Annals of vascular surgery. Brief reports and innovations最新文献

A 30-year-old male patient diagnosed leiomyosarcoma originating from level II of inferior vena cava (IVC). The tumor involved IVC, right renal vein, the confluence of left renal vein and IVC, and the dorsal part of pancreatic head. An enbloc resection was performed and multiviscera including involving IVC, right renal vein, the inferior wall of confluence of left renal vein and IVC, and pancreaticoduodenum were resected with tumor. To ensure the patency of the left renal vein and avoid serious vascular complications of vascular reconstruction after pancreaticoduodenectomy, a segment of distal IVC, as long as 2 cm, was excised to bridge right renal vein and the proximal end of IVC. The patient recovered smoothly after the operation. we named the strategy of vascular reconstruction as “sacrificing a rook to save the king.”

A Swan-Ganz catheter is an intravenous device used for the invasive measurement of pulmonary capillary wedge pressure and other cardiovascular measurements often utilized in major surgical procedures and critical care units. Several device-related complications were reported in literature - arterial puncture, pneumothorax, inadvertent arterial catheter insertion due to non-ultrasound-guided placement, and formation of knots. This paper presents a case of inadvertent left carotid artery insertion of a Swan-Ganz catheter, complicated by a knot formation requiring surgical intervention to successfully remove the catheter.

Fenestrated Branched Endovascular Aortic Repair (FBEVAR) typically requires placement of large sheaths into bilateral femoral arteries. However, for patients with hostile iliofemoral arteries due to small caliber, severe occlusive disease, or high tortuosity, various endovascular and open adjunctive techniques have been described. Here, we describe a case in which a femoral conduit was utilized to enable FBEVAR through a single access point, adding to the armamentarium of adjunctive access techniques.

Introduction

Gender dysphoria refers to the distress or discomfort experienced when a person's gender identity does not align with the sex assigned at birth. While many transgender individuals affirm their gender identity without surgical intervention, an increasing number undergo gender-confirming surgery. It is essential to recognize and promptly treat vascular complications that can arise during these procedures. There are no previous reports addressing arterial injuries during the implantation of penile prostheses for gender-confirming surgery.

Case presentation

A 33-year-old patient with gender dysphoria underwent female-to-male surgical interventions for gender confirmation. During the latest urologic procedure, which involved the implantation of a three-piece inflatable penile prosthesis, a vascular complication occurred, resulting in injury to the right common femoral artery. Given the extent of the injury and the difficulty in repairing the arterial wall, vascular surgeons resected the damaged artery segment and performed an end-to-end anastomosis. Intraoperative duplex ultrasound at the conclusion of the surgery showed a triphasic waveform in the distal vessels. The urologist decided to postpone the implantation of the penile prosthesis. The patient was discharged on the sixth postoperative day without systemic or local complications and was prescribed single antiplatelet therapy.

Conclusions

With the increasing number of transgender individuals seeking gender-affirming surgery, it is important to conduct a multidisciplinary preoperative evaluation to minimize complications that could affect their quality of life.

The anomalous origin of the left vertebral artery from the aorta is the second most common anatomical alteration of the aortic arch. We present a case of a patient with a descending thoracic aortic aneurysm and an anomalous origin of a dominant left vertebral artery. The artery was treated by transposition to the left common carotid artery via a cervical approach, followed by endovascular correction of the thoracic aortic aneurysm using a subclavian branched thoracic endoprosthesis. The patient had a good postoperative recovery with complete occlusion of the aneurysm and patency of the carotid-vertebral shunt and left subclavian artery.

We report the case of a 66-year-old man diagnosed with multiple pulmonary angiosarcomas 4 years post-endovascular aneurysm repair (EVAR). The patient was healthy with a good postoperative course, besides requiring additional coil embolization for a lumbar artery type 2 endoleak (T2EL) 3 years post-EVAR. He presented to the emergency department with sudden respiratory distress and severe anemia. Computed tomography (CT) revealed multiple pulmonary nodules bilaterally. Thoracoscopic pulmonary nodule resection and pathological examination revealed angiosarcoma. The condition progressed rapidly, and the patient died 17 days post-admission. Postmortem pathological analysis demonstrated angiosarcomas of the primary residual aneurysmal mass post-EVAR, inferior vena cava invasion adjacent to the mass, and multiple pulmonary metastases bilaterally. Findings suggestive of angiosarcoma were found 6 months post-T2EL coil embolization when reviewing the annual positron emission tomography CT. We suspect that irradiation during T2EL treatment post-EVAR may have triggered angiosarcoma development. To the best of our knowledge, this is the first study to evaluate the relationship between T2EL and angiosarcoma.

Introduction

Chronic Limb-Threatening Ischemia (CLTI) represents a severe form of peripheral arterial disease characterized by ischemic rest pain, non-healing wounds, and/or gangrene. Deep Venous Arterialization (DVA) is an option when there is inadequate distal inline flow to allow for wound healing (No Option CLTI). There is a paucity of data on DVA; which prompted our interest in presenting our experience with DVA.

Methods

We performed a retrospective review on all patients undergoing DVA from January 2022 through February 2024. The procedure was indicated for patients with CLTI as a last resort for limb salvage. Patient demographics, surgical techniques, and postoperative variables were recorded. Outcomes included were mortality, time to wound healing, minor and major amputations. All other operative complications were also recorded.

Outcomes

There were eleven patients with a total of thirteen DVAs performed. Two DVAs were performed on the same limb. The mean age was 67.4 ± 11.3 years, with seven patients (63.6 %) being male. Comorbidities included were hypertension in nine (81.8 %), coronary artery disease in seven (63.6 %), hyperlipidemia in six (54.5 %), and type 2 diabetes mellitus in three (27.3 %) patients, respectively. At a median follow-up of 112.5 days (range: 76- 742 days), limb salvage was achieved in eight (66.7 %) and complete wound healing in four limbs (33.3 %). Seven (58.3 %) limbs required minor amputations. Four (33.3 %) limbs required major amputation including two (16.7 %) due to occluded bypass and two (16.7 %) due to uncontrolled infection. Two (18.2 %) deaths were recorded during the follow-up period.

Conclusion

DVA has acceptable short outcomes with good limb salvage and wound healing rates. Timing to achieve mobility with associated deconditioning, quality of life, and cost are areas to be explored in larger studies in comparison to those patients undergoing primary amputation with immediate rehabilitation.

Objective

Transcarotid artery revascularization (TCAR) has emerged as a safe and effective method for carotid revascularization, offering several key advantages over carotid endarterectomy (CEA) and carotid artery stenting (CAS). Intraoperative transcranial Doppler (TCD) monitoring plays a pivotal role in assessing cerebral hemodynamics and detecting embolic signals during TCAR at our institution.

Methods

This review synthesizes the current literature and provides guidance for TCD monitoring throughout the various phases of TCAR, from preoperative assessment to postoperative management. Key considerations include probe placement, waveform evaluation, interpreting monitoring parameters such as mean flow velocity (MFV), pulsatility index (PI), and percentage change in the MFV (Δ%). Techniques for maintaining the insonation of the middle cerebral artery (MCA) M1 segment and optimal parameter settings for intraoperative TCD monitoring are detailed.

Results

TCAR phases are highlighted, including transcarotid access and vessel control, sheath insertion, the establishment of flow reversal, pre-dilation, stent placement, post-dilation, and closure, while emphasizing the importance of real-time feedback provided by TCD monitoring in identifying embolic signals and assessing changes in cerebral perfusion. The review discusses limitations of TCD monitoring, such as inadequate temporal windows, incorrect vessel identification and reliability issues with automatic emboli detection counters. Furthermore, practical advice is provided on how to navigate common pitfalls encountered during intraoperative TCD monitoring.

Conclusion

By understanding the nuances of TCD monitoring and its application in TCAR, intraoperative TCD monitoring may aid to minimize the low but potential risk of intraprocedural embolic events, periprocedural hypoperfusion and postoperative hyperperfusion. Finally, we suggest opportunities for further research in embolization quantification and additional strategies to optimize quality control in TCAR.

Occluded aortobifemoral (ABF) bypass grafts in multilevel peripheral artery disease pose a complex challenge. A 52-year-old female with prior ABF grafting and recent large ventral hernia repair presented with tissue loss and bilateral graft limb occlusion. Thrombectomy and angioplasty of the graft limbs with deployment of elevated covered stent grafts and bilateral common femoral artery (CFA) endarterectomy initially improved flow. However, thrombosis of graft limbs necessitated two successive re-interventions. Extension stent angioplasty converted the previous end-to-side configuration into an end-to-end, addressing progression of proximal progression of disease maximizing distal flow dynamics. Postoperative workup revealed antiphospholipid antibody positivity. Subacute ABF graft occlusion can be managed endovascularly in the setting of a hostile abdomen.

Central venous access is one of the most commonly performed medical procedures, requested often to initiate chemotherapy or hemodialysis. Duplicate superior vena cava (SVC) or left sided SVC are rare venous anomalies, more often seen in patients with congenital cardiac issues. Most patients are asymptomatic and the anomaly is an incidental finding at time of catheter placement. This case report presents a duplicate superior vena cava discovered when attempting Mediport placement under fluoroscopy for chemotherapy. Clinical awareness and recognition of this rare venous anomaly is important because it can lead to life threatening events.