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

Iliac arteriovenous fistula is a rare vascular disease defined as the formation of an abnormal channel between the iliac artery and vein. The high mortality rate associated with an iliac arteriovenous fistula resulting from a ruptured iliac arterial aneurysm necessitates early diagnosis and timely, appropriate management.

We report a case of an 86-year-old man presenting with lower limb pain and edema. Computed tomography angiography demonstrated a large internal iliac artery aneurysm with a fistula to the adjacent vein. Symptoms resolved once a hybrid repair was performed.

Objective

There are various techniques for additional placement of Gore Excluder Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, AZ) for common iliac artery aneurysms following endovascular aneurysm repair (EVAR). However, these techniques do not always allow for the placement of approved, dedicated, self-expanding stent grafts (SESGs), such as internal iliac components, for internal iliac artery bridging. Here, we introduce the “U-turn Dryseal sheath technique,” which can successfully place SESGs using only a unilateral femoral approach.

Method

We inserted a modified 16-Fr Gore Dryseal Flex Introducer sheath (Dryseal sheath) and placed an iliac branch component. Then, we inserted a 12-Fr Dryseal sheath (33 cm) into a 16-Fr sheath and created a U-turn shape of the 12-Fr sheath toward the internal iliac artery portion using an ipsilateral U-turn wire. Next, we placed the SESG through the 12-Fr sheath via the shortest route.

Results

We used this technique to perform IBE placement following EVAR in eight cases and successfully placed the SESGs in all cases without any type Ⅰ or Ⅲ endoleaks.

Conclusion

The U-turn Dryseal sheath technique allows the stable additional placement of IBE with approved SESGs for internal iliac artery bridging in selected cases.

Objective

Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass/antegrade angioplasty and stenting in patients with acute and chronic mesenteric ischemia. We present a case and literature review utilizing ROMS in a patient with severe vascular occlusive disease to treat her superior mesenteric artery (SMA) stenosis.

Case report

A 63-year-old woman with a history of severe vascular occlusive disease and previous extensive surgical interventions required ROMS due to SMA stenosis for acute on chronic mesenteric ischemia. There were no in-hospital complications. We also performed a review of the literature to assess the technical success and clinical outcomes of ROMS.

Results

A total of six articles with 210 patients (92 males, 118 females) were included. In the studies where the celiac artery and SMA were implicated, technical success was 92.9%, conversion to bypass was 4.3%, and 30-day mortality was 29.5%. In the studies where only the SMA was implicated, technical success was 90.7%, conversion to bypass was 7.2%, and 30-day mortality was 23.7%. In cases of acute mesenteric ischemia, the 30-day mortality rate was 34.2%.

Conclusion

Though open surgical bypass and antegrade endovascular angioplasty and stenting have been the first-line treatment options for mesenteric ischemia, ROMS is an excellent alternative option with a high technical success rate that can be utilized when conventional treatment modalities are not technically feasible or in the setting of concomitant open abdominal exploration for the assessment of bowel ischemia.

Successful thoracic endovascular aortic repair (TEVAR) for type B aortic dissections (TBAD) relies on securing the stentgraft's distal landing zone to prevent retrograde flow and false lumen pressurization. We describe a 60-year-old male with a TBAD undergoing TEVAR with electrocautery-wire fenestration of the dissection septum, providing a controlled method to enhance the distal landing zone for graft placement. Postoperatively, the patient experienced spinal cord ischemia, resolving with the placement of a lumbar drain and increasing mean arterial pressures. Follow-up imaging demonstrated a well-sealed repair without endoleaks. This case highlights the importance of surgical technique selection and postoperative monitoring for complications.

Thoracic outlet syndrome (TOS) is a rare condition that results from compression of the neurovascular structures as they pass through the thoracic outlet. In this case series, we report on three patients who developed TOS following the creation of an upper extremity arteriovenous fistula (AVF). Patients were successfully treated with first rib resection and pec minor release with venoplasty and neurolysis as indicated. Surgical intervention improved symptoms and preserved dialysis access function in all patients. Thus, with the right constellation of symptoms, clinicians should consider TOS as a differential in patients following AVF creation.

