Internal iliac artery aneurysm in a patient with proximal occlusion at its origin.

We present the case of an 87-year-old man with a ruptured right internal iliac artery aneurysm with hemoperitoneum. The right internal iliac artery aneurysm appeared to fill from the retrograde profunda femoris artery in the setting of a previously repaired abdominal aortic aneurysm with aorta-bi-iliac bypass with ligation of the bilateral internal iliac arteries. Abdominal computed tomography revealed an aneurysm of the right internal iliac artery measuring 8.9 cm, with filling through the collateral vessels. Open repair was performed, leading to complete exclusion of the aneurysm with no perioperative complications.

Aortoenteric Fistula through a Thrombosed Graft.

BACKGROUND Aortoenteric fistula is a dreadful and uncommon complication after abdominal aortic aneurysm repair. Continuous friction against the intestine and the aortic graft along with local inflammation is thought to be the major cause of aortoenteric fistula formation, although it is unexpected to have fistula formation with a thrombosed aortic graft. CASE REPORT Here, we report a case of an aortoenteric fistula between a thrombosed aortoiliac bypass graft and the duodenum in a 75-year-old male patient who presented with a 2-month history of melena. In this case, the aortoduodenal fistula was repaired with excision of the aortic graft, proximal and distal oversewing of the aorta, omental flap coverage, pyloric exclusion and loop gastrojejunostomy creation. CONCLUSIONS An aortoenteric fistula can form through a thrombosed graft. Since this is not an expected route of fistula formation, there may be a delay in identification.

Outcomes of endovascular treatments for in-stent restenosis in patients with mesenteric atherosclerotic disease.

OBJECTIVE: Mesenteric angioplasty and stenting (MAS) has surpassed open revascularization as the treatment of choice for mesenteric ischemia. Despite the lower perioperative mortality associated with MAS, the need for reintervention is not infrequent. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR). METHODS: Clinical data from a single center between 2004 and 2017 were retrospectively analyzed. Standard statistical analysis including Kaplan-Meier estimate for time-dependent outcomes, χ2 test for categorical variables, and two-sample t-test for continuous variables was performed. Primary end points included stent patency and reintervention rate. Secondary end points included mortality and morbidity. RESULTS: During the study period, 91 patients underwent primary MAS. In total, 113 mesenteric vessels were treated with 20 covered stents and 93 bare-metal stents. Overall primary patency was 69% at 2 years. At 2 years, primary patency was 83% for covered stents compared with 65% for bare-metal stents (P = .17). Of these 91 primary MAS patients, 27 (30%) were treated for MAISR (32 vessels). Two covered stent patients developed significant restenosis (11%) compared with 25 (34%) bare-metal stent patients (P = .02). The mean age of patients requiring reintervention was 69 years (36% male), with the majority having a history of tobacco use (85%), hypertension (75%), and hyperlipidemia (78%). Fourteen reintervention patients (52%) presented with recurrent symptoms, 10 (37%) had asymptomatic restenosis, and 3 (11%) developed intestinal ischemia. Twelve patients (44%) underwent reintervention with balloon angioplasty alone and 15 (56%) underwent repeated stent placement. Of the 15 patients who had repeated stent placement, 7 patients had covered stents placed. The 30-day mortality rate after reintervention for mesenteric stent restenosis was 0%. Postoperative complications occurred in 15% of patients (myocardial infarction, 4%; reversible kidney injury, 4%; and bowel ischemia requiring surgical exploration, 7%). There was no difference in the perioperative morbidity in comparing symptomatic and asymptomatic patients undergoing reintervention. Mean follow-up after mesenteric reintervention was 31 months, with one-third of patients (n = 9) requiring another reintervention because of either recurrence of symptoms or asymptomatic high-grade restenosis. Assisted primary patency at 2 years was 92% after reintervention with balloon angioplasty and 87% for repeated stent placement, with no statistically significant difference between the groups (P = .66). CONCLUSIONS: Treatment of MAISR is associated with low mortality and acceptable morbidity. The initial use of covered stents may reduce the need for reintervention.

Adductor canal compression syndrome in an 18-year-old female patient leading to acute critical limb ischemia: A case report.

BACKGROUND: Adductor canal compression syndrome is a rare non-atherosclerotic cause of arterial occlusion and limb ischemia. PRESENTATION OF CASE: The patient is an 18-year-old healthy female who presented to the emergency department with acute left lower extremity ischemia. Her symptoms began as sudden onset mild foot pain approximately two months ago. Over the 72h prior to presentation, she developed severe pain, pallor, paralysis, loss of pedal pulses, paresthesia, and poikilothermia. Due to her advanced ischemia, she was taken immediately to the operating room for angiography and intervention. Initial angiography demonstrated distal superficial femoral and popliteal artery occlusions along with lack of tibial or pedal artery blood flow. She underwent percutaneous mechanical thrombectomy and initiation of catheter directed thrombolysis. After 48h of catheter directed thrombolysis and repeat mechanical thrombectomy, computed tomography (CT) was performed and demonstrated external compression of the superficial femoral artery in the adductor canal and residual chronic thrombus. Echocardiography and CT of the thoracic aorta was also performed, and were negative, therefore excluding other potential sources of arterial embolism. She next underwent surgical exploration, division of an anomalous musculotendinous band compressing the left superficial femoral artery and thromboendarterectomy of the distal left superficial femoral artery. The patient recovered well without any post-operative complications and could return to her daily activities 3 weeks following surgery. CONCLUSION: Knowledge of rare non-atherosclerotic vascular disorders, such as adductor canal compression syndrome, is paramount when treating patients who present with limb ischemia and lack traditional risk factors.

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report.

BACKGROUND: Emergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch. PRESENTATION OF CASE: The patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore® TAG® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion. CONCLUSION: Right-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.