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

Introduction

The management of thoracoabdominal aortic aneurysms (TAAA) presents significant challenges for vascular and cardiothoracic surgeons due to the risk of ischemic complications. Various strategies have been implemented over time, including open repair with or without left heart bypass (LHB), endovascular, and hybrid approaches. Here, we explore the application of temporary extra-anatomic bypasses (TEAB) as a technique for complex open TAAA repair when the traditional standard of care is not feasible (i.e. Unavailability of LHB) or indicated (i.e. contraindication for systemic heparinization for LHB).

Case reports

Case 1 is an undomiciled 59-year-old male with a chronic type B dissection (CTBD) and degenerative TAAA with failed attempt at endovascular repair at an outside institution. An open repair of the visceral segment was performed with TEAB due to risk of impending rupture, prior failed endovascular repair, and unavailability of cardiac surgery. Additionally, a staged TEVAR was planned for treatment of the thoracic portion of the CTBD in two weeks’ time. The patient experienced sudden chest pain 10 days following the TAAA repair, prompting urgent TEVAR. No complications were observed. Case 2 is a 65-year-old male with a type 2 TAAA who underwent an open repair with the use of TEAB. Technical success was achieved with no complications.

Discussion

TAAA repair poses significant challenges regardless of the approach selected. However, the use of TEAB has shown promise in ensuring adequate perfusion of vital organs during complex repair when LHB is not an option. Preoperative planning is essential to minimize ischemic time and reduce complications. Studies have shown favorable outcomes with TEAB, however, evidence relies only on small series and case reports.

Conclusion

The use of TEAB is a valuable technique for safeguarding organ perfusion during open repair of TAAA. While further research and experience are needed, TEAB offers a promising alternative for cases where traditional approaches are not available. Continued exploration and documentation of TEAB in current literature will contribute to optimizing TAAA management strategies.

Introduction

Aneurysms of the splenomesenteric artery variant are extremely rare with an unusual location; making its management approach challenging.

Case presentation

We report a case of splenomesenteric artery aneurysms that was managed in an endovascular approach in a 56-year-old gentleman with co-morbidity, obesity and anticoagulation treatment. A computed tomography investigating a left flank pain found a left sub-capsular renal hematoma and an incidental finding of a fusiform splenic artery aneurysm originating from the SMA measuring 3.2 × 3.4 cm. An endovascular intervention was performed by combining an embolization of the aneurysm and emplacement of stent graft at the superior mesenteric artery to isolate the aneurysm and prevent coil migration. The patient was discharged at day 2 post-operatively with excellent clinical and radiographic findings upon follow-ups.

Discussion

Splenomesenteric artery aneurysms is rare as there are 47 published cases reported in the literature. They may present with abdominal pain, back pain, flank pain or discovered incidentally. Its open surgical management approach pose various potential difficulties due to its retropancreatic location. Other approaches were proposed in the literature including laparoscopic and endovascular managements.

Conclusion

An appropriate endovascular management can be more feasible and suitable approach management of splenomesenteric artery aneurysms in patients with complicated medical condition.

Background

Aneurysms of visceral abdominal arteries represent less than 3 % of all splanchnic aneurysms. Pathology is poorly understood but recent studies have focused on the role of inflammation which it can be further enhanced by a systemic inflammatory disease.

Materials and Methods

A systematic literature review was conducted to highlight the unsolved aspects of this pathology and a total of 43 patients were retrieved to whom we added 1 patient treated at our Institution.

Results

Mean age at presentation was 54 years with a peak of incidence between the 6th and the 7th decades of life. No racial, sex, and age differences were observed among the two groups (P=NS). In 10 (23 %) patients an inflammatory disease was associated. However, the risk of rupture was similar between patients affected with an inflammatory disease and those with a sporadic presentation (P=NS). Color ultrasound was seldomly used but its role is questionable especially in an emergency setting because of the well-known limitations. On the other hand, computed tomography angiogram always permitted diagnosis. Surgery is the treatment of choice to prevent emergent surgery. If feasible, an endovascular approach should be used either in elective or emergent setting. However, hemodynamically unstable patients should be promptly operated on with an open approach. There were 4 (9 %) deaths 1 before surgery, 3 during operation.

