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Simple Summary Total mesorectal excision is the cornerstone for rectal cancer curation. However, elderly and frail patients may not be able to undergo a surgical procedure. These patients often receive no treatment at all and are at risk for developing debilitating symptoms that impair quality of life. Recent developments in the non-operative management of rectal cancer have increased the possibilities to provide patients with an alternative treatment if surgery is not possible, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The heterogeneity within the elderly and frail population requires a patient-centred approach to optimise treatment. The aim of this narrative review was to discuss a multidisciplinary and patient-centred treatment approach for the personalised non-operative management of elderly and frail rectal cancer patients. The narrative review also provides a practical suggestion of a successfully implemented multidisciplinary clinical care pathway, based on a literature review. Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.

To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch.Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared.The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P .001), endovascular treatment (3.5% vs 25.0%; P .001), and medical management (16.2% vs 51.4%; P .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant.Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.

The purpose of this research is to analyze factors associated with delays to surgical management of Type A acute aortic dissection patients.Time from diagnosis to surgery and associated factors were evaluated in 1880 surgically managed Type A dissection patients enrolled in the International Registry of Acute Aortic Dissection.The majority of patients were transferred (75.7% vs 24.3%). Patients who were transferred had a median delay from diagnosis to surgery of 4.0 hours (interquartile range 2.5-7.2 hours), compared with 2.3 hours (interquartile range 1.1-4.2 hours; P .001) in nontransferred patients. Among patients who were transferred, those with worst-ever, posterior, or tearing chest pain those with severe complications, and those receiving transthoracic echocardiogram prior to a transesophageal echocardiogram or as the only echocardiogram were treated more quickly. Those undergoing magnetic resonance imaging, or who had prior cardiac surgery, had longer delays to surgery. Among nontransferred patients, those with coma were treated more quickly. In both groups, patients presenting with emergent conditions such as cardiac tamponade, hypotension, or shock had more rapid treatment. Among transferred patients, surviving patients had longer delays (4.1 [2.6-7.8] hours vs 3.3 [2.0-6.0] hours, P = .001). Overall mortality did not differ between patients who were transferred vs not (19.3% vs 21.1%, P = .416).Simply being transferred added significantly to the delay to surgery for Type A acute aortic dissection patients, but a number of factors affected its extent. Overall, signs and symptoms leading to a definitive diagnosis or indicating immediate life threat reduced time to surgery, while factors suggesting other diagnoses correlated with delays.

Background Optimal management of acute type B aortic dissection with retrograde arch extension is controversial. The effect of retrograde arch extension on operative and long-term mortality has not been studied and is not incorporated into clinical treatment pathways. Methods The International Registry of Acute Aortic Dissection was queried for all patients presenting with acute type B dissection and an identifiable primary intimal tear. Outcomes were stratified according to management for patients with and without retrograde arch extension. Kaplan-Meier survival curves were constructed. Results Between 1996 and 2014, 404 patients (mean age, 63.3 ± 13.9 years) were identified. Retrograde arch extension existed in 67 patients (16.5%). No difference in complicated presentation was noted (36.8% vs 31.7%, p = 0.46), as defined by limb or organ malperfusion, coma, rupture, and shock. Patients with or without retrograde arch extension received similar treatment, with medical management in 53.7% vs 56.5% ( p = 0.68), endovascular treatment in 32.8% vs 31.1% ( p = 0.78), open operation in 11.9% vs 9.5% ( p = 0.54), or hybrid approach in 1.5% vs 3.0% ( p = 0.70), respectively. The in-hospital mortality rate was similar for patients with (10.7%) and without (10.4%) retrograde arch extension ( p = 0.96), and 5-year survival was also similar at 78.3% and 77.8%, respectively ( p = 0.27). Conclusions The incidence of retrograde arch dissection involves approximately 16% of patients with acute type B dissection. In the International Registry of Acute Aortic Dissection, this entity seems not to affect management strategy or early and late death.

Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.

Purpose: To demonstrate explantation of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the setting of infection. Case Reports: Two male patients, 71 and 83 years old, underwent Nellix implantation for asymptomatic infrarenal aortic aneurysms measuring 5.1 and 6.3 cm, respectively. Each developed late infections at 8 and 4 months post EVAS, respectively. The first patient experienced aneurysm rupture after medical therapy failed; the Nellix endosystem was explanted in an uneventful procedure. The second patient developed an aortoduodenal fistula, which was sutured before the Nellix device was removed without complications. The patient died 3 months later, presumably due to ongoing infection. Conclusion: The need to explant a Nellix EVAS System due to graft infection is a straightforward procedure compared to the removal of a conventional endograft with suprarenal fixation. It requires only temporary suprarenal clamping. The devices can be easily removed due to the lack of penetrating components and without damage to the aortic segment needed to create an anastomosis.

Thoracic endovascular aneurysm repair (TEVAR) is currently the therapy of first choice for most thoracic aortic disease. Because aortic stent grafts are placed in the vicinity of aortic side branches, unintentional coverage of these arteries may occur.We report a case of a 69-year-old male with an asymptomatic penetrating ulcer of the aortic arch, based at the origin of the left subclavian artery. Due to his medical story, we decided to perform an endovascular procedure with placement of a stent graft in the left hemi-ach wit previous left common carotid subclavian bypass. During the deployment of the aortic stent graft, the proximal margin of the stent graft displaced, inadvertly covering the origin of the left common carotid artery. As a bail out procedure, we successfully revascularized the left common carotid artery with the use of the chimney technique.Endovascular treatment of aortic disease has gained popularity over the last decade. Despite increasing experience, these procedures remain technically challenging. Unintentional coverage of main aortic side branches during TEVAR is a serious complication, which requires immediate intervention. The chimney technique offers a minimal invasive procedure in such case, with promising results.

Background To report one the most feared complication of thoracic endovascular aneurysm repair (TEVAR); a retrograde aortic dissection who can involve the aortic arch or ascending aorta, which require commonly coextensive open surgical repair. Case Reports We report 2 cases of combined retrograde and antegrade dissection after endovascular treatment of an aneurysm of the descending aorta. In both cases, a dissection was identified at short-term follow-up; which required open surgical repair in one case and an additional endovascular treatment for the second case. Conclusions The incidence of extensive iatrogenic dissection after TEVAR is relatively low, open repair should be considered as a primary option in some cases with limited aortic dilatation to avoid such life-threatening complications.

We present a case of a patient with a spinal epidural abscess (SEA) and meningitis following short-term epidural catheterisation for postoperative pain relief after a laparoscopic sigmoid resection. On the fifth postoperative day, 2 days after removal of the epidural catheter, the patient developed high fever, leucocytosis and elevated C reactive protein. Blood cultures showed a methicillin-sensitive Staphylococcus aureus infection. A photon emission tomography scan revealed increased activity of the spinal canal, suggesting S. aureus meningitis. A gadolinium-enhanced MRI showed a SEA that was localised at the epidural catheter insertion site. Conservative management with intravenous flucloxacillin was initiated, as no neurological deficits were seen. At last follow-up, 8 weeks postoperatively, the patient showed complete recovery.