Myasthenia Gravis and Abdominal Aortic Aneurysm: A Rare Combination.

Abdominal aortic aneurysm in a patient with myasthenia gravis (MG) is extremely rare. We present a 64-year-old male with MG and an asymptomatic abdominal aortic aneurysm treated endovascularly. After extubation, he suffered a cardiac arrest due to an acute myocardial infarction. Cardiopulmonary resuscitation and a primary coronary angioplasty led to a satisfactory outcome. Special care is needed due to higher rates of postoperative complications in these patients.

FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY.

Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.

Endovascular Repair of an Inflammatory Abdominal Aortic Aneurysm Combined with a Congenital Pelvic Kidney: Case Report and Literature Review.

The coexistence of an abdominal aortic aneurysm and a congenital pelvic kidney is extremely rare. We present a 66-year-old male with an inflammatory aneurysm and an aberrant origin of the superior mesenteric artery. The inflammatory infrarenal abdominal aortic aneurysm with a congenital left pelvic kidney was successfully treated with endovascular repair. Coverage of one out of the two renal ectopic arteries was performed, without clinical evidence of renal function impairment.

Treatment options for dialysis access steal syndrome.

Vascular access-induced limb ischemia is a known complication of arteriovenous fistulas and grafts. Many techniques have been adopted to prevent steal in high-risk patients and to treat steal in cases of moderate ischemia not controlled with conservative management. A major factor guiding treatment is access flow volume. Management is different when ischemia is combined with the excessive flow in contrast to the combination with normal flow. We describe the most popular techniques encountered in the English literature as a part of a stepwise approach to treating dialysis access steal syndrome. In absence of ischemia, when cardiac issues emerge due to extreme access flow volumes, some of these techniques are also used to decrease flow and protect the heart. Patient's history, focused clinical examination, color duplex ultrasound examination, pulse oximetry and an angiogram are essential tools to approach this entity.

Endovascular Juxtarenal Aortic Aneurysm Repair Using the ALTO Abdominal Stent Graft System: The First Case Series.

The ALTO abdominal stent graft system (Endologix Inc., Irvine, CA, USA) is a latest-generation polymer-based device used to treat patients with abdominal aortic aneurysms. The present study describes the first case series of patients with abdominal aortic aneurysms, including two patients with juxtarenal aneurysms, treated using the ALTO stent graft system. Six males were treated using the ALTO device at a single public center. All procedures were uneventful, and the dosimetric results recorded in terms of kerma-area product and fluoroscopy time were similar to those reported in previous studies. At the 1-month follow-up, computed tomography angiography showed no evidence of endoleak, device migration, thrombosis, or structural graft failure. This clinical series demonstrates that the use of the ALTO stent graft system is associated with promising patient outcomes. Lifelong postoperative imaging surveillance may highlight possible late failures and suggest potential graft improvements.

A case report of surgical repair of a post-catheterization radial pseudoaneurysm.

We report an 83-year-old patient with a huge post-catheterization right radial pseudoaneurysm, presented 17 months after a coronary angiography. Cases of radial post-catheterization pseudoaneurysms with a similar size are scarce in the literature. Delay in presentation led to painful skin ischemia due to tension, a sign of imminent rupture, which is also rare in the literature. Symptomatology included severe wrist pain and clinical signs consisted of a pulsatile painful mass in the right distal forearm. Management consisted of surgical excision and ligation of the radial artery in an urgent base. This case emphasizes the need for early diagnosis and management of post-catheterization pseudoaneurysms as delay may lead to severe enlargement with skin necrosis and imminent rupture. Ligation of the radial artery is an acceptable option when reconstruction of the artery is troublesome, provided that the palmar arch remains patent.

Treatment of Dialysis Access Steal Syndrome with Concomitant Vascular Access Aneurysms.

Limb ischemia is a known complication of vascular access that may appear early postoperatively or after years. Over the last few decades, various techniques based on different physiological mechanisms have been used for treatment. A standardized treatment does not exist, and must be individualized based on the flow volume, and the type and location of the access. True and false vascular access aneurysms are another common complication of arteriovenous fistulas, which develop because of venous hypertension or repeated needling. Evidence in the literature regarding treatment of patients with steal syndrome and concomitant true arteriovenous aneurysms is scarce. A female with a brachiocephalic fistula complicated by steal syndrome and vascular access aneurysms was treated successfully with tapered graft placement and aneurysm exclusion.

Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy.

A 75-year-old male presented with an immediately threatened grade IIb acute ischemia of the left leg due to thrombosis of a femoro-infrapopliteal prosthetic bypass graft. After an urgent Computed Tomography Angiography, an urgent graft thrombectomy was performed using a 5 Fr Fogarty catheter, which had a troublesome distal passage, causing a tibial A-V fistula.

Custom-Made Bifurcated Prosthetic Graft for Aortoiliac Aneurysm Repair.

Revascularization of the internal iliac artery during open repair of aortoiliac aneurysms can be challenging, especially if there is a significant distance between the orifices of the internal and external iliac arteries owing to common iliac aneurysmal dilatation. We describe a technique involving insertion of an 18-mm tube graft between the proximal aortic neck and aneurysmal common iliac artery bifurcation. Revascularization of the contralateral external iliac artery is accomplished through an 8-mm side arm graft.

Free-Floating Thrombus in the Distal Internal Carotid Artery Causing a Stroke.

We present a patient suffering from a stroke with a free-floating thrombus extending up to the distal internal carotid artery. The thrombus was totally resolved after a 2-week anticoagulation regimen without leaving behind any severe residual stenosis in the carotid bulb. The optimal treatment of this rare condition remains uncertain. We report some important treatment strategies that have been used in the literature, emphasizing the anticoagulation as the mainstay of therapy. Immediate surgical and interventional manipulations carry the risk of thrombus dislodgement and embolization and should be considered if there are recurrent symptoms despite medical management.

Long-term results of a prospective comparison of Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population (BMI 35-50 kg/m(2)).

BACKGROUND: This study presents late results of a previously published 2-year prospective comparison between Roux-en-Y gastric bypass (RYGBP) versus biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) in an exclusively non-superobese population. METHODS: From a cohort of 130 patients with a BMI of 35-50 kg/m(2), 65 were randomly selected to undergo RYGBP and 65 to BPD-RYGBP. All underwent follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. RESULTS: Follow-up at the eighth year was achieved in 60% of the BPD-RYGBP and in 58% of the RYGBP group (p = 1.00). Mean excess weight loss (EWL%), was significantly higher following BPD-RYGBP (76.89 ± 1.53) as compared to RYGBP (67.17 ± 1.43) (p = 0.0004). The mean success rate (percentage of patients with EWL% ≥50%) was significantly higher after BPD-RYGBP (95.85 ± 1.01) than RYGBP (75.91 ± 3.58) (p = 0.0001). No significant differences were observed for late non-metabolic complications. The incidence of anemia, iron deficiency, B12 deficiency, and low-ferritin levels was relatively high in both groups with not always significant differences. Severe protein malnutrition occurred in four patients (three BPD-RYGBP and one RYGBP) (p = 0.37). In only one BPD-RYGBP patient (1.54%) was revision surgery to RYGBP necessary, due to recurrent episodes of hypoproteinemia. The remaining patients were treated successfully with total parenteral nutrition and nutritional counseling. CONCLUSIONS: Late results presented in this paper agree with the previously published 2-year results of the same patient cohort. Although both procedures are safe and effective, BPD-RYGBP seems to prevail in terms of successful weight loss without a significantly higher incidence of metabolic and non-metabolic complications.