Complex and Successful Management of a Symptomatic Isolated Abdominal Aortic Aneurysm in a Pregnant Woman with Marfan Syndrome.

Aortopathies associated to Marfan syndrome (MFS) are important causes of maternal death during pregnancy. We present a 27-year-old and 24-week pregnant MFS woman who arrived to the emergency department with increasing abdominal pain; an obstetric ultrasound showed an Abdominal Aortic Aneurysm (AAA), a multislice computed tomography angiography (CTA) confirmed and demonstrated a 7.3 centimeter (cm) infrarenal AAA without evidence of dissection. A multidisciplinary committee determined that an open repair would lead to a significantly high maternal-fetal morbidity and mortality. Although endovascular repair (EVAR) in MFS patients remains controversial, an urgent bridge therapy was considered to be the best option. She was transferred to the angiography suite for EVAR to prevent AAA rupture and ensure a satisfactory pregnancy. The patient and fetus presented no complications during the procedure and were discharged 3 days later. She continued her pregnancy without eventualities and an elective C-section was performed on week 36. A CTA imaging at 12 months revealed type 1A and 3 endoleaks, we decided to perform endograft explant and a definitive open repair, there were no complications during the procedure, the patient is currently asymptomatic. Our case illustrates a complex decision and management that successfully avoid morbidity and mortality of a MFS mother and her product; additionally, this experience reinforces the need for lifelong and close surveillance in these patients.

Physician-Modified Endovascular Gore Excluder Graft (Handmade Modified) for Complex Abdominal Aortic Aneurysm: A Step-by-Step Approach.

Endovascular repair has become the gold standard for the treatment of infrarenal abdominal aortic aneurysmal disease. Branched and fenestrated commercially custom-made devices have been developed as a treatment option for short necks or juxtarenal aneurysms. However, the lack of availability in some countries and centers, manufacturing time (6-8 weeks requirements), urgent setting in ruptured abdominal aortic aneurysms, and elevated costs make them not a widespread option. Hereby, we expose our step-by-step technique of physician modified Gore Excluder  to treat complex aneurysms. Physician-modified endovascular graft (PMEG) has emerged as an alternative to open repair for the treatment of complex aortic aneurysms. The ultimate goal of fenestrations is to increase the proximal sealing zone length. The Gore C3 delivery system allows repositioning of the graft by constraining the proximal part after a back-table physician modification; the PMEG technique with the Gore Excluder C3 delivery system can be used for complex aortic aneurysms repair as an alternative treatment option.

Segmental T12 Vertebral Artery Injury Treated by Endovascular Coil Placement after Kyphoplasty for Symptomatic Spinal Angioma. Case Report of a Minimal Invasive Solution for a Complication of a Minimally Invasive Spine Procedure.

BACKGROUND: Vertebral angioma is a tumor defined as an abnormality of vascular tissue development. It usually has an asymptomatic behavior, being present in 10%-12% of autopsies and imaging studies. CASE DESCRIPTION: A 70-year-old man consulted because of a long history of low back pain. Imaging studies were compatible with vertebral angioma at T12; we decided to perform a minimally invasive surgical procedure, such as kyphoplasty. During surgery, there was a sharp decrease in pulmonary saturation, and the patient underwent a computed tomography scan evaluation confirming a left hemothorax due to segmental branch vascular injury at T12. Given the patient's poor medical condition and the complexity of an emergent open procedure in the thoracic spine, we decided to undertake a minimally invasive endovascular coil placement to repair the vascular injury. Due to a favorable outcome, we discharged the patient after 72 hours of surveillance. CONCLUSIONS: Even in the case of a complication to occur, we should always consider a minimally invasive solution to solve the problem because patients undergoing these procedures correspond to elderly patients with poor medical conditions or comorbidities.

Percutaneous Endovascular Aortic Aneurysm Repair with INCRAFT Endograft Guided by CO2 Digital Subtraction Angiography in Patients with Renal Insufficiency.

Iodinated contrast is the most common contrast agent used during endovascular abdominal aneurysm repair (EVAR). However, its use may worsen kidney function in patients with renal insufficiency. Previous studies have demonstrated the safety and effectiveness of carbon dioxide (CO2)-EVAR. Here, we report cases of three male patients with mild renal insufficiency (mean age: 79 years) that successfully underwent CO2-EVAR using INCRAFT ultra-low profile endografts. CO2 angiography provided the necessary vascular roadmap for safe and effective percutaneous EVAR, eliminating the need for iodinated contrast media and preventing contrast-induced nephropathy.

Let It Chill: The Role of Interventional Radiology in Complicated Appendicitis. A Case Report.