A 52-year-old woman presented with acute digital ischemia and pain in all five digits of her right hand. Upper extremity arterial duplex demonstrated normal flow to the wrist, but upper extremity Computed Tomography Angiography (CTA) demonstrated an atretic appearing brachial artery at the mid-humerus, variant superficial ulnar artery, and a radial artery that truncated at the wrist. The patient was diagnosed with digital ischemia secondary to polycythemia and was started on intravenous anticoagulation. Her symptoms improved and she was converted to oral anti-coagulation and anti-platelet therapy supplemented by weekly therapeutic phlebotomy. The patient's condition improved at 1-month follow up, as indicated by laboratory, imaging, and symptoms. In this case report, we detail the presentation and management of upper extremity ischemia in the setting of polycythemia in a patient with small, tortuous, and aberrant vasculature.

A 63-year-old male developed a mycotic pseudoaneurysm (MPA) two months after a renal transplant at the anastomotic site. He presented with uncontrolled hypertension and elevated creatinine. The pseudoaneurysm occurred at the anastomosis between the two donor renal arteries and the left external iliac artery. We describe a unique surgical reconstruction where the MPA was resected and the vasculature was reconstructed using deceased donor vessels. A deceased donor common iliac artery including superior gluteal and inferior gluteal branches were used as a jump graft from the contralateral common iliac artery to the two transplanted renal arteries. The external iliac artery was repaired with an interposition bypass using deceased donor iliac vein. The patient received 8 weeks of antifungal therapy after the specimen grew candida albicans. Post-operatively, the patient had an acute kidney injury requiring dialysis, but after two months of dialysis, his renal function returned to normal and he remains dialysis-free.

In the past four decades, reports of an unusual vascular disease affecting young and otherwise healthy endurance athletes have begun to emerge. This rare entity has been coined as external iliac artery endofibrosis (EIAE). It has been primarily described in high-level competitive cyclists, suggesting a biomechanical etiology given the repetitive flexion and extension of the hip joint associated with cycling.^1,2 Patients present with symptoms of claudication at peak levels of exertion, levels not usually achievable by the untrained individual. Lesions are predominantly isolated to the external iliac artery (EIA), and histologic examination reveals endothelial thickening and fibrosis without evidence of atherosclerosis.^1–5 Cases of EIAE have been overwhelmingly described in male athletes, with a paucity of reports in females.^2,3 We herein describe two cases of elite female athletes afflicted by EIAE and review the current literature pertaining to this entity in females. Both patients consented to publication of their case details and images.

The infectious pseudoaneurysm of the common carotid artery is a rare observation in children. We present a case of ruptured infectious common carotid aneurysm in a 14-year-old girl managed in the Democratic Republic of Congo. We performed an arterial reconstruction with a saphenous vein patch. Post-operative course was simple. The patient was discharged from the hospital at post-operative day 15. She was doing well and had returned to school. Rupture of an infectious pseudoaneurysm of the common carotid artery constitutes a serious, life-threatening accident. As we have shown in this case report, its management with successful results is indeed possible, even in a resource-limited environment.

Introduction

Peripheral artery disease (PAD) affects over 200 million people globally. A small subset of PAD patients are a result of radiation-induced peripheral artery disease (RIPAD). Radiation changes affect vascular physiology and cause arteriopathy with vessel damage and subsequent occlusion. This report details a case of common femoral and superficial femoral artery RIPAD with a review of the existing literature.

Case report

A 40-year-old male patient presented with a six-month history of left leg rest pain. He had 30 years prior synovial cell sarcoma of the thigh treated with chemo- and radiation therapy with chronic residual lymphedema managed with compression therapy. Preoperative non-invasive studies demonstrated an ankle-brachial index of 0.42. Computed tomography angiography of the leg demonstrated a small caliber external iliac artery and occlusion of the common femoral and superficial femoral arteries. A left external iliac to above-the-knee popliteal artery bypass using a contralateral great saphenous vein was performed. Six weeks after operative intervention, the groin wound broke down and became infected. He required emergent repair of this bypass using 4 cm cryopreserved vein interposition graft. Intraoperative cultures were positive for Staphylococcus epidermidis and Finegoldia magna. At a 4.5-year follow-up, the patient remains active with a patent bypass and continues to manage his leg lymphedema with thigh-high elastic compression stockings.

Conclusion

Clinical expertise is required to detect RIPAD early on. There is a high risk for post-operative complications due to radiation damage to surrounding tissues. Open surgical repair is the preferred treatment strategy. Lymphedema and wound healing complications are key to managing patients affected by RIPAD.