Case Report: A Pseudoaneurysm Involving the Left Common Iliac Artery Secondary to Brucellosis: A Rare Case Report

Pseudoaneurysms of the common iliac artery caused by Brucellosis are exceedingly uncommon. Infected common iliac artery pseudoaneurysms, particularly those caused by brucellosis, are more difficult to diagnose and cure than general pseudoaneurysms. The risk of mortality is significantly high in this condition. Nonsurgical treatment of a brucellosis-induced common iliac artery pseudoaneurysm is futile, and it should be operated on as soon as feasible. Long-term and multi-course antibacterial therapy with combