Koji Idoguchi

Ectopic variceal hemorrhage caused by sinistral portal hypertension after splenic vein ligation during a pyloric-preserving pancreatoduodenectomy is a rare entity. We report the case of a 58-year-old man with symptoms of refractory melena. The varices could not be treated endoscopically and surgery was considered unsuitable due to severe adhesions and altered anatomy. Following clinical failure of partial splenic embolization, an alternative obliteration method by a retrograde trans-portal-venous approach was successfully performed and resolved the problem. It seems to be an effective method for ectopic variceal bleeding, especially when other interventions are unavailable or highly risky.

This study was designed to analyze the outcomes of endovascular treatment for internal iliac artery aneurysm (IIAA) at mid-term follow-up. We retrospectively analyzed 33 patients (28 males, mean age 77.4 years) who underwent endovascular treatment of 35 IIAAs (mean diameter 39.8 mm) from 2002 to 2012. We attempted to completely and selectively embolize all distal branches with permanent embolic materials, followed by proximal controls either by stent-graft placement (type 1) or coil embolization (type 2). Procedural success rate was 97.1 % (n = 34). Complete permanent distal branches embolization was achieved in 27 (79.4 %), type 1 in 24 (70.6 %), and type 2 in 10 (29.4 %) cases. During mean follow-up period of 29.1 months (range, 1.2–92.8), no IIAA-related mortality and stent/stent-graft related complications occurred. Pelvic ischemia occurred and resolved in 8 (25 %) patients. Among 32 cases followed by CT, the aneurysm diameter was stable in 18 (56.3 %), shrank in 11 (34.4 %), and enlarged in 3 (9.4 %) cases. In 22 assessed by contrast-enhanced CT, secondary endoleak occurred in 3 (13.6 %) cases and 2 required secondary interventions (2/32, 6.3 %). Type 1 procedure tends to have better mid-term outcomes. Incomplete permanent distal branches embolization was associated with enlargement and secondary intervention (p = 0.007 and p = 0.042, respectively). The secondary intervention-free rate at 3 years in the complete and incomplete distal embolization group was 100 and 83.3 %, respectively (p = 0.128). Endovascular treatment for IIAA is feasible and safe. Complete permanent distal branches embolization is important to achieve satisfactory mid-term outcomes.

To evaluate the safety, efficacy, and long-term results of endovascular stent graft placement for ureteroarterial fistula (UAF). We retrospectively analyzed stent graft placement for UAF performed at our institution from 2004 to 2012. Fistula location was assessed by contrast-enhanced computed tomography (CT) and angiography, and freedom from hematuria recurrence and mortality rates were estimated. Stent graft placement for 11 UAFs was performed (4 men, mean age 72.8 ± 11.6 years). Some risk factors were present, including long-term ureteral stenting in 10 (91 %), pelvic surgery in 8 (73 %), and pelvic radiation in 5 (45 %). Contrast-enhanced CT and/or angiography revealed fistula or encasement of the artery in 6 cases (55 %). In the remaining 5 (45 %), angiography revealed no abnormality, and the suspected fistula site was at the crossing area between urinary tract and artery. All procedures were successful. However, one patient died of urosepsis 37 days after the procedure. At a mean follow-up of 548 (range 35–1,386) days, 4 patients (36 %) had recurrent hematuria, and two of them underwent additional treatment with secondary stent graft placement and surgical reconstruction. The hematuria recurrence-free rates at 1 and 2 years were 76.2 and 40.6 %, respectively. The freedom from UAF-related and overall mortality rates at 2 years were 85.7 and 54.9 %, respectively. Endovascular stent graft placement for UAF is a safe and effective method to manage acute events. However, the hematuria recurrence rate remains high. A further study of long-term results in larger number of patients is necessary.