Conclusions

Although in our revision we were unable to demonstrate that patients affected with an autoimmune diseases or chronic inflammatory conditions might have a higher risk of visceral aneurysm rupture, we recommend a proactive screening approach based on regular monitor of these patients for the presence of visceral aneurysms.

Intracardiac leiomyomatosis (ICL) is an exceptionally rare benign smooth muscle mass originating in the pelvis that has extravagated into the inferior vena cava to the right atrium. Due to the extensive nature of these tumors, they may cause occlusion of blood flow to the heart with potential for high mortality. The low prevalence of this condition and the affected area, which traverses pelvic, thoracic, and cardiac fields, pose obstacles for surgical planning. We describe a multidisciplinary surgical approach utilized to remove ICL in one patient to successfully eliminate risk of mortality from this condition.

Background

Isolated iliac aneurysms are difficult to diagnose. In this unique case report, we present an unusual incident in which the diagnostic for a ruptured iliac aneurysm was unexpectedly initiated through the misplacement of a suprapubic catheter.

Methods

We retrospectively collected patient's data, medical history and imaging using our electronic data base. The consent of the patient family was collected.

Result

We report a case of a ruptured iliac aneurysm that clinically imitated urinary retention with hemodynamic shock, the misdiagnosis caused insertion of a suprapubic catheter into the iliac aneurysm. Following active bleeding through the catheter, a CT-scan was immediately performed and retrieved the ruptured iliac aneurysm. The patient underwent immediate surgery consisting of aorto-bi-femoral bypass. No complications occurred during the post-operative course and follow-up. Fortunately, the vessel trauma was without major consequences for the patient as the catheter was left in place and clamped before surgery.

Conclusion

We report a case of a ruptured iliac aneurysm that clinically imitated urinary retention with hemodynamic shock with insertion of a suprapubic catheter into the iliac aneurysm successfully treated by aorto-bi-femoral bypass. Isolated iliac aneurysms are a relatively rare, they remain asymptomatic and are mostly discovered by chance. We recommend an ultrasonography screening before the insertion of a suprapubic catheter, especially for patients at-risk, to avoid bleeding caused by potential vascular trauma.

We present a case report of a 55-year-old woman who had a femoral vein intravascular papillary endothelial hyperplasia that required excision of the mass and subsequent repair of the right femoral vein using her right anterior accessory saphenous vein. She first presented with findings of a non-occlusive deep vein thrombus. However, after 6 months of persistent and enlarging mass with subsequent intravascular component on a follow-up duplex scan, a decision was made to bring her to the operating room for exploration and excision.

Intravascular Lithotripsy (IVL) is a relatively modern endovascular tool accepted for use to address vascular calcification in the iliac arterial system and below. This case study shows evidence of successful application of IVL followed by stent placement to calcific disease present within the aorta as well. A 78-year-old female with numerous comorbidities and a history of an aorto right femoral left iliac bypass graft in 1998 presented with severe lifestyle limiting claudication secondary to high-grade atherosclerotic stenosis of her infrarenal abdominal aorta at the level of the proximal anastomosis of her bypass graft. Initial ABIs were 0.54 and 0.55 on the right and left respectively. Initially the operative plan was to conduct a retroperitoneal aortic endarterectomy. However, after the surgical optimization center deemed the patient intermediate risk and her pulmonary function decreased prior to the procedure, the decision was made to proceed with IVL followed by angioplasty and aortic stent placement. The patient tolerated the procedure well without complication and she was discharged home the following day. At follow up appointment 6 weeks later, the patient's repeat ABIs were significantly improved to 0.77 in the right and 0.86 in the left with a coinciding improvement in symptoms. In conclusion, IVL is safe and effective in calcific aortic disease and should be considered in patients who are not optimal open surgical candidates.

