Surgical Excision of a Contained Rupture of an Inferior Mesenteric Aneurysm

Inferior mesenteric artery (IMA) aneurysms represent the minority of visceral aneurysm presentations. A 57-year-old female was admitted with a symptomatic IMA aneurysm secondary to atherosclerotic disease. She was treated with open excision which revealed a contained ruptured of a true aneurysm. This case highlights the challenges of an accurate preoperative diagnosis of IMA aneurysm and the correct position of the recent guidelines on visceral aneurysms issued by the Society of Vascular Surgery (SVS).

Post-infarction ventricular septal rupture with a contained right ventricular pseudoaneurysm formation

Mechanical complication of acute myocardial infarction (MI), such as left ventricular free-wall or septal rupture, pseudo-aneurysm or true aneurysm, are uncommon but potentially fatal conditions, that require an early diagnosis and management. We describe a case of post-infarction ventricular septal rupture with pseudoaneurysm formation included in the right ventricle.

Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding

The pancreaticoduodenal arteries are rare sites for true aneurysm formation, but these may develop in association with occlusion of the coeliac circulation, degenerative conditions or inflammatory vascular disorders. These have a high risk of rupture regardless of size or other factors. One identified cause is polyarteritis nodosa (PAN), which is an autoimmune necrotising vascular condition that affects small-sized and medium-sized arteries. We report a case of a 40-year-old man with massive gastrointestinal tract bleeding from a ruptured pancreaticoduodenal artery aneurysm secondary to PAN. This was managed with emergent open aneurysm ligation followed by high-dose corticosteroids and cyclophosphamide pulse therapy. Only three other cases of PAN-associated pancreaticoduodenal artery aneurysms have been reported in the literature.

Myocardial rupture and left ventricular pseudoaneurysm due to late STEMI presentation during the COVID-19 pandemic lockdown: a classical case report

Background Left ventricular (LV) pseudoaneurysm is a serious and rare complication of myocardial infarction (MI). It occurs when an injured myocardial wall ruptures and is contained by overlying adherent pericardium or scar tissue, most commonly it develops in patients with late presentation of MI and delayed revascularization. Case summary A 64-year-old man presented to the emergency department with intermittent central chest pain radiating to back and neck and increasing on deep inspiration, which was considered to be of musculoskeletal origin for a week, but worsened despite medications. Electrocardiography showed features of ST-elevation MI; a circumflex artery occlusion was found on coronary angiogram and angioplasty was performed. Cardiovascular magnetic resonance (CMR) revealed features of healed lateral wall rupture with adherent parietal pericardium and the patient was managed conservatively. Two months later the patient returned with severe chest pain; echocardiogram and cardiac computed tomography showed significant interval progression of the pseudoaneurysm. Aneurysmectomy was performed, after which the patient recovered and had none of the previous symptoms since. Follow-up CMR study revealed improvement of LV systolic function. Discussion A rare case of post-infarction LV pseudoaneurysm was reported. Multimodality imaging helped to detect and to differentiate this complication from the true aneurysm and to follow it up and plan the treatment. Conservative treatment was not effective in this case as the pseudoaneurysm progressed; aneurysmectomy helped to improve LV systolic function.

THREAT ANALYSIS OF REASONS LEADING TO FAILURE OF PERMANENT HEAMODIALYSIS ACCESS

Objective: To analyze the commonest threats which lead to the failure of a permanent vascular haemodialysis access. Study Design: Prospective observational study. Place and Duration of Study: Department of Vascular Surgery, Combined Military Hospital Rawalpindi, from Nov 2018 to Nov 2019. Methodology: All patients who presented with arteriovenous fistula (AVF) or arteriovenous graft (AVG) related complications which can potentially fail an access were included. The frequency, with which these complications occurred, was noted. Results: A total of 158 patients were included, 73 (46.20%) were male and 85 (53.80%) were females. The complications observed in order of frequency were arteriovenous fistulathrombosis (anastomotic or draining vein) in 60 (38%), pseudo aneurysms in 39 (24.68%), stealing veins causing non-maturity of the access in 14 (8.86%), venous hypertension causing extremity edema in 14 (8.86%) (7 due to stealing veins and 7 due to central venous stenosis), AVF anastomotic or draining vein stenosis in 8 (5.06%), wound hematoma in 5 (3.16%), wound infection in 5 (3.16%), true aneurysm of the draining vein in 4 (2.56%), steal syndrome in 3 (1.9%), wound seroma in 3 (1.9%), post op arm edema(not related to central vein stenosis orstealing veins) in 2 (1.26%) and compression neuropathy in 1 (0.6%) of the patients. Conclusion: Complications of vascular access are the potential threats to the life of a permanent vascular access. Early diagnosis and timely intervention can help in fistula salvage.

Dual-energy Computed Tomography Delayed Myocardial Enhancement in the Diagnostic Dilemma of True versus False Left Ventricular Aneurysm – A Case Report

The aim of this case report is to show the capability of cardiac computed tomography (CT) in combination with dual-energy CT (DECT) delayed myocardial enhancement to support diagnostic decision making in the complicated differential diagnosis of true versus false left ventricle (LV) aneurysm, as well as provide additional information that can influence overall patient outcome. We present a 71-year-old obese patient with metabolic syndrome, stable chronic coronary syndrome with three-vessel disease, and recent chest discomfort. His coronary angiogram showed no significant coronary artery stenosis, but suspicion of LV apical pseudoaneurysm was expressed. Neither transthoracic nor transesophageal echocardiography was able to dismiss this suspicion. Consequently, coronary CT angiography (CCTA) followed by DECT delayed myocardial enhancement was performed. Findings on CCTA and DECT confirmed the diagnosis of a true aneurysm. Moreover, fibrotic changes within the hypertrophic myocardium were visualized. This finding will influence further patient therapy as well as the outcome. DECT delayed myocardial enhancement can be an important complementary tool for distinguishing true versus false LV aneurysms. Moreover, it can provide additional information for making complex diagnose. Adding DECT delayed myocardial enhancement to CCTA can replace cardiac magnetic resonance imaging evaluation in certain settings.