Accessory renal arteries involved in atherosclerotic occlusive disease at the aortic bifurcation.

Accessory renal arteries (ARAs) are embryonic remnants found in more than one-third of patients and occurring bilaterally in 10% of the population. Very few reports have documented such vessels arising near or at the level of the aortic bifurcation. Furthermore, the presence of ARAs has yet to be described in the context of atherosclerotic disease. Here, we present a unique case of large bilateral ARAs originating above the aortic bifurcation concurrent with symptomatic aortoiliac atherosclerotic disease. We highlight the embryologic and clinical significance of these vessels as well as discuss their potential role in accelerating atherosclerotic disease processes.

Pseudoaneurysm of Patent Ductus Arteriosus Following Previous PDA Closure: Case Report and Literature Review.

BACKGROUND: Pseudoaneurysm developing after repair of a patent ductus arteriosus (PDA) is uncommon, with only a handful of cases reported in the literature. While older literature cites infection, recent series suggest that formation of pseudoaneurysm off of a ligated PDA attributed to breakdown in the suture line. Thoracic endovascular aortic repair (TEVAR) for this rare pathology has been demonstrated in selected case reports. METHODS/RESULTS: A 61-year-old woman presented with enlarging left chest mass and shortness of breath. The patient reported a history of a PDA with 2 attempts at closure. At age 6, she had undergone an attempt at endovascular closure of the PDA; this subsequently resulted in right lower extremity limb ischemia with resultant below-knee amputation. At age 12, she underwent open thoracotomy with ligation of the PDA; at this procedure, she had injury to her recurrent laryngeal nerve, resulting in permanent hoarseness of voice. A computed tomography angiogram of the chest was obtained, which demonstrated a saccular 4.5 × 3.8 cm pseudoaneurysm in the region of the PDA with calcific wall changes. Recommendation was made to proceed with operative repair and she agreed. A TEVAR was performed using a commercially available stent graft. During the procedure, intravascular ultrasound was performed; however, the connection between the PDA pseudoaneurysm and the aorta was not visualized. She had an uncomplicated operative and postoperative course. Follow-up imaging showed complete thrombosis of the pseudoaneurysm. CONCLUSIONS: Pseudoaneurysm from previous PDA repair is a rare pathology. We present a unique case in which the patient had undergone attempts at both endovascular and open surgical repair. Open repair for PDA is still advocated; however, TEVAR appears to be a safe treatment in adults with this pathology following failed open closure.

Bile Duct Injury Repairs after Laparoscopic Cholecystectomy: A Five-Year Experience in a Highly Specialized Community Hospital.

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20-83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.

Howship-Romberg Sign and Bowel Obstruction: A Case Report.

Small bowel obstruction (SBO) is associated with high morbidity and mortality in acute care surgery practice, with hernias constituting a significant portion of the underlying etiology. Physical examination and maneuvers such as changing the extremity position of the patient can further improve clinician's diagnostic acumen to identify the cause of the disease. We present a case of SBO in an 83-year-old female whose physical exam was consistent with an underlying obturator hernia.

Hybrid Aortic Arch Debranching and TEVAR Is Safe in a Private, Community Hospital.

BACKGROUND: Hybrid open cervical vessel debranching and thoracic endovascular aortic repair (TEVAR) is a treatment option in the management of aortic arch or proximal descending thoracic aortic aneurysms. However, these patients are often referred to tertiary care academic centers for aneurysm repair. Our study looks to assess the safety and outcomes of open cervical debranching and TEVAR within a private, community hospital setting. METHODS: A total of 12 patients underwent hybrid open cervical vessel debranch with staged TEVAR from 2015 to 2018 at Riverside Community Hospital (Riverside, California). Three patients underwent open sternotomy with innominate artery bypass; four patients underwent combined carotid-carotid bypass with left carotid-axillary bypass or left subclavian transposition; three patients solely underwent left carotid-axillary bypass or left subclavian transposition. In cases involving multiple cervical bypasses, two surgeons were present. TEVAR was performed in a staged fashion during the same hospitalization. RESULTS: There were no patient deaths, MI, or stroke within the 30-day postoperative period and at 1-year follow-up. One patient suffered a small subdural bleed after ascending aorta to innominate bypass involving redo sternotomy and hypothermic circulatory arrest. The mean aortic zone stented was zone 1. On follow-up imaging, all bypass grafts were patent, all aneurysms demonstrated thrombosis without endoleak. Average follow-up was 20 months. CONCLUSIONS: Hybrid cervical debranching with staged TEVAR can be safely performed by experienced vascular surgeons in the community setting. Staged repair appears to confer better operative and patient outcomes.