antiplatelet therapy (aspirin 100mg once daily) was continued, low molecular weight heparins were administered in prophylactic dose during hospital stay. Complete resolution of the haematoma was noted at one-month follow-up consultation. Ultrasound examination revealed successful exclusion of the popliteal artery aneurysm. Conclusion: Popliteal artery aneurysms have a low overall incidence, and rupture of these aneurysms is infrequent. Correct diagnosis is not straightforward, and there is at present no consensus on the optimal treatment strategy for ruptured popliteal artery aneurysms. Considering treatment of popliteal aneurysms in general, literature suggests that endovascular repair of popliteal artery aneurysms is a viable alternative to open repair. In our experience, a ruptured popliteal aneurysm was successfully treated with endovascular repair using covered stents.

ABSTRACT. Objective: 

To assess the safety, short and 1 year efficacy of endovascular atherectomy with Jetstream device in our center.  

Methods: 

Between March 2021 and February 2023, a total of 46 atherosclerotic lesions in 34 patients were treated with endovascular atherectomy using the Jetstreamâ device. Severe calcified superficial femoral artery (SFA), common femoral artery (CFA) and popliteal lesions were included. Primary outcomes were technical success, procedure related complications, 30 days, and 1-year primary patency. Secondary outcomes were need for bailout stenting and amputation at 30 days and one year follow-up. 

Results: 

A total of 7 CFA, 30 SFA and 9 popliteal lesions were treated. Mean lesion length was 58mm ± 57mm with a mean stenotic degree of 78% ± 15%. Technical success was obtained in 100% of the patients. In 4 patients distal embolization occurred which required treatment. The patency at 30d follow-up was 100% and one-year patency was 83%. Follow-up of at least one year was only obtained in 17 cases. 

Mandatory balloon dilatation after Jetstream was performed with a DCB in 45/46 cases. In 8 patients additionally stent placement was necessary.  

3 patients had an amputation (1 minor and 2 major), all in patients with at least Rutherford 5. 

Conclusion:  

Jetstream atherectomy device is a safe and effective tool in the endovascular treatment of severe calcified lesions. More data and follow-up are needed to properly evaluate the long-term outcome, which is on the way.

ABSTRACT. Introduction: The catheter tip of totally implanted venous access devices (TIVAD) is a risk factor for postoperative complications. The study aim was to assess the early (EC) and late complications (LC) associated with the position of the catheter tip in patients with cancer. Patients and Methods: We reviewed cancer patients who had a TIVAD placed in 2020. EC (<90 days) and LC (>90 days), and risk factors for TIVAD-associated thrombotic (TC), non-thrombotic (NTC) and infectious complications (IC) were assessed. They have been associated with the position of the catheter tip according to a “ideal position”: >10mm below the carina. Results: 301 patients underwent TIVAD placement for chemotherapy (83.7%) or supportive care.The median time of port follow was 9.4 months. All of TIVADs were inserted via the internal jugular vein (IJV), with a predominance for the right approach (77.4%) The average distance between the catheter tip and the carina was 21.3mm (SD 18.6mm). In total, 34 (11.3%) TIVADs developed EC and 17 patients (5.6%) had LC. By univariate analysis an association has been found between the position of the catheter tip from the carina (≤ 10mm vs > 10mm) and the occurrence of EC (18.3% vs 8.6%, p=0.01). The insertion site has also been shown to be a risk factor for EC, with 19.1% for left IJV placement and 9% for right IJV (p=0.02). No statistically significant associations was found for LC. In the multivariate analysis, left IJV insertion (OR 2.76, p=0.010), and the catheter tip located ≤ 10 mm below the carina (OR 2.71 p=0.009) were the significant independent risk factors of EC. Conclusion: position of the TIVADS catheter tip is at risk of EC (OR 2.76) if it is not located at least >10mm under the carina. The left (19%) approach is more at risk of EC compared to the right approach (9%).

ABSTRACT. OBJECTIVE: the ROTAREX® system has been known for several years for the endovascular and anterograde treatment of lower limb stenosis, with good results. Nevertheless, there are a few cases described in the literature of retrograde use of this system for the upper limbs.

METHODS: We present the case of a 57-year-old patient presenting recurrent stenosis of his left subclavian artery. Indeed, in the context of pain and functional impotence of the left upper limb he underwent artery stenting in 2020. Due to the recurrence of the symptoms in 2022, it was necessary to perform a new stenting. Currently, the patient presents again a stenosis of his stent, which is symptomatic and disabling. We therefore used the ROTAREX® endovascular rotational thrombectomy system by retrograde approach by puncturing the axillary artery of our patient under ultrasound control, with prior preclosing. During the procedure, we had to concomitantly infuse intravascular physiological fluid, given the slowing of the flow.

RESULTS: After several passages of the ROTAREX® system, we obtained a good result in terms of hemodynamics and iconography with restoration of the permeability of the vascular axis. Then we consolidated our result through the use of drug eluting balloon (DEB). No immediate intraoperative or postoperative complication was observed and the patient was able to return home the day after the operation.

CONCLUSIONS: The endovascular rotational atherectomy system of the ROTAREX® type is therefore an interesting therapeutic option, particularly in the upper limbs and by the retrograde approach.