Purpose: The aim of this study was to review the results of fenestrated stent-graft (Fenestrated Endovascular Aortic Repair [FEVAR]) implantation to treat patients with type IA endoleaks after prior infrarenal endovascular aortic repair (EVAR). Methods: A retrospective single-center analysis of prospectively collected data was conducted, including consecutive patients who underwent FEVAR to correct a type IA endoleak between November 2009 and April 2021. All devices were manufactured by Cook Medical (INC, Bloomington, Indiana). Demographic details, anatomical features, fenestrated stent-graft configuration, technical success, and major adverse events (MAEs) were recorded according to current SVS standards. The primary endpoint was freedom-from-significant aneurysm sac expansion (≥5 mm) and survival according to the Kaplan-Meier analysis. Secondary endpoints included 30-day outcomes, freedom-from-all-cause mortality, and aortic-related secondary interventions. Multivariate Cox regression was performed to identify factors associated with the study endpoints. Results: Overall, 47 patients (89% male, median age 80) were included. Median time from initial EVAR was 60 months [41-72]. Median pre-FEVAR maximal aneurysm diameter was 68mm [62-79]. Median fluoroscopy time and dose area product were, respectively, 49 min [36-63] and 66 Gy.cm 2 [38-101]. Technical success rate was 96% with no 30-day deaths reported. Two (4.3%) renal MAE occurred. Median follow-up was 22 months [12-36]. Two-year freedom-from-aneurysm sac expansion and aortic-related secondary intervention were 80% [66-96] and 69% [55-87], respectively. From the multivariate analysis, the configuration of the fenestrated device was not predictive of aneurysm sac expansion, whereas only the preoperative aneurysm maximal diameter was an independent predictor (hazard ratio [HR] [per 1 mm increment]=1.05 [1.01-1.10]; p=0.016) and was associated with a higher risk of aortic-related secondary intervention (HR [per 1 mm increment]=1.07 [1.02-1.12]; p=0.006). Other predictors of aortic-related secondary intervention were pre-existing type IB or III endoleak (HR=7.89 [1.39-44.8]; p=0.020) and aortic degeneration above the primary EVAR (HR=16.6 [1.88-147], p=0.011). Conclusion: Late type IA endoleak after EVAR can be treated safely with a fenestrated stent-graft; preoperative maximum aneurysm diameter is associated with an increased risk of later aneurysm sac growth. Close follow-up is mandatory in this subgroup of patients given the high reintervention rate. Clinical Impact Type IA endoleak following endovascular aneurysm repair (EVAR) can be treated using a fenestrated stent-graft (FEVAR). Treatment options include the addition of a fenestrated cuff alone or complete relining of the previous graft with either a 3-component device or a unibody bifurcated FEVAR. Regardless of the device configuration the treatment appears to be safe but remains associated with high rates of reintervention and aneurysm growth. Although no significant differences have been observed in long-term outcomes, a complete relining with a bifurcated FEVAR may be preferred as a first-line approach, as it offers the advantage of addressing occult associated Type III endoleaks and reducing the risk of component disconnection.
