Hybrid approach to management for a patient with culture negative infective endocarditis with profunda femoris mycotic pseudoaneurysm: A case report and review of the literature.

Mycotic pseudoaneurysms can be a serious and life threatening complication of left sided infective endocarditis. They most commonly affect the major axial vessels. Profunda femoris artery (PFA) aneurysms are rare and present in only 0.5% of all peripheral aneurysms, regardless of the underlying etiology. We present a case of a patient who underwent mitral valve repair for severe mitral regurgitation secondary to culture negative IE which was complicated by multiple mycotic pseudoaneurysm. The PFA pseudoaneurysm which was affected and was complicated with a large hematoma compressing the femoral nerve. This was managed by a staged hybrid approach. Endovascular stenting was performed first to seal the pseudoaneurysm and facilitate open surgical repair using a reversed interposition saphenous vein graft. To the best of our knowledge, this is the first reported case of a PFA mycotic aneurysm (MA) being managed by a hybrid approach using endo-vascular and open surgical repair. MAs and pseudoaneurysms are complex and life threatening conditions requiring meticulous planning for optimal management. Endovascular stenting can be considered as an alternative to surgical management in certain cases or as a bridge to definitive open surgical repair depending on anatomical location and associated complications.

Carotid Body Tumor with Skull Base Extension.

BACKGROUND Carotid body tumors are rare tumors that arise from the paraganglionic cells of the carotid body. They are usually benign, requiring surgical resection as the treatment of choice. CASE REPORT We present a case of a 59-year-old man with a benign left carotid body tumor that progressed to a very large size, compromised the patient's airway, completely encased the carotid vessels, vagus and hypoglossal nerves ipsilaterally, and reached the contralateral carotid vessels and ipsilateral skull base. Because of the cranial extension of the tumor, the patient had to undergo preoperative endovascular coiling of the carotid vessels prior to total excision of the tumor. CONCLUSIONS Due to the critical location of carotid body tumors, their vascularity, and high risk of neurovascular complications, surgical resection can be quite challenging, especially when the tumor is large. We propose an approach to managing large parapharyngeal tumors by endovascular occlusion of the internal carotid artery above the skull base. Further, a suggestion is made to add a category to Shamblin's classification - Shamblin IV - for patients with skull base extension requiring preoperative endovascular intervention.

Prevalence and Correlates of Lower-Extremity Amputation in Patients With Diabetic Foot Ulcer in Jeddah, Saudi Arabia.

This cross-sectional study investigated the prevalence and correlates of lower-extremity amputation (LEA) in a Saudi population with diabetic foot ulcer. The study population consisted of 91 participants, with a median age of 55.0 years. Biomarkers were measured following standard protocols. Local symptoms of foot ulcer, including peripheral neuropathy (PN), peripheral artery disease (PAD), and foot infection were diagnosed by standard objective diagnostic tools or diagnosed clinically by a specialized surgeon. The severity of foot ulcer was classified according to the Wagner wound classification system. The prevalence of LEA was 29.7% in this population. The odds ratio for LEA comparing extreme tertiles was 2.42 (95% confidence interval [CI] = 0.70-8.45; P for trend = .03) for ulcer size and 0.22 (95% CI = 0.06-0.87; P for trend = .03) for high-density lipoprotein cholesterol. C-reactive protein and homocysteine levels were each positively associated with odds of LEA, but the associations became nonsignificant in multivariable models. Participants with foot infection showed a significantly higher adjusted prevalence of LEA (40.7%, 95% CI = 27.1%-54.3%) compared with those without foot infections (19.3%, 95% CI = 6.0%-32.4%, P = .03). Participants with Wagner grade ≥3 presented a significantly higher prevalence (40.5%, 95% CI = 27.8%-53.2%) than those with Wagner grade of 1 or 2 (16.4%, 95% CI = 2.4%-30.5%, P = .02). Participants with PN and PAD showed nonsignificantly higher prevalence of LEA. We found a relatively high prevalence of LEA as well as several clinical markers and local symptoms associated with LEA in this Saudi population with diabetic foot ulcer.

Development of stroke-induced quadriplegia after endovascular repair of blunt aortic injury pseudoaneurysm.

Endovascular repair of blunt aortic injury is now a first-line approach in management. This can warrant coverage of the left subclavian artery (LSA), which could lead to posterior strokes. In this case report, we present a severe complication of endovascular repair of a traumatic aortic aneurysm. A 53-year-old man presented with blunt aortic injury, endovascular repair was carried out where the left subclavian artery was covered. The intervention had a 100% technical success. Twelve hours later, he was discovered to have quadriplegia, a CT scan showed a large left cerebellar infarction extending to the medulla oblongata and proximal spinal cord. Strokes complicate 3% of thoracic endovascular aortic repairs, 80% of those strokes occur in patients who had their LSA`s covered. Most patients however, tolerate the coverage. Although our patient had a dominant right vertebral artery, and lacked risks for these strokes, he developed an extensive stroke that left him quadriplegic.