Endovascular Management of Superficial Femoral Artery Occlusion Secondary to Embolization of Celt ACD® Vascular Closure Device.

BACKGROUND This report describes the endovascular management of a Celt ACD® vascular closure device (VCD) lodged in the superficial femoral artery (SFA), 1 year after its deployment. There is a paucity of evidence in the existing literature regarding the management of complications related to embolized VCD discovered months or years after its deployment. CASE REPORT A 70-year-old male patient, who was a heavy smoker, presented with right lower-limb intermittent claudication of 2 months' duration. He underwent a successful left retrograde iliac artery and left SFA angioplasty 1 year ago. The right femoral pulse was normal, whereas the right popliteal pulse was absent. The right ankle-brachial index was 0.64. Doppler ultrasound showed evidence of mid-right SFA occlusion. Angiogram showed an embolized Celt ACD VCD in the right SFA causing segmental occlusion. An endovascular attempt to retrieve the embolized VCD via a snare failed, as the VCD got deeply embedded in the vessel wall. After successful balloon angioplasty, a stent was placed into the SFA with excellent angiographic and clinical outcomes. CONCLUSIONS This case demonstrates the risk of dislodgement of the VCD and its distal embolization with a risk of late ischemia. Endovascular retrieval may be unsuccessful for chronically embolized VCD. Therefore, stent angioplasty is an acceptable option.

Endovascular Management of May-Thurner Syndrome in a Patient with Left-Sided Superior Vena Cava: A Case Report.

BACKGROUND May-Thurner syndrome (MTS) is a condition characterized by compression of the left common iliac vein (LCFV) between the right common iliac artery (RCIA) and the lumbar vertebrae. This anatomical entrapment typically affects young women and is mostly asymptomatic. High index of suspicion is required in cases of recurrent left-sided deep vein thrombosis (DVT) and severe leg pain. We describe a case of MTS in a young male patient with a left-sided superior vena cava (LSSVC) that was successfully managed by an endovascular approach. To the best of our knowledge, the coexistence of MTS and LSSVC anomaly has not been reported previously. CASE REPORT A 31-year-old man presented with a history of left-sided iliofemoral deep vein thrombosis and disabling venous claudication of 2 years' duration. Duplex ultrasound and computed tomography venogram (CTV) revealed evidence of MTS with chronic subtotal occlusion of the left common iliac vein (LCIV) with extensive venous collaterals. Venogram via the left femoral vein puncture confirmed the aforementioned findings. Retrograde recanalization of the occluded segment was attempted without success. Therefore, an antegrade approach via the right internal jugular vein was performed to facilitate recanalization. Surprisingly, venography revealed an LSSVC. The occluded CIV was successfully stented and the patient had complete resolution of his symptoms at 22-month follow-up. CONCLUSIONS MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this coincidence is essential to prevent unwarranted mishaps during endovascular management when the jugular approach is used.

Laparoscopic approach to acute small bowel obstruction: review of 1061 cases.

BACKGROUND: Acute small bowel obstruction has previously been considered a relative contraindication for laparoscopic management. As experience with laparoscopy grows, more surgeons are attempting laparoscopic management for this indication. The purpose of this study is to define the outcome of laparoscopy for acute small bowel obstruction through an analysis of published cases. METHODS: A literature search of the Medline database was performed using the key words laparoscopy and bowel obstruction. Further articles were identified from the reference lists of retrieved literature. Only English language studies were reviewed. We excluded studies that included patients with chronic abdominal pain, chronic recurrent small bowel obstruction, or gastric or colonic obstruction, when the data specific to acute small bowel obstruction could not be extracted. Data was analyzed based on an intention to treat. RESULTS: Nineteen studies from between 1994 and 2005 were identified. Laparoscopy was attempted in 1061 patients with acute small bowel obstruction. The most common etiologies of obstruction included adhesions (83.2%), abdominal wall hernia (3.1%), malignancy (2.9%), internal hernia (1.9%), and bezoars (0.8%). Laparoscopic treatment was possible in 705 cases with a conversion rate to open surgery of 33.5%. Causes of conversion were dense adhesions (27.7%), the need for bowel resection (23.1%), unidentified etiology (13.0%), iatrogenic injury (10.2%), malignancy (7.4%), inadequate visualization (4.2%), hernia (3.2%), and other causes (11.1%). Morbidity was 15.5% (152/981) and mortality was 1.5% (16/1046). There were 45 reported recognized intraoperative enterotomies (6.5%), but less than half resulted in conversion. There were, however, nine missed perforations, including one trocar injury, often resulting in significant morbidity. Early recurrence (defined as recurrence within 30 days of surgery) occurred in 2.1% (22/1046). CONCLUSION: Laparoscopy is an effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity and early recurrence.