Complex aortic-arch pseudoaneurysm with aorto-innominate vein fistula in a case of traumatic chest injury.

A patient in his late 30s presented with issues of retrosternal chest pain and palpitations. He had sustained a splinter injury to the left hemithorax a year ago for which he had been managed with a tube thoracostomy. During subsequent evaluations, he was found to have atrial fibrillations and a CT angiography revealed an arch of the aorta pseudoaneurysm with a fistulous communication with the innominate vein, which being a rare condition has no established treatment protocols. Endovascular salvage of the condition required an aortic Ishimaru zone 2 deployment of the thoracic endovascular aortic repair stent graft to provide an adequate landing zone. The elective left subclavian artery revascularisation was obtained by a left carotid artery to left subclavian artery bypass. Post procedure there was complete exclusion of the pseudoaneurysm sac, and the fistulous aorto-venous communication inflow tract. The patient recuperated well and has returned to full active duties.

Carotid Body Tumor: A Case Report and Review of Literature.

Carotid body tumour (CBT) is a rare hypervascular tumor in the head and neck region. It develops from neural crest origin paraganglionic tissue which is an arterial chemoreceptor. It presents as a slow growing mass at the carotid bifurcation. Its optimal evaluation and treatment requires involvement of multiple specialities. Because of the high rate of neurovascular complications, resection of this tumor is challenging for surgeons. Early tumor detection, meticulous evaluation and multidisciplinary approach are vital for successful management of these tumors. A case of CBT in a 50 year-old lady managed at our centre is being reported here along with a review of literature.

Dual mutation (MTHFR A1298C with PAI (4G) mutation) manifesting with bilateral lower limb gangrene in a neonate.

Neonates are at highest risk of thrombosis among paediatric patients. The relative prothrombotic state in a well neonate is compensated by other factors preventing spontaneous thrombosis; however, in a neonate with genetic predisposition, the balance is tilted predisposing them to a life-threatening thrombotic episode. We describe a rare case of methylenetetrahydrofolate reductase A1298C (homozygous) mutation along with plasminogen activator inhibitor (4G) mutation in a neonate who developed bilateral lower limb gangrene following thrombosis of the iliac vessels without any triggering factor. The neonate underwent thrombectomy as debulking measure along with thrombolytic therapy followed by unfractionated heparin and low-molecular-weight heparin which is still being continued along with oral aspirin. The neonate had to undergo amputation of both the involved lower limbs in view of dry gangrene. This case highlights that the dual mutations causing the prothrombotic state predispose the individual to the spontaneous life-threatening thrombotic episode as compared with the single mutation.

Medical therapy versus TEVAR for uncomplicated type B aortic dissection.

The standard of care in uncomplicated acute type B aortic dissection (uTBAD) has been optimal medical management. Surgical repair and endovascular interventions are adjuncts in managing complicated type B dissection. Increasing safety and confidence in the thoracic endovascular aortic repair (TEVAR) and recent data indicating long-term complications in medical management of uTBAD has brought a shift in treatment approach. TEVAR at best remains controversial, yet there is a subset, which will definitely benefit from intervention.