Cancer is an increasing problem in the Middle Eastern (ME) countries. It is the fourth leading cause of death in this region. At present, resources for cancer control in the ME countries as a whole are not only inadequate but directed almost exclusively to treatment. In the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced stage. Pain is prevalent among people who have cancer, and is one of the most feared and burdensome symptoms. Pain negatively affects the quality of life of patients with cancer. Inadequate and inappropriate pain management of patients who experienced cancer pain has been documented in several studies and this is possibly due to insufficient understanding of pain assessment and management. Middle Eastern countries include a wide range of economically diverse countries, from technically advanced countries with high level cancer care to countries with little or no cancer treatment capabilities. There are large differences in population size, wealth and health expenditure. Palliative care (PC) is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases; relieving pain and suffering is an essential part of PC. The need for improved palliative care in ME countries is great. Of 58 million people who die every year, 45 million die in developing countries. An estimated 60% (27 million) of these people in developing countries would benefit from palliative care, and this number is growing as chronic diseases such as cancer rise rapidly. From the situation analysis of palliative care in the ME countries, suggesting that pain relief is insufficient, improvements in palliative care delivery are a high priority.We reviewed the situation of pain management and pain control in Lebanon and the ME countries, the barriers that are present, and we propose the priorities and a reform for an integrated approach to address the problem of under-treated pain at all levels:
The unprecedented wave of refugee migration from Africa and the Middle East to Europe presents major challenges to European health professionals and to society at large. A recent workshop which took place in Syracuse, Sicily, brought together physicians, nurses and psychologists and managers of governmental agencies from Italy, Lebanon, Israel, Iraq, Iran, Sudan, Tunisia, Jordan, and the European Society of Medical Oncology, aimed to create a training program to formulate a dialogue between professionals in their regions and refugees in Italy. A major barrier refugees face is a lack of communication (verbal and cultural) which hinders their smooth absorption into society. Cultural mediators who speak Arabic and Italian and understand the refugees’ faith, tradition and beliefs, are paramount to successfully building bridges between such diversities. Predictably, most asylum seekers undergo anxiety, fear, and depression after arriving in Europe. Following intensive deliberations, all workshop participants agreed that applying palliative care methodologies, as practiced in cancer patients, would be therapeutically advantageous in overcoming the psychological suffering that refugees experience during their initial stay in Europe. Accordingly, all agreed to start with training courses, both in refugees’ countries of origin and in Europe, for representatives or mediators (preferably with some clinical background and experience); whereby tremendous efforts would be made to create a working palliative care model that includes bio-psycho-social elements. This model or paradigm will employ a culturally sensitive approach that takes refugees’ spiritual needs into consideration, relying on core ethical principles.
The continuous waves of refugees from Africa and the Middle East to Europe present major inter¬cultural challenges to European health professionals and to society at large. A recent workshop in Sicily brought together local physicians, nurses, psychologists and managers of governmental agencies, along with representatives from Lebanon, Israel, Iraq, Iran, Sudan, Tunisia, Jordan and the European Society of Medical Oncology (ESMO) to develop training programs aimed at formulating dialogue between regional professionals and refugees. A major barrier refugees face is a lack of verbal and cultural communication, which hinders their smooth absorption into the new society. Cultural mediators who speak Arabic and Italian and understand the refugees' faith, tradition and beliefs are vital to successfully build bridges of trust between caregivers and refugees. Most asylum seekers experience anxiety, fear, and depression upon arrival in Europe. To achieve trust, all workshop participants agreed to develop a palliative care model that would best suit the unique circumstances now facing some Mediterranean countries and assist in overcoming the suffering of refugees during their initial stay in Europe. Such a model would include bio-psychosocial elements, essential for a culturally sensitive approach and based on core ethical principles.
A B S T R A C T : Aconsiderable number of patients with c a n c e r s u ff e r considerable pain during their d i s e a s e . Most of these patients achieve analgesia using opioids and adjuvant medication ; however, 5-10% of them still experience inadequate pain control despite aggre ssive combined pharmacological therapy and their u s e is often associated with adverse events. P roviding effective pain management for p a t i e n t s with severe pain that affects quality of life confr o n t s the oncologist orpain specialist with clinical challenges that often re q u i re multifaceted therapeutic measure s . Interventional pain therapies are a diverse set of pro cedural techniques for c o n t rolling pain that may be useful when systemic analgesics failed to provide adequate control of cancerpain orwhen the adverse eff e c t s cannot be managed re a s o n a b l y. Commonly used interventional therapies for c a n c e r pain include neuroaxial, neurolytic including sympathetic block and paravertebral block ; in addition, n e u rosurgical pro c e d u res are used as last rescue once o t h e r techniques failed in order to achieve the highest possible success while minimizing potential complications and side effects. The intent of alternative therapies is to provide adequate and effective pain management in the oncology and palliative care arena with i m p rovement in patient quality of life.
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