Vascular leiomyosarcoma of the femoral vein: an unusual cause of a femoral triangle mass.

Lumps in the femoral triangle are common. The differential diagnosis includes lymphadenopathy and femoral hernias. Rarer causes of lumps are saphena varix, femoral artery aneurysm or a psoas abscess. We present a leiomyosarcoma of the femoral vein that presented as a femoral triangle mass.

Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms.

PURPOSE: To evaluate the suitability of a standardized fenestrated endograft in patients with juxtarenal abdominal aortic aneurysms. METHODS: High resolution computed tomographic angiograms from 100 consecutive patients (96 men; mean age 72 years) with juxta- (n = 78) and pararenal (n = 22) aneurysms treated electively between 2005 and 2010 with custom-made fenestrated endografts were reviewed. A centerline of flow reconstruction was carried out in a 3D imaging workstation to precisely define the aortic morphology, including aortic diameters and distances between visceral and renal arteries. The applicability of 2 different "off-the-shelf" standardized fenestrated endografts designed by the manufacturer was evaluated in this cohort. Both designs included 2 fenestrations for the renal arteries, 1 for the superior mesenteric artery (SMA), and a scallop for the celiac trunk. The designs differed in the lengths of the SMA to renal fenestration and renal to renal fenestration. RESULTS: Endovascular treatment with one or both "off-the-shelf" endografts was deemed possible in 72 patients (56 with design 1, 52 with design 2, and 36 with both endografts). Of the 28 patients who were not candidates for a standardized fenestrated stent-graft of either design, the primary cause was a right renal artery that did not match the position of its corresponding fenestration. CONCLUSION: Standardized fenestrated designs suitable for endovascular treatment of >70% of patients with juxta- and pararenal aneurysms currently treated with custom-made fenestrated endografts will soon be available. This new generation of endografts will permit rapid treatment of a large majority of patients requiring fenestrated endograft repair.

Fenestrated endovascular repair of type IV thoracoabdominal aneurysms: device design and implantation technique.

Treatment of thoracoabdominal aortic aneurysms has traditionally been by means of open surgery, but in recent years endovascular approaches have emerged as a viable and perhaps superior alternative. Some confusion appears to exist in discussions in the literature regarding the exact definition of the various types of thoracoabdominal aneurysm depending on whether open or endovascular repair is undertaken, with some authors comparing the preoperative extent of disease and others comparing the degree of aortic coverage required. Accurate preoperative planning and meticulous implantation technique are critical to successful outcomes with the endovascular approach. This study discusses the anatomical classification of type IV thoracoabdominal aneurysms as applied in open and endovascular surgery and outlines the authors' approach to the critical preoperative planning of endografts used to treat these aneurysms. The authors describe their techniques used to implant these devices, whether they consist of fenestrated or branched components, and some of the mechanisms by which minimization of complications such as spinal cord ischemia is sought.

Superficial and deep vein thrombosis associated with congenital absence of the infrahepatic inferior vena cava in a young male patient.

BACKGROUND: Congenital absence of the inferior vena cava (AIVC) is a rare vascular anomaly that may be associated with deep vein thrombosis (DVT). It is underreported and may be present in up to 5% of young patients with DVT. We report a unique case of simultaneous thrombosis of both superficial and deep veins in a patient with AIVC. METHODS AND RESULTS: A 20-year-old man presented with a 2-week history of a swollen, painful, left lower limb. On examination, the left leg and thigh were found to be swollen and varicosities were present along the lower abdominal wall. Ultrasound showed extensive superficial and deep venous thrombosis of the entire left lower limb. Computed tomography venogram revealed an infrahepatic AIVC with lower limb drainage through enlarged intrathoracic continuations of the azygous and hemiazygous veins. The patient was put on oral anticoagulant therapy and was well at 6-month follow-up. CONCLUSION: The hypothesis for DVT in patients with AIVC is that venous drainage of the lower limbs is inadequate, leading to venous stasis and thrombosis. All young patients presenting with idiopathic DVT should be investigated for inferior vena cava anomalies with computed tomography if ultrasound does not visualize the inferior vena cava.

Inverted limbs in fenestrated and branched endografts.

PURPOSE: To describe our experience with the use of custom-designed branched or fenestrated endoprostheses incorporating an inverted contralateral limb in the bifurcated component. METHODS: Retrospective analysis was performed of a prospectively maintained database of all patients undergoing endovascular aneurysm repair using modular branched or fenestrated devices at a university teaching hospital between January 2004 and February 2010. Of 102 cases, 7 male patients (mean age 69 years) were treated with modular devices that incorporated an inverted contralateral limb in the bifurcated component. Five patients had thoracoabdominal aortic aneurysm (4 type IV and 1 type II), 1 patient had a pararenal abdominal aortic aneurysm, and another had type I endoleak from a migrated AneuRx stent-graft. The technique was used primarily because of an existing bifurcated prosthesis (n=5), but in 2 patients without prior open surgery, this technique was needed because of anatomical constraints. RESULTS: All devices were implanted as planned. There was no mortality. One patient required temporary hemodialysis prior to discharge; another patient developed permanent paraplegia, likely related to extensive aortic coverage. No device migration, component separation, or type I or III endoleaks were detected during a mean follow-up of 25 months, and no reinterventions have been necessary. CONCLUSION: The use of an inverted limb in the bifurcated component of modular endografts may allow endovascular treatment in scenarios where there is insufficient space to deploy a standard bifurcated component. This design modification allows an adequate sealing zone between the iliac extension limbs and the bifurcated component.

Challenging treatment of a secondary endoleak in a fenestrated endograft.

PURPOSE: To describe the novel use of an Amplatzer occluder device to seal a secondary endoleak arising at a scallop in a fenestrated stent-graft. CASE REPORT: A 67-year-old man with comorbidities precluding standard endovascular repair of a pararenal aortic aneurysm was treated with a fenestrated endoprosthesis containing one fenestration for the left renal artery and one scallop for the celiac trunk; the right renal and superior mesenteric arteries were occluded at presentation. Interval imaging at 2 years showed a proximal type I endoleak at the celiac trunk scallop associated with expansion of the aneurysm sac. Attempted repair with an aortic extension cuff and a "chimney" stent was unsuccessful. An Amplatzer Patent Foramen Ovale occluder device was deployed across the endoleak to provide aneurysm sac exclusion, which has been maintained at 6-month follow-up. CONCLUSION: Treatment of a secondary type I endoleak after implantation of a fenestrated endoprosthesis is challenging. The novel use of an Amplatzer occluder in this setting may be applicable to other situations in which an endovascular solution is desirable for complications of complex endovascular aneurysm repair.

Challenging catheterization of a branch in an endovascular thoracoabdominal aneurysm repair.

PURPOSE: To describe a novel technique of cannulating a side branch during endovascular repair of a thoracoabdominal aneurysm (TAAA). TECHNIQUE: The approach evolved during endovascular repair of a type III TAAA in which a custom-designed graft with 3 caudally directed branches was being deployed in a patient who had a prior surgical repair for a type IV TAAA. Two of the branches were successfully cannulated and stented, but repeated efforts to cannulate the left renal branch and artery via the standard brachial approach were unsuccessful. A catheter positioned between the graft and the aneurysm sac was used to gain retrograde access to this branch. From a left brachial access this guidewire was snared and used to allow bridging stent deployment between the branch and the renal artery, thus completing the procedure. CONCLUSION: This report describes a novel technique to deal with challenging side branch cannulation that may be encountered during branched stent-graft deployment.

Mycotic aneurysm of the popliteal artery secondary to Streptococus pneumoniae: a case report and review of the literature.

INTRODUCTION: Cases of true mycotic popliteal artery aneurysm are rare. Presentation is variable but invasive and non-invasive investigations collectively facilitate diagnosis and guide operative procedures. Definitive treatment generally utilizes surgical intervention with excision and reconstruction using autologous vein graft. Prolonged targeted antibiotic therapy is an important adjuvant. CASE PRESENTATION: We describe the clinical presentation, radiological investigations and strategies on the management of a 47-year-old Caucasian Irish man who presented with a mycotic aneurysm of the popliteal artery due to thromboembolisation from Streptococus pneumoniae endocarditis. CONCLUSION: Cases of true mycotic popliteal artery aneurysms are rare. To the best of our knowledge this is the first documented case of a popliteal artery mycotic aneurysm developing secondary to Streptococus pneumoniae highlighting the changing profile of causative microorganisms.

The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures.

Although it is widely accepted that aspirin will increase the risk of intra- and post-operative bleeding, clinical studies have not consistently supported this assumption. We aimed to assess the effect of pre-operative aspirin on blood loss and transfusion requirements in patients undergoing emergency fixation of femoral neck fractures. A prospective case-control study was undertaken in patients presenting with femoral neck fractures. Parameters recorded included intra-operative blood loss, post-operative blood loss, transfusion requirements and peri-operative reduction in haemoglobin concentration. Of 89 patients presenting with femoral neck fractures 32 were on long-term aspirin therapy. Pre-operative aspirin ingestion did not significantly affect peri-operative blood loss, or change in haemoglobin concentration or haematocrit. However those patients taking aspirin pre-operatively had a significantly lower haemoglobin concentration and haematocrit and were more likely to be anaemic at presentation than those who were not receiving aspirin. Patients taking aspirin were also more likely to receive blood transfusion post-operatively.

Our interest is swelling: a collaborative venture to establish the world's first free public screening for lymphoedema.

This article describes the collaborative processes involved in the implementation of a free public health screening program for people at risk of lymphoedema following the removal of lymph nodes during surgery to control breast, prostate and other cancers, or injury. The planning phase of the program is described with emphasis on the need to secure a well situated venue, the commitment of a cohort of key health professionals, service club and lay volunteers, and the need to carefully target and publicise the event widely. The implementation phase requires careful consideration of the physical layout of the event, the direction and management of the flow of human traffic, information and equipment requirements, and recognition that screening programs place people in vulnerable positions. Effective communication skills are essential, as is a knowledge of where people can be referred should the need arise. A budget is provided together with discussion regarding the success of the program and recommendations for future consideration such as the need to target men to attend screening and for long term follow up of the outcomes.