Mechanical aortic valve may no longer be a contraindication to inner branch aortic arch endografts.

OBJECTIVES: The presence of a mechanical aortic valve has been a contraindication to the use of an arch branch aortic endograft due to the risk of damaging the valve, resulting in acute aortic regurgitation, or a trapped endograft. METHODS: We present a 67-year-old woman, with a background of Marfan's syndrome and a previous Bentall's procedure, who presented with a symptomatic enlarging aortic arch and descending thoracic aortic aneurysm, with a type 1A endoleak. RESULTS: Using an inner branch arch endograft (Cook Medical, Bloomington, Indiana), the nose cone of the delivery system was passed laterally through the semi-circular aperture of the mechanical aortic valve to facilitate deployment just distal to the coronary buttons. CONCLUSIONS: With advancement of endovascular technology, techniques and experience, endovascular aortic arch repair in the presence of a mechanical aortic valve is feasible.

Novel modification of a branched arch endograft with a retrograde left common carotid branch for acute pseudoaneurysm post type A repair.

OBJECTIVE: Pseudoaneurysm formation post type A aortic dissection repair is rare. Revision surgical repair is challenging, with a risk of death from haemorrhage. METHODS: We present a 56-year-old man who presented with a rapidly enlarging distal ascending aortic anastomotic pseudoaneurysm following a recent ascending and hemiarch replacement for acute type A aortic dissection. RESULTS: A tight kink in the ascending aortic graft precluded an endovascular repair utilizing two antegrade branches, and so a novel custom-made 3 inner branched aortic endograft was designed, with an antegrade brachiocephalic inner branch and retrograde left common carotid and subclavian artery inner branches. The patient required an angioplasty to dilate the kinked/coarcted surgical graft, but made an uneventful recovery. CONCLUSION: An aortic arch inner branch design with an antegrade brachiocephalic branch but retrograde left common carotid and left subclavian branches was feasible and may prove particularly useful when there is limited space in the ascending aorta.

An open approach to a ruptured common iliac artery aneurysm with resultant ilio-iliac arteriovenous fistula.

OBJECTIVE: Presentations of a spontaneous ilio-iliac arteriovenous fistula are considered a rare occurrence and warrant urgent intervention. They are usually a result following trauma, previous surgery or uncommonly from a ruptured aneurysm. METHOD: We describe a case of a patient presenting with general malaise who examined to have a pulsatile abdominal mass with an associated bruit. He was found to have an ilio-iliac arteriovenous fistula secondary to a ruptured iliac aneurysm that was treated successfully with open surgical repair. RESULT: The patient was brought forward for open surgical repair due to haemodynamic instability as well as likely predicted difficulties with endovascular repair. Intra-operatively, his sigmoid colon was adherent to the aneurysm prompting the need for a Hartmann's procedure to allow for better visualisation of the aneurysm. A combination of external digital compression and Prolene suture was used to close the arteriovenous fistula. CONCLUSION: Open surgical repair of an ilio-iliac arteriovenous fistula secondary to a ruptured iliac aneurysm appears to be safe and feasible approach. The advancement of medical technology does open up the possibility of an endovascular approach; however, in a small subset of patients, open repair would appear to be better.

Outcome of acute hospital admission for non-specific low back pain: what is the role of MRI?

BACKGROUND: Low back pain is a common worldwide condition, affecting most people during their lifetime. Various imaging modalities are being used to assist clinicians in diagnosing and thus, aid in formulating a suitable management plan. Extensive research has been carried out in assessing this condition due to its high prevalence, with many guidelines published internationally. AIM: To determine whether MRI imaging influences the management of patients admitted with acute, non-specific low back pain between 1 January 2013 and 31 December 2015. METHOD: A total of 209 patients who met the inclusion criteria were included in the study. Suitable patients were initially identified from the ward admission book. Subsequently, relevant data regarding patient admission and management within the two-year period were obtained from the hospital patient management system, including radiology reports. RESULTS: Out of the 209 patients included in this study, 131 patients (63%) had an MRI as part of the diagnostic process. Most patients were managed non-operatively with only 41 (20%) out of the 209 patients having undergone acute surgery while an inpatient. In this subgroup, 38 had an MRI done prior to surgery. Among the 168 patients who were treated non-operatively, including epidural steroid injection, 13 patients (8%) had elective surgery within one year from their initial presentation. CONCLUSION: Use of MRI can aid in the early diagnosis and facilitate faster rehabilitation for patients. It can also potentially reduce patient stay in hospital and result in significant cost savings for the healthcare system. Imaging guidelines should be developed in the assessment of patients with low back pain in an acute hospital setting.