Brachial artery aneurysm after hemodialysis fistula ligation: Case reports and review of literature.

INTRODUCTION: Brachial artery aneurysm (BAA) following long-standing arteriovenous fistula (AVF) ligation after renal transplantation is odd. CASE PRESENTATION: Two cases of brachial artery aneurysm treated with bypass (a saphenous vein graft and a PTFE graft). In the first patient no complications were recorded whereas an infection was diagnosed after 6 months from the procedure in the second treatment. CLINICAL DISCUSSION: Multiple factors activated by stress on the vessel wall followed by fistula ligation are the cause of vascular remodeling of the three layers making up the wall with possible evolution in aneurysmatic lesions. In literature the gold standard for this lesion is the surgical approach, only one endovascular procedure is reported. The traditional surgical approach uses the autologous vein or prosthetic PTFE grafts. CONCLUSION: Brachial artery aneurysm is a complication that affects patients undergoing renal transplantation who have already undergone AVF ligation. In our experience autologous vein graft represented the best solution.

Composite femoro-tibial bypass as alternative solution in complicated revascolarization: Case report.

INTRODUCTION: Peripheral Arterial Disease (PAD) in diabetic patients is a significant cause of Morbility. Long arterial occlusion in patient previously treated can require unusual and complex solution. Herein we report a case of complicated bypass in diabetic patient with history of bypass for bilateral popliteal aneurysm. PRESENTATION OF CASE: A 51-year-old male, smoker, with hypertension and diabetes mellitus was referred to our hospital for rest pain in left limb and peripheral cyanosis. Ultrasound doppler (US) showed an occlusion after common femoral artery with patency of Anterior-tibial artery (ATA) two centimeters after the origin. The unavailability of adequate autologous conduit necessitated an alternative solution and was chosen a composite femoro-anterior tibial artery bypass with successive ATA angioplasty to ensure the patency of graft. DISCUSSION: The autogenous vein is the preferred conduit in below-knee vascular reconstructions but in redo-procedures in the absence of vein, synthetic or biologic vascular prostheses must be considered as graft material. In these cases tibial angioplasty can improve the outflow and the patency. CONCLUSION: Composite Femoro-ATA bypass with tibial angioplasty is an alternative technique for critically ischemic legs with limited autologous vein material. In our experience this approach was safe and effective.

Staged acute mesenteric and peripheral ischemia treatment in COVID-19 patient: Case report.

INTRODUCTION: COVID-19 is an infectious disease that has been associated not only with respiratory complications. The COVID-19 disease includes, also damage to other organ systems as well as coagulopathy. The present report describes a case of COVID-19 presenting with acute mesenteric ischemia (AMI) and subsequent acute limb ischemia (ALI). PRESENTATION OF CASE: An 84-years old hospitalized female patient presenting diabetes and recent COVID-19 reported acute onset of abdominal pain and typical findings of AMI. The CT-angiography confirmed the AMI secondary to a superior mesenteric artery (SMA) occlusion. The patient was managed through an endovascular approach using a SMA mechanical thrombectomy and stenting with a good result. DISCUSSION: Treatment of this life-threatening condition includes surgical resection of the necrotic bowel, restoration of blood flow to the ischemic intestine and supportive measure - gastrointestinal decompression, fluid resuscitation, hemodynamic support. Endovascular management of AMI is preferred over the standard surgical approach due to a reduced mortality and morbidity rates. Imaging findings of intestinal necrosis, however, represent an indication for AMI surgical treatment with explorative laparotomy. Different endovascular solutions have been employed to address AMI including mechanical thrombectomy, local thrombolysis, and PTA-stenting. CONCLUSION: COVID-19 clinical presentation can be atypical, including gastrointestinal symptoms. If a first embolic event occurs, an aggressive anticoagulation treatment could be inefficient to reduce the risk of subsequent embolization events. The limited life expectancy of such revascularization procedures should orientate towards less invasive treatments.

TEVAR and periscope graft technique to treatment of huge aneurysm of aortic isthmus: Case report.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of thoracic aortic aneurysms. Innovative techniques as chimney and periscope grafts can improve the outcomes of procedure. Herein, we report a case in emergency of huge Thoracic aortic aneurism. PRESENTATION OF CASE: An 86-year-old male with hypertension, diabetes mellitus, was referred to our hospital for chest pain. CT-angiography showed a huge aneurysm of aortic isthmus with signs of rupture. The patient was considered unfit for open surgery and an endovascular approach was chosen. This patient underwent endovascular repair with TEVAR, using the periscope graft technique to preserve patency in left subclavian artery (LSA). DISCUSSION: Symptomatic ischemia from LSA coverage has been reported to occur in only a modest 6-10% of patients and is often sacrificed with impunity given coverage rates between 10 and 50%. In this case reported the lack of revascularization of LSA increased the risk of neurological manifestations or stroke. Periscope technique is feasible and safe to maintain perfusion to the subclavian artery, with a 93% primary patency at 2 years. CONCLUSIONS: Our experience using TEVAR with periscope graft technique as solution to address thoracic aneurysm of aortic isthmus was feasible and safe.