Appendicitis is a common cause of acute abdominal syndrome that affects different group ages. In some cases, complications such as abscess formation or perforation may make taking an immediate surgical approach difficult. We report a case of a 39-year-old male who presented with appendicitis, with the presence of a well-circumscribed abscess. The surgeons and interventional radiologists at our institution preferred a conservative approach by placing ultrasound-guided percutaneous drainage and performing an interval appendectomy weeks after the initial symptoms. Through the presentation of this case, we want to make physicians, mostly in developing countries, aware of the benefits of interventional radiology in the management of complicated appendicitis.

Successful Embolization of a Ruptured Ovarian Artery Aneurysm in a Postmenopausal Woman: Case Report and Literature Review of Gonadal Artery Aneurysms.

Gonadal artery aneurysms (GADs) are extremely rare; their prevalence and natural history are unknown and their pathogenesis remains poorly understood. Based on the limited literature reports, these might present with rupture (ovarian artery) or pain and acute thrombosis (testicular artery). The present article reports the case of an 80-year-old woman who came to the emergency department (ED) with acute onset of abdominal and left flank pain. A computed tomography angiography (CTA) revealed a large retroperitoneal hematoma associated with the presence of a left ovarian artery aneurysm. The patient was taken to the angiography suite for a selective vessel catheterization and embolization with N-butyl-2-cyanoacrylate (NBCA). Following the procedure, her serial hemoglobin remained stable, her symptoms subsided, and she was discharged home 2 days later. The GADs are unrecognized entities until an acute event such as rupture occurs, and vessel embolization is effective for hemorrhage control. Close communication and collaboration with gynecologists and urologists are crucial to better define the prevalence, natural history, and the appropriate behavior and timing for elective treatment. With this article, the authors additionally present a review of the literature.

Analysis of the MELD Score Impact in the Outcome of Endovascular Portal Vein Reconstruction.

INTRODUCTION: Endovascular therapy represents a less invasive alternative to open surgery for reconstruction of the portal vein (PV) and the spleno-mesenteric venous confluence to treat Portal hypertension. The objective of this study is to determine if the Model for End-Stage Liver Disease (MELD) score is a useful method to evaluate the risk of morbidity and mortality during endovascular approaches. MATERIAL AND METHODS: Patients that underwent endovascular reconstruction of the PV or spleno-mesenteric confluence were identified retrospectively. Data were collected from November 2011 to August 2016. The MELD score was calculated using international normalized ratio, serum billirubin and creatinine. Patients were grouped into moderate (≤ 15) and high (> 15) MELD. Associations of the MELD score on the postprocedural morbidity, mortality and vessels patency were assessed by two-sided Fisher's exact test. RESULTS: Seventeen patients were identified; MELD score distribution was: ≤ 15 in 10 patients (59%) and > 15 in 7 (41%). Even distribution of severe PV thrombosis was treated in both groups, performing predominately jugular access in the high MELD score group (OR 0.10; 95%; CI 0.014-0.89; p = 0.052) in contrast to a percutaneous transhepatic access in the moderate MELD score group. Analysis comparing moderate and high MELD scores was not able to demonstrate differences in mortality, morbidity or patency rates. CONCLUSION: MELD score did not prove to be a useful method to evaluate risk of morbidity and mortality; however a high score should not contraindicate endovascular approaches. In our experience a high technical success, good patency rates and low complication rates were observed.

Endovascular Reconstruction of Extrahepatic Portal Vein in Noncirrhotic and Nonmalignant Chronic Portal Vein Thrombosis Secondary to an Iatrogenic Stenotic Lesion.

Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm × 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.

Eversion Subclavian Endarterectomy and Transposition for Coronary-Subclavian Steal Syndrome in a Patient with Refractory Angina Pectoris.

Late onset of angina pectoris associated with subclavian artery (SA) atherosclerotic occlusive disease is a rare and recognized cause of myocardial ischemia when the lesion is proximal to a left internal mammary artery (LIMA) to coronary bypass. The symptoms typically exacerbate by increasing the flow demand in the extremity; this phenomenon is known as late coronary-subclavian steal syndrome. We describe the case of a 66-year-old woman who underwent coronary artery bypass grafting from the LIMA to the left anterior descending coronary artery in 2000. Years later, she experienced refractory angina pectoris associated to an occlusive lesion in the proximal left SA. SA endarterectomy with eversion technique and subclavian-carotid transposition restored the antegrade flow with resolution of the symptomatology.

