Massive Scrotal Hematoma due to Ruptured Anastomotic Pseudoaneurysm in a Patient with Aortobifemoral Bypass Surgery: CTA Evaluation.

A 74-year-old male patient was presented with scrotal swelling and a pulsatile mass of the left femoro-inguinal region. His medical history included hypertension, coronary artery disease, respiratory failure, and an aortobifemoral bypass surgery performed 7 years ago. Ultrasound evaluation revealed a massive scrotal hematoma. Computed tomography angiography (CTA) was conducted, confirming the aortobifemoral graft existence and revealing bilateral anastomotic pseudoaneurysms with the left one being ruptured, resulting in extension of the hematoma to the left femoro-inguinal region and the scrotum. An emergency surgery was performed, where proximal control of the left limb of the synthetic graft as well as distal control of the iliac vessels were accomplished. After the control of the hemorrhage, an iliofemoral bypass with a Polytetrafluoroethylene (PTFE) 6 mm synthetic graft was placed. Unfortunately, the patient passed away during the first postoperative day due to myocardial infarction.

Combined Type III and Type II Endoleaks after Endovascular Aneurysm Repair: Presentation of 2 Cases and a Literature Review.

Although endovascular aneurysm repair is a feasible option for high-risk patients resulting in lower perioperative mortality when compared with open repair, the need for reintervention and long-term follow-up affects its use. The aim of the current report is to present 2 cases of patients with type IIIa endoleak from limb disconnection (one patient with double-bilateral endoleak) combined with a late type II endoleak and symptomatic sac growth treated in our department. We also performed a literature review about type III endoleaks and their treatment options.

Thrombolysis in Acute Lower Limb Ischemia: Review of the Current Literature.

BACKGROUND: Catheter-directed thrombolysis (CDT) is a therapeutic option with acceptable results in patients with acute limb ischemia (ALI) but with severe systemic or intracranial bleeding being the most significant clinical complication. The aim of the study is to collect and present direct results of CDT in patients treated for ALI. METHODS: Reports on CDT treatment in ALI until December 2016 were searched in PubMed using the keywords catheter direct thrombolysis, acute lower limb ischemia, and any combination. RESULTS: A total of 256 clinical trials were identified. After the exclusion criteria were applied, 10 articles were selected including 1,249 patients and 1,361 lower extremities treated for ALI. Acute thrombosis of a limb artery or bypass graft was the main cause of ischemia ranging from 77.7% to 98.0%. The overall technical success rate of the applied method reached 79.3% (1,079 successful cases). Complications of any type occurred in 358 (28.7%) patients. Of them, 72 (20.1%) experienced a minor complication while 286 (79.9%) had a major life-threatening complication. The need for secondary interventions was 77.8% (935 patients). The death rate during the first month was 4.2% (56 patients), while the percentage of patients who suffered amputation because of a failed thrombolysis during the same period was 11.5% (156 patients). Finally, the survival rate without amputation within 30 days was 88.5% (1.105 out of a total of 1,249 patients studied). CONCLUSIONS: Results confirm the high direct technical success rate of CDT and the high percentage of patients survived without amputation within 30 days, although major complications are a great disadvantage of the method.

AAA Rupture and Psoas Hematoma due to Type II Endoleak from Inferior Mesenteric Artery "Unusual" Collaterals.

Although endovascular aneurysm repair (EVAR) in the abdominal aorta has reduced the perioperative mortality when compared with open repair, the need for reintervention after complications such as endoleak may be presented in up to 20% of the cases. Type II endoleak from branch vessels is often benign but can potentially be associated with progressive abdominal aortic aneurysm growth and sac expansion. We present a rare case of a patient who presented with sac expansion and psoas hematoma due to Type II endoleak from "unusual" collaterals of IMA and was treated successfully with endoleak microembolization and percutaneous decompression of the hematoma.

Acutely bleeding aortoduodenal fistula: staged endovascular and open surgical repair.

