BACKGROUND:Neoadjuvant chemotherapy (NAC) may improve outcomes in perihilar cholangiocarcinoma (PHC); however, its efficacy compared with upfront surgery (US) for resectable PHC remains unclear. We compared survival and clinicopathological characteristics between NAC and US in patients with technically resectable PHC, using propensity score matching (PSM). METHODS:We retrospectively analyzed 261 patients with resectable PHC who underwent surgical treatment (2016-2024) across multiple institutions. Among them, 50 received NAC and 199 underwent US. The 38 patients receiving NAC were matched 1:1 with patients undergoing US using PSM. Overall survival (OS) and progression-free survival (PFS) were compared between groups. Pathological response to NAC and its association with chemotherapy doses were also evaluated. RESULTS:Before PSM, OS and PFS did not differ significantly between the US and NAC groups. After PSM, OS did not differ significantly between groups, but PFS was significantly longer in the NAC group, where patients with a therapeutic-effect grade ≥1b had better PFS than those with US. Grade ≥1b response was associated with receiving ≥7 NAC doses. DISCUSSION:NAC may improve PFS in selected patients with resectable PHC, especially those showing major pathological responses. Prospective studies should validate these findings and define optimal selection criteria and regimens.
Background Systemic capillary leak syndrome (SCLS) is a rare disorder characterised by recurrent episodes of hypovolemic shock, haemoconcentration, and hypoalbuminaemia, caused by transient increases in vascular permeability. Although venous thromboembolic complications have been reported in patients with SCLS, arterial thrombosis involving the ascending aorta is rare. Herein, we report a case of cerebral infarction caused by an ascending aortic thrombus associated with SCLS and discuss the possible pathophysiological mechanisms. Case presentation A 62-year-old man presented with generalised oedema, oliguria, severe hypotension, marked haemoconcentration (haematocrit, 70%), acute kidney injury, and hypoalbuminaemia. Based on the recurrent episodes of hypotension, haemoconcentration, hypoalbuminaemia, and the presence of serum IgG-kappa monoclonal protein, the patient was diagnosed with SCLS. During the acute leak phase, the patient developed compartment syndrome requiring a decompressive fasciotomy. Two days after admission, he suddenly developed aphasia and right hemiplegia while eating breakfast. Magnetic resonance imaging (MRI) of the brain revealed an acute cerebral infarction due to occlusion of the left internal carotid artery. Endovascular thrombectomy achieved successful reperfusion (Thrombolysis in Cerebral Infarction grade 2b). Contrast-enhanced computed tomography angiography revealed a mural thrombus in the ascending aorta without evidence of an aneurysm, dissection, or significant atherosclerosis. Anticoagulation therapy with heparin, followed by warfarin, resulted in complete resolution of the thrombus. Histopathological examination revealed a fibrin-rich thrombus with neutrophil and lymphocyte infiltration, compatible with an early stage thrombus. Conclusions This case suggests that severe haemoconcentration, abnormal blood flow, and endothelial dysfunction during the acute phase of SCLS may synergistically promote de novo ascending aortic thrombus formation, resulting in cerebral embolism. Comprehensive vascular imaging should be considered to identify potential arterial embolic sources in patients with SCLS who develop acute neurological deficits. Further accumulation of similar cases is required to clarify the mechanisms and optimal management of arterial thrombotic complications in SCLS.
Animal experimental studies involving the Igaki-Tamai stent (ITS), a bioresorbable poly-l-lactic acid scaffold, in peripheral arteries are limited, and existing studies evaluated only short-term (3-month) outcomes. This study compared arterial responses associated with the ITS and bare metal stent (BMS) over 6 months using intravascular ultrasound (IVUS) analysis and evaluated feasibility in porcine iliac arteries. Four miniature pigs underwent stent implantation with the ITS in the right iliac artery and the BMS in the left iliac artery. Follow-up evaluations at 6, 12, and 24 weeks included angiographic and IVUS analyses to assess neointimal hyperplasia, percent area stenosis (%AS), and percent in-stent volume obstruction (%VO). Histological analysis was performed to evaluate tissue injury and inflammation scores. At 6 weeks, the neointimal area did not differ significantly between the ITS and BMS groups (8.49 ± 2.10 mm² vs 13.47 ± 6.67 mm², P = .205). However, the ITS group exhibited a significantly smaller neointimal area at 12 weeks (6.87 ± 1.15 mm² vs 20.65 ± 10.99 mm², P = .050) and 24 weeks (5.20 ± 0.85 mm² vs 22.32 ± 12.03 mm², P = .042). %AS and %VO were significantly lower in the ITS group at all follow-ups. The ITS group showed reduced tissue damage (injury score: 0.80 ± 0.430 vs 1.74 ± 0.908, P < .001) and inflammation (inflammation score: 1.25 ± 0.516 vs 1.67 ± 0.832, P < .001) compared with the BMS group. The ITS was associated with reduced vessel injury, lower inflammatory response, and favorable luminal remodeling over 6 months in healthy porcine iliac arteries.
OBJECTIVE:TheGore EXCLUDER Conformable abdominal aortic aneurysm endoprosthesis with ACTIVE CONTROL System (EXCC; W. L. Gore & Associates) is designed to treat abdominal aortic aneurysms with a challenging proximal neck. This study was conducted to investigate the safety and efficacy of the EXCC device in patients with an angulated proximal neck at 23 Japanese institutions (Excluder Conformable endoprosThesis foR angulatEd proxiMal nEck anatomy [EXTREME registry]). METHODS:A retrospective analysis was conducted on all endovascular aneurysm repairs (EVARs) using an EXCC device. The primary end point was freedom from late complications (composite outcomes of aneurysm-related death, reinterventions, and aneurysm sac enlargement of >5 mm after 30 postoperative days). Secondary end points included intraoperative major adverse events, intraoperative endoleaks, perioperative outcomes, postoperative endoleaks, and aneurysm size. RESULTS:The EXTREME registry consisted of 215 patients, of whom 109 were included in the angulated neck group (angulation >60°) and 106 in the nonangulated group (angulation ≤60°) according to the proximal neck (infrarenal) angulation. Technical success rates were 93.5% and 94.3% (P = .81), the incidence of type Ia endoleak at final aortogram was 5.5% and 1.8% (P = .16), and the incidence of major adverse events was 1.8% and 0.9% (P = .54) in the angulated and nonangulated groups, respectively. On postoperative (in-hospital) computed tomography examination, the incidence of type Ia endoleak was higher in the angulated group (3.6%) than in the nonangulated group (0%; P = .12). The mean follow-up period was 404 ± 190 days. Freedom from reintervention rates were 98.9% and 96.6% in the angulated group and 99.0% and 95.7% in the nonangulated group at 6 and 12 postoperative months, respectively (log-rank P = .99). Freedom from late complications rates were 99.0% and 96.6% in the angulated group and 99.0% and 95.8% in the nonangulated group at 6 and 12 postoperative months, respectively (log-rank P = .63). CONCLUSIONS:Our multicenter study demonstrated the safety and efficacy of the EXCC device in patients with an angulated proximal neck (angle >60°), with low rates of type Ia endoleak. Long-term follow-up is required to understand the true efficacy of the EXCC device in challenging neck anatomy.
