Penumbra aspiration thrombectomy of the superior mesenteric artery for mesenteric ischemia.

Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc).

External iliac vein aneurysm treated via balloon-assisted aneurysmorrhaphy with a contemporary review of the literature.

Isolated external iliac vein aneurysm is exceedingly rare, not well-described in the literature, and presents several potential surgical approaches. Herein, we describe the case of a 72-year-old woman who presented with incidentally found 4.3 cm × 3.4 cm × 5.6 cm right external iliac vein aneurysm after undergoing magnetic resonance imaging for orthopedic work-up. She was treated via parallel supra- and infra-inguinal incisions and novel combination of primary aneurysmorrhaphy with intraluminal balloon mandrel-assisted closure. The patient was discharged on postoperative day two, and 6-month follow-up ultrasound showed a normal caliber vessel with normal compressibility, suggesting this technique is safe and effective for appropriately selected patients.

Acute occlusion of aortic endovascular aneurysm repair stent graft with bilateral limb ischemia.

Endovascular aneurysm repair has dramatically changed the management of abdominal aortic aneurysms as an alternative to open repair. However, complications can occur, including stent graft migration, kinking, and occlusion, leading to compromise of the excluded aneurysm walls and acute limb ischemia. In the present report, we have described a case of migration and kinking of an abdominal aortic stent graft in the main body that led to occlusion of the abdominal aorta and bilateral acute limb ischemia. The patient required emergent explantation of the stent graft and open repair of the abdominal aneurysm with a rifampin-soaked Dacron graft, which achieved a favorable outcome.

Complications of Peripheral Cannulation Site in Obese Patients on Adult Extracorporeal Membrane Oxygenation.

Placement of extracorporeal membrane oxygenation (ECMO) in obese patients has been challenging; however, cannulation risk in obese patients has not been clearly investigated. We therefore explored ECMO cannulation complications in this obese population. Data were reviewed from adult ECMO database from 2010 to 2019. Patients were stratified by body mass index (BMI) (normal weight [NW] [BMI 18.5-24.9], overweight [BMI 25-29.9], class I [BMI 30-34.9], class II [BMI 35-39.9], class III [BMI >40]). Patients with central cannulation were excluded from this study. Combined ECMO cannulation complications and survival data were retrospectively analyzed. There were 233 patients, 156 venoarterial (VA) ECMO patients (45 [28%] NW, 51 [33%] overweight, 37 [24%] class I, 12 [8%] class II, and 11 [7.0%] class III) and 77 venovenous (VV) ECMO patients (14 [18%] NW, 13 [17%] overweight, 17 [22%] class I, 11 [14%] class II, and 22 [29%] class III). There were significantly more cannulation site bleeds in VA class III (55%) patients compared with VA NW patients (22%), p = 0.006. There was no significant difference in cannulation site bleeding between BMI groups for VV ECMO. There was no difference in 30 day mortality, ECMO survival for all BMI groups in both VA and VV ECMO. There is significant increased risk of bleeding with peripheral VA cannulation of obese patients with BMI > 35. Cannulating surgeon should be aware of this bleeding risk in morbidly obese patient who undergo VA ECMO.

A rare case of Clostridium septicum aortitis with colon adenocarcinoma.

Clostridium septicum aortitis is a rare, highly morbid condition typically accompanied by malignant disease, such as hematologic cancer or colon adenocarcinoma. Presenting symptoms commonly described include acute onset of abdominal pain, nausea, and fevers. Prompt diagnosis of infectious aortitis is critical to prevent deadly complications, such as sepsis and vascular catastrophe. The described management largely involves surgical resection of the infected aorta, débridement, and arterial revascularization through extra-anatomic bypass or aortic graft placement.

Atypical Mycotic Aortic Aneurysms.

Mycotic aortic aneurysms are rare occurrences and such aneurysms associated with Streptococcus pneumoniae are seldom seen in the current antibiotic era. We present the unusual case of a 68-year-old healthy female with a Streptococcal mycotic abdominal aortic aneurysm of unknown etiology treated with antibiotics and open surgical intervention. Postoperative imaging revealed multiple new thoracic mycotic aortic aneurysms for which she was treated with thoracic endovascular aortic repair. Sequential abdominal and thoracic Streptococcal mycotic aortic aneurysms treated with a combination of open and endovascular surgery demonstrate a unique and rare case.

Endovascular Repair of Ruptured Infected Arteries as a Temporizing Measure Versus Destination Therapy.

OBJECTIVE: Mycotic rupture of the arteries is a rare but deadly disorder. Current management typically involves open surgical repair. However, endovascular repair is a potential treatment that can be used to delay open repair, especially in acutely unstable patients. A case report and review of the literature was conducted to determine whether endovascular therapy could be a destination therapy for patients with arterial rupture secondary to infection. METHODS: We present the case of a 72-year-old man with a left common iliac artery aneurysm rupture secondary to Salmonella infection treated with endovascular therapy upon initial presentation. A literature review of PubMed yielded 29 patients with ruptured aortic and iliac infected aneurysms that were initially treated with endovascular repair. RESULTS: Majority of the patients (76.7%, 23 of 30) were successfully treated with the endovascular treatment and did not require open revision. These patients were often placed on long-term antibiotics. CONCLUSION: The literature review supports endovascular repair with a stent graft as a temporizing measure for infected ruptured arteries in an emergent setting and, in select cases, as a destination therapy.

Chronic mesenteric ischemia after partial coverage of the celiac artery during TEVAR, case report, and review of the literature.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has emerged as a safe and effective alternative to open surgery for treatment of thoracic aortic aneurysms. It has recently been reported that stent-graft coverage of the celiac artery (CA) during TEVAR is associated with a low risk of acute mesenteric ischemia. However, the long-term effect of CA coverage on foregut perfusion is unknown. Here, we report the case of a patient who underwent TEVAR with partial coverage of the CA and subsequently developed symptoms of chronic mesenteric ischemia (CMI). She was successfully treated with CA stent placement. METHODS: Preoperative imaging included computed tomography (CT) angiography of the abdomen and conventional aortogram of a redo-TEVAR, revealing near complete coverage of the CA orifice. Endovascular repair was done using a 7 mm × 20 mm biliary balloon-expandable stent (Cook Medical Inc, Bloomington, IN). A review of the current literature for this rare problem was performed. RESULTS: Completion arteriography demonstrated successful revascularization of the CA without evidence of endoleak. Postoperatively, the abdominal pain was alleviated with early improved diet tolerance and weight gain. Follow-up CT at 6 month demonstrated widely patent CA. A PubMed review showed no reported cases of CMI secondary to CA coverage during TEVAR in the literature. CONCLUSIONS: CMI may develop with coverage of the CA during TEVAR. When other causes of abdominal pain and weight loss have been ruled out, revascularization of the CA can help alleviate the symptoms.

Middle aortic coarctation.

BACKGROUND: Middle aortic coarctation (MAC), a variant of middle aortic syndrome, is a rare entity with only ∼200 cases described in the literature. It classically presents with early onset and refractory hypertension, abdominal angina, and lower extremity claudication. Although endovascular repair has been described for focal stenoses, open bypass remains the standard to restore abdominal inflow and correct renovascular hypertension. METHODS: We describe an unusually late presentation of MAC in a 52-year-old man from El Salvador with refractory hypertension since age 8 requiring 5 antihypertensive medications. He presented with acute chest pain and severe hypertension. He denied mesenteric and peripheral vascular symptoms. Distal pulses were not palpable. Creatinine was 1.9 mg/dL (peak 4.0 mg/dL). Computed tomography angiography demonstrated coarctation of the descending thoracic aorta with extensive collateralization. RESULTS: After control of blood pressure, the patient's singular anatomy dictated a descending thoracic aorta-infrarenal aortic bypass using a 16-mm woven Hemashield tube graft via a left fifth-interspace anterolateral thoracotomy and left retroperitoneal incision. The graft was tunneled through the posterior left hemidiaphragm. Patient had excellent recovery, with decrease in antihypertensive medications (5 to 2), restoration of all distal pulses, and no neurologic complications. Postoperative creatinine was 0.9 mg/dL. CONCLUSIONS: MACs are rare entities with presentation usually in youth or adolescence, comprising only 0.5-2% of all aortic coarctation cases. Etiologies include congenital, acquired, inflammatory, and infectious causes. If untreated, most patients do not survive past the fourth decade because of the sequelae of renovascular hypertension including myocardial infarction, heart failure, intracranial hemorrhage, and aortic rupture. Depending on technical considerations, open surgical bypass remains the standard repair for MAC.