Secondary aortoduodenal fistula is an uncommon but potentially fatal complication that can occur after aortic reconstruction surgery and usually presents with upper gastrointestinal hemorrhage. Taking into account the accompanying multiple comorbidities of those patients, conventional open surgical repair carries with it significant mortality and morbidity rates. The purpose of this case report is to describe the successful combined endovascular and open surgical repair of an acutely ruptured aortoduodenal fistula in a 67-year-old male patient. Four months after the procedure, the patient remains well.

Surgical revision of complicated false and true vascular access-related aneurysms.

PURPOSE: This prospective observational study examined the effect of revision surgery in patients who present solely with complicated arteriovenous access (AVA)-related aneurysms. METHODS: The demographics and comorbid conditions of 44 hemodialysis access patients who presented with complicated true or false AVA-related aneurysms and underwent revision surgery during a 7-year period were prospectively entered into our AVA database. Also recorded were AVA characteristics before and after revision. Arteriovenous access anatomy was evaluated preoperatively using color Doppler ultrasonography, and AVA adequacy was assessed in all patients postoperatively after the first needle puncture and every month thereafter. Postintervention access function and primary patency rates were analyzed. Patency was evaluated using the Kaplan-Meier method and compared between groups of patients with different AVA characteristics before and after revision using the log-rank test. RESULTS: The cases of initial AVA with complicated aneurysms comprised 16 radiocephalic, 8 brachiocephalic, 2 basilic vein transposition, and 18 prosthetic fistulas (7 and 11 of the lower and upper arm, respectively), of which 42 were dysfunctional and 2 had thrombosed early at presentation. Primary indications for revision were danger of aneurysm rupture in 26, duplication in graft aneurysm diameter in 18, painful aneurysm in 12, stenosis due to partial aneurysm thrombosis in 12, shortness of the potential cannulation area in 12, aneurysm enlargement in 4, infected aneurysm in 2, and completely thrombosed aneurysm in 2. The mean postintervention primary patencies were 93%, 82%, 57%, and 32% at 3, 6, 12, and 24 months, respectively. The outcomes was better in autogenous than prosthetic corrections, in true than false aneurysms, in patients with two or fewer than more than 2 previous AVAs on revised arms, and in forearm than upper-arm corrections (P = .0197, P = .004, P = .0022, and P = .0225, respectively). CONCLUSIONS: Surgical revision of complicated false and true AVA-related aneurysms reveals acceptable postintervention primary patency rates and therefore is justified. This outcome measure was superior in the following specific groups of corrections: autogenous were better than prosthetic, true aneurysms were better than false aneurysms, patients with one or two previous AVAs in the revised arm were better than those with more than two previous accesses in the revised arm, and finally, forearms were better than those in the upper arm.

A meta-analysis of dialysis access outcome in elderly patients.

BACKGROUND: Many authors report inferior patency rates of distal arteriovenous fistulas in elderly patients and others present contradictory results. A meta-analysis of available evidence was performed to assess (1) whether non-elderly adults have the same risk of forearm arteriovenous fistula failure as elderly patients with end-stage renal disease and (2) whether such a distal access has the same risk of failure as more proximal access procedures or grafts in elderly patients. METHODS: A literature search was performed using the MEDLINE and SCOPUS electronic databases. The analysis involved studies that comprised subgroups of elderly patients and compared their outcomes with those of non-elderly adults. Articles comparing patency rates of radial-cephalic and proximal fistulas or grafts in elderly patients were also included. Thirteen relevant studies (all cohort observational studies, 11 retrospective) were identified and included in the final analysis. RESULTS: The meta-analysis revealed a statistically significantly higher rate of radial-cephalic arteriovenous fistula failure in elderly patients compared with non-elderly adults at 12 (odds ratio [OR], 1.525; P = .001) and 24 months (OR, 1.357, P = .019). The primary radial-cephalic arteriovenous fistula failure rate was also in favor of the non-elderly adults (OR, 1.79; P = .012). Secondary analysis revealed a pooled effect in favor of the elbow brachiocephalic fistulas that was statistically significant (P = .004) compared with distal fistulas in elderly patients. CONCLUSION: This meta-analysis found an increased risk of radial-cephalic fistula failure in elderly patients and significant benefit from the creation of proximal autologous brachiocephalic fistulas. If confirmed by further prospective studies, these differences should be considered when planning a vascular access in incident elderly patients.