Obstrucción de la vía aérea por higroma quístico en un recién nacido / Airway obstruction due to cystic hygroma in a newborn

Introducción: El higroma quístico es una dilatación difusa de los conductos linfáticos. Puede diagnosticarse prenatalmente a través de una ecografía obstétrica. La incidencia aproximada es de 1/6,000 nacidos vivos y de 1/750 abortos espontáneos. Esta lesión puede presentarse a nivel cervical en la parte inferolateral del cuello, donde aparece con grandes cavidades únicas o multiloculares. En general, se producen por la falta de conexión de los vasos linfáticos con los sacos linfáticos yugulares, o de estos con el sistema de drenaje venoso. Caso clínico: Con el fin de enfatizar sobre la notificación de estas enfermedades y las opciones de tratamiento no quirúrgico, se presenta una paciente con higroma quístico cervical (cara lateral del cuello) con compromiso de la vía aérea y digestiva por la extensión del tumor. Se trató con etanol puro por medio de múltiples infiltraciones guiadas por ultrasonido. Conclusiones: Dependiendo de las características de la lesión, el tratamiento puede ser quirúrgico, farmacológico o mixto. Cuando la extensión es importante o se relaciona con órganos vitales, la mejor opción de tratamiento es, en primer lugar, reducir el tamaño de la lesión y el compromiso de los órganos contiguos. Esto se hace por medio de escleroterapia. Posteriormente, de ser necesario, se realiza cirugía.

Background: Cystic hygroma is a diffuse dilatation of the lymphatic system, which can be prenatally diagnosed by ultrasound. The incidence is 1/6,000 live births and 1/750 spontaneous abortions. This malformation can occur at the cervical level located in the inferior lateral part of the neck where it appears with large single or multilocular cavities. It is generally caused by a lack of connection with jugular lymphatic channels or with the venous drainage system lymph sacs. Case report: In order to emphasize these diseases and non-surgical treatment options, we present a patient with a cervical cystic hygroma that compromises the airway and digestive tract due to tumor extension and treatment with pure ethanol with clinical improvement. Conclusions: Depending on the characteristics of the lesion, treatment options are surgery, pharmacological or mixed. When the extension involves vital organs, the best option is to reduce the size of the lesion and the compromise of the adjacent organ. This is done by sclerotherapy and, if necessary, surgery.

[Airway obstruction due to cystic hygroma in a newborn]. / Obstrucción de la vía aérea por higroma quístico en un recién nacido.

BACKGROUND: Cystic hygroma is a diffuse dilatation of the lymphatic system, which can be prenatally diagnosed by ultrasound. The incidence is 1/6,000 live births and 1/750 spontaneous abortions. This malformation can occur at the cervical level located in the inferior lateral part of the neck where it appears with large single or multilocular cavities. It is generally caused by a lack of connection with jugular lymphatic channels or with the venous drainage system lymph sacs. CASE REPORT: In order to emphasize these diseases and non-surgical treatment options, we present a patient with a cervical cystic hygroma that compromises the airway and digestive tract due to tumor extension and treatment with pure ethanol with clinical improvement. CONCLUSIONS: Depending on the characteristics of the lesion, treatment options are surgery, pharmacological or mixed. When the extension involves vital organs, the best option is to reduce the size of the lesion and the compromise of the adjacent organ. This is done by sclerotherapy and, if necessary, surgery.

Arcuate ligament compression as a cause of early-onset thrombosis of the hepatic artery after liver transplantation.

BACKGROUND: Early hepatic artery thrombosis (HAT) is a potentially lethal complication after orthotopic liver transplantation (OLT) requiring immediate intervention. AIM: To report an infrequent cause of HAT after OLT and by itself a controversial clinical entity, the median arcuate ligament celiac artery compression. CASE REPORT: A 59-year-old female with hepatitis C virus-induced cirrhosis, Child B, MELD 15, underwent cadaveric-donor OLT with complete vena cava exclusion. Type 1 hepatic artery anatomy was found both in the donor and the recipient, the gastroduodenal artery was ligated. During the first eight postoperative days, clinical and analytical evolution was satisfactory and Doppler ultrasound showed no abnormalities. On the ninth postoperative day, the patient developed hypovolemic shock due to bleeding at the hepatic artery anastomosis, surgical reconstruction was performed. Postoperative color Doppler showed absent hepatic artery flow and an angiography suggested celiac artery compression. The patient was explored again the same day, liberating the celiac artery from the median arcuate ligament and performing thrombectomy and reconstruction of the hepatic artery anastomosis. The patient made a satisfactory recovery and color Doppler showed adequate flow in the hepatic artery. She is alive, free of biliary complications and enjoying a good quality of life 12 months after transplantation. CONCLUSION: Median arcuate ligament celiac artery compression is an infrequent anatomical variant that should be intentionally evaluated in the recipient at the time of arterial reconstruction in OLT and specifically be considered in early HAT to allow recognition and effective correction.