Management of Spontaneous Aortic Thrombus Following Cisplatin-Based Chemotherapy in Urothelial Cancer: A Case Report.

Spontaneous aortic thrombosis is exceedingly rare, and optimal treatment remains uncertain. We present an unusual case of a spontaneous aortic thrombus at the renal artery level in a patient undergoing active cisplatin treatment for urothelial carcinoma. Management included catheter-directed thrombolysis followed by thrombectomy. An open cutdown was performed on the left common femoral artery (CFA), with right groin access via a 6-Fr sheath. Clamping of the left superficial and deep femoral arteries, along with balloon occlusion of the right common iliac artery, prevented distal embolization. A Coda balloon introduced via direct left CFA puncture with a 20-Fr sheath was positioned above the aortic thrombus. After inflation, clots were trawled to the sheath, "sandwiching" the clots before removal of the balloon and sheath via the left groin. Post-operatively, the patient recovered well and received continued therapeutic anticoagulation.

Aortic endograft infection secondary to Burkholderia pseudomallei: A case report and review of the literature.

Aortic graft infection is a rare complication after endovascular aneurysm repair that is usually caused by gram-positive organisms such as Staphylococcus spp or gram-negative organisms such as Enterobacteriaceae or Salmonella spp. We have presented a unique case of a patient with acute graft infection secondary to Burkholderia pseudomallei. Because treatment of B. pseudomallei infections is challenging owing to its inherent resistance to multiple antibiotics, we have proposed an approach for managing similar cases in the future. Lifestyle advice on avoiding soil exposure in the postoperative period after endovascular aneurysm repair might be an important preventative measure in endemic regions.

Use of the Gastroduodenal Artery in Hepatic Artery Reconstruction for Iatrogenic Hepatic Artery Injury During Laparoscopic Total Gastrectomy: Case Report and Review of the Literature.

Iatrogenic injury of the hepatic artery is a potential hazard of hepatopancreatobiliary and gastric surgery. Prompt recognition and specialist management is paramount to limit morbidity for the patient. Several reconstruction options have been reported in the literature, but the optimum approach should be tailored to the individual patient bearing in mind variations in anatomy, clinical conditions, and other concurrent operative interventions. We report the case of a successful hepatic artery reconstruction using the gastroduodenal artery as a transposition graft for inadvertent transection of the common hepatic artery during laparoscopic total gastrectomy. In expert hands, the use of the gastroduodenal artery for extra-anatomic reconstruction of the hepatic artery is a safe, feasible, and effective option.

Maximally Disfiguring Surgery for Forefoot Osteomyelitis: Time for a Rethink?

The treatment of choice for diabetic foot osteomyelitis is surgical debridement and targeted antibiotics with or without revascularization, depending on vascular status. In our society, debridement is done by either a vascular or orthopedic surgeon, and the common teaching is that generous amputation of bone with the accompanying soft tissue envelope is essential for adequate source control and to prevent recurrence (which remains as high as 30% even with this approach). Most of our patients undergo formal ray amputation through the metatarsal neck, while a few get digital amputations through the interphalangeal joints. Many of the resultant wounds cannot be closed and are left to heal by secondary intention. These amputations invariably alter the biomechanics of the foot and leave large and slow-healing open wounds, which have associated adverse psychosocial impacts. We describe 2 cases of patients who had osteomyelitis in the region of the forefoot who underwent complete bony resections of the osteomyelitis but with sparing of the soft tissue envelopes with good outcomes, and we challenge the dogma that maximal debridement of soft tissue must accompany debridement of necrotic and infected bone.

Limb Stent Occlusion from Intraoperative Nellix Stent Migration and Prolapse.

BACKGROUND: Incidence of Nellix stent migration is uncommon despite the absence of a proximal fixation mechanism. We present a case of intraoperative Nellix stent migration to highlight the potential complications. Our patient had renal artery occlusion and threatened limb stent perfusion as a result of intraoperative stent migration, with resultant prolapse of the Nellix endobag. We also present a successful salvage procedure to deploy an additional stent to restore limb stent flow. CASE: A 71-year-old Chinese gentleman with symptomatic concomitant infrarenal abdominal aortic aneurysm and bilateral common iliac aneurysms was discussed at a multidisciplinary meeting and deemed suitable for endovascular sealing of the aneurysms with the Nellix device. Prefilling imaging confirmed satisfactory stent positions bilaterally below the level of renal arteries. Routine filling of endobag was performed with stent-graft molding by standard angioplasty technique. Final check angiogram did not identify any endoleaks and demonstrated adequate sealing of the aneurysm. Unfortunately, patient developed acute kidney injury postoperatively. This was attributed to contrast-induced nephropathy. The creatinine level peaked at 150 µmol/L and stabilized. Ultrasound duplex on the seventh postoperative day however diagnosed absent left renal artery flow. An interval computed tomography aortogram at 3 month also detected threatened limb stent occlusion from the contralateral endobag prolapse. Subsequently, the patient underwent successful extension of the threatened limb stent to restore luminal flow. DISCUSSION: Retrospective examination of angiographic images confirmed that the left renal artery flow was preserved on the completion angiogram. The difference in level of limb stents observed postmolding compared to premolding widened from 1 mm to 6 mm due to a degree of stent bowing within the iliac arteries. We postulate the left renal artery occlusion was either caused by further proximal migration of the right limb stent due to the left stent bowing within the curve of the iliac artery or endobag prolapse post molding. Mismatched, unopposed filling of the endobags after the molding process could result in an unexpected behavior of prolapsing into the contralateral limb stent and obstruct luminal flow. This case highlights a significant sequalae of proximal migration after the molding process of Nellix. Augmenting the level of limb stent to the same level may be necessary and easily achieved with additional stent deployment. We recommend close inspection of completion angiogram to check for stent migration, and if required for additional angiograms to be taken perpendicular to each other or use of adjuncts such as intravascular ultrasound post endobag filling to document stent positions in relation to adjacent renal arteries, luminal flow, and detect any early intraoperative migration.

A Rare Case of Multifocal Papillary Thyroid Cancer in Bilateral Thyroid Cysts.

Papillary thyroid cancer (PTC) can present as a thyroid cyst. In its more aggressive form, PTC may be multifocal in nature and is associated with a poorer prognosis. In patients whom PTC is diagnosed incidentally after a diagnostic lobectomy, the decision whether to offer completion thyroidectomy is sometimes challenging to make if such patients fall in the 'low-to-intermediate' risk category. We present a case of a 55-year-old lady who had a predominantly cystic left thyroid nodule with no suspicious features on ultrasound as well as 2 subcentimetre simple right-sided cysts. She subsequently underwent left hemithyroidectomy, and this reported a T2 PTC in the thyroid cyst. This was followed by completion thyroidectomy which yielded the surprising finding of PTC in the two tiny right sided cysts. This case highlights the need for vigilance in managing patients with thyroid cysts even though thyroid ultrasound scan did not reveal any overt suspicious features.

Undifferentiated pleomorphic sarcoma of the neck - A case report.

Undifferentiated pleomorphic sarcoma very rarely affect the neck. We report a case of a 62year old man who presented with a right sided skin lump which he noticed after sustaining a neck contusion in a road traffic accident about one year ago. The initial CT and ultrasound scans of the lump were suggestive of a thrombosed varix. Clinical examination showed a hard skin nodule with signs of tethering. He underwent a wide excision of the skin nodule and the histology showed undifferentiated pleomorphic sarcoma with margins involved. He subsequently underwent another re-excision of margins and pectoralis major flap reconstruction. Following surgery, he was also prescribed adjuvant radiotherapy and he remains well about 12 months after follow up. The surgical management of undifferentiated pleomorphic sarcoma in the neck is challenging due to the proximity of critical neck structures and the need to obtain clear margins. Thus, adjuvant radiotherapy is often used to improve disease control.

A case report of an anterior tibial artery pseudo-aneurysm open surgical management: A rare complication post total knee arthroplasty.

INTRODUCTION: Complications involving injury to neurological and vascular structures are infrequently reported after total knee arthroplasty (TKA). They are associated with significant morbidity and can be limb threatening. PRESENTATION OF CASE: We present a patient with an anterior tibial artery (ATA) aneurysm post total knee arthroplasty. A 69-year-old female was referred for a swelling over her left antero-lateral aspect of her leg 4 years post TKA. Radiological investigations showed an ATA pseudo aneurysm. The aneurysm was repaired by open ligation. DISCUSSION: ATA pseudo aneurysm is a rare condition post arthroplasty. Patients can complain about calf pain, digits discoloration, paresthesia and the presence of a pulsating or enlarging mass. Symptomatic aneurysms require surgical intervention. CONCLUSION: ATA pseudo aneurysms are uncommon. They are usually identified shortly after the initial insult. A delayed manifestation of a post knee arthroplasty complication as illustrated in our case is likely the first reported case of its kind. Clinicians should maintain a high index of suspicion should there be persistent localised swelling post TKA. However, due to the rarity of this condition, a variety of interventions have been reported in the English medical literature with probably no compelling evidence that favors one modality over the others.

Repair of a complex post-EVAR type III endoleak using a chimney aortouniiliac stent graft and femorofemoral crossover bypass.

Post-EVAR type III endoleaks present a particular challenge as they carry a significant risk of rupture. We present a case of an 81-year-old gentleman, 10 years post-EVAR, with complex type III endoleak with component separation that was successfully treated with a combination of left renal artery chimney, aortouniiliac stent grafting and femorofemoral crossover bypass.