The downstaging of gastric cancer has recently gained particular attention in the field of gastric cancer surgery. The phenomenon is mainly due to an inappropriate sampling of lymph nodes during standard lymphadenectomy. Hence, collection of the maximum number of lymph nodes is a critical factor affecting the outcome of patients. None of the techniques proposed so far have demonstrated a real efficiency in increasing the number of identified lymph nodes. To harvest the maximum number of lymph nodes, we designed a protocol for on-site macroscopic evaluation and sampling of lymph nodes according to the Japanese Gastric Cancer Association protocol. The procedure was carried out by a surgeon/pathologist team in the operating room. We enrolled one hundred patients, 50 of whom belonged to the study group and 50 to a control group. The study group included patients who underwent lymph node dissection following the proposed protocol; the control group encompassed patients undergoing standard procedures for sampling. We compared the number and maximum diameter of lymph nodes collected in both groups, as well as some postoperative variables, the 30-day mortality and the overall survival. In the study group, the mean number of lymph nodes harvested was higher than the control one (p = 0.001). Moreover, by applying the proposed technique, we sampled lymph nodes with a very small diameter, some of which were metastatic. Noticeably, no difference in terms of postoperative course was identified between the two groups, again supporting the feasibility of an extended lymphadenectomy. By comparing the prognosis of patients, a better overall survival (p = 0.03) was detected in the study group; however, to date, no long-term follow-up is available. Interestingly, patients with metastasis in node stations number 8, 9, 11 or with skip metastasis, experienced a worse outcome and died. Based on our preliminary results, the pathologist/surgeon team approach seems to be a reliable option, despite of a slight increase in sfaff workload and technical cost. It allows for the harvesting of a larger number of lymph nodes and improves the outcome of the patients thanks to more precise staging and therapy. Nevertheless, since a higher number of patients are necessary to confirm our findings and assess the impact of this technique on oncological outcome, our study could serve as a proof-of-concept for a larger, multicentric collaboration.

Late type II endoleaks (T2ELs) arising from the internal iliac artery (IIA) may present during follow-up after endovascular aortic repair (EVAR) of aortoiliac aneurysm and may warrant embolization if enlargement of the aneurysmal sac is demonstrated. When coverage of the IIA ostium has been made due to extensive iliac disease, access options can be challenging. Different treatment options have been reported over recent years, and a careful selection of the best one must be made based on the characteristics of each case. The present study reports a simple and reproducible sheathless percutaneous superior gluteal artery (SGA) access and provides a discussion based on a review of the existing literature on this topic.

Late type II endoleak (T2EL) arising from internal iliac artery (IIA) network may occur after endovascular aortic repair (EVAR) of aortoiliac aneurysm and may require embolization if sac enlargement is demonstrated. When direct antegrade access to ipsilateral IIA is not achievable due to previous vessel coverage and/or embolization, access to the nidus can be challenging. We report a case of T2EL originating from IIA network causing iliac sac enlargement in a patient previously treated by EVAR for artoiliac aneurysm with IIA embolization and coverage, in which embolization of the nidus was performed through a percutaneous sheathless access to ip-silateral superior gluteal artery (SGA). A literature review dealing with all cases of percutaneous direct SGA access for retrograde embolization of T2EL arising from IIA after previous EVAR is also reported. The research was conducted on Pubmed database using keywords “superior glu-teal artery access,” “transgluteal embolization” and “retrograde embolization for type II endo-leak”. Related articles and references were screened for suitable articles.

Severe iliofemoral calcification can compromise emergency endovascular control of access‐site bleeding by preventing full covered‐stent expansion at the landing zone. A 78‐year‐old man developed hemodynamic instability, right‐flank pain, and severe anemia 6 h after ultrasound‐guided right transfemoral primary percutaneous coronary intervention for anterior ST‐segment elevation myocardial infarction. Contrast‐enhanced computed tomography demonstrated a large right retroperitoneal hematoma with active extravasation from the distal external iliac artery, immediately proximal to a bulky calcified plaque involving the proximal common femoral artery (CFA). Through ultrasound‐guided contralateral femoral access, an 8 mm × 60 mm self‐expanding covered stent achieved immediate sealing of the external iliac artery injury but remained markedly underexpanded distally at the calcified CFA landing zone. Conventional 8‐mm balloon post‐dilation was attempted, but residual underexpansion persisted; further high‐pressure dilation was avoided because of concern for rupture or perforation of the calcified iliofemoral segment and loss of the newly achieved seal. Bailout intravascular lithotripsy (IVL) with an 8 mm × 60 mm balloon consisted of 150 pulses delivered at 4 atm in repeated sequences, each followed by nominal‐pressure post‐dilation of the same balloon at 6 atm. Final angiography showed improved covered‐stent expansion with approximately 30% residual stenosis and no recurrent extravasation, dissection, perforation, or distal embolization. The patient was discharged on postoperative day 8. At 12‐month follow‐up, duplex ultrasound confirmed covered‐stent patency without edge stenosis, pseudoaneurysm, or hemodynamically significant restenosis. This case illustrates that IVL may provide a low‐pressure bailout option for calcium‐mediated peripheral covered‐stent underexpansion during emergency vascular access‐site repair; however, this off‐label use requires careful device sizing, attention to covered‐stent integrity, and structured imaging surveillance.