Objectives

The combination of severe aortic stenosis (AS) and abdominal aortic aneurysm (AAA) is not uncommon in elderly patients and should be optimally managed. However, the guidelines do not provide recommendations for clinical practice, thus reinforcing the need for further analysis of this complex, challenging condition.

Methods

We report 2 cases of patients with severe AS patients with high surgical risk for aortic valve replacement (AVR) and AAA with a diameter of more than 5.5 cm who underwent simultaneous transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (EVAR).

Results

The patients were successfully treated with EVAR and TAVI and had an uncomplicated postoperative course. The importance of this combined pathological condition is emphasised as the need for simultaneous treatment with an endovascular technique, after a thorough study of the clinical and imaging data of the patients and decision-making by the teams of interventional cardiologists and vascular surgeons. The case reports are limited to one or a small number of incidents that occurred simultaneously or sequentially, without specifying the most appropriate method.

Conclusions

Severe AS and AAA can be treated with combined procedures with EVAR followed by TAVI simultaneously, with a safe and effective result. The study by a multidisciplinary team highlights the importance of a thorough evaluation of all patients before intervention and the need for more studies and guidelines.

Background

Embryological aortic development is characteristically asymmetric, and as such, abnormalities in formation can present unique issues. Right-sided aortic arch is one such variant; repairing acute pathologies in this population requires technical and anatomic proficiency. Yet given the rarity of these conditions, there are few evidence-based guidelines outlining proper interventional management. This case serves as a demonstration of successful endovascular repair of a Stanford type B dissection in the setting of right aortic arch and congenital vascular ring.

Case summary

An 82-year-old female with a past medical history of hypertension, status-post coronary artery bypass grafting, presented to the emergency department (ED) with acute onset severe back and chest pain. An urgent computerized tomography angiography (CTA) subsequently revealed a type B aortic dissection with aberrant RAA anatomy along with a vascular ring. Due to hemodynamic instability and concern for hemothorax, the patient was taken emergently to the operative theater for endovascular repair and was successfully treated with a single aortic stent graft. Follow-up CTA 1 month later showed a proximal type I endoleak, and in efforts to promote remodeling, the repair was extended to the proximal descending aorta with coil embolization of the vascular ring.

Discussion

In patients with Type B dissection in the setting of right-sided aortic arch, surgical versus endovascular approaches are influenced by anatomic understanding and technical feasibility. This case serves as an example of a successful endovascular repair in an abnormal aortic environment, which may potentially reduce post-procedure morbidities compared to open surgery.

Introduction

Numerous pulmonary embolism response teams (PERT) have emerged to direct management of pulmonary embolism in hospitalized patients; few of these teams consist of vascular surgeons.

Methods

This study presents a single-center retrospective review aimed at evaluating the outcomes of patients who underwent suction thrombectomy by vascular surgeons within the timeframe of 2022 to 2023. Differences in preoperative and postoperative outcomes were compared using a samples t-test for continuous data. Statistical analyses were performed using JASP Team 2022, JASP (Version 0.16.3) [Computer software]. A p value < 0.05 was considered significant.

Results

50 patients were assessed that underwent suction thrombectomy. The majority of patients were female (64 vs 36 %). Ages ranged from 26 to 94 and the mean was 65 years old. The majority of patients were Black or African American (62 %). The majority of patients (52 %) had moderate right heart strain (RHS) preoperatively. There were no postoperative wound infections or bleeding complications. All-cause mortality within 30 days was 2 %; procedure-related or pulmonary embolism-related mortality was 0 %.

Conclusion

Suction thrombectomy remains a safe option for management of pulmonary embolism; a PERT can successfully comprise vascular surgeons as the primary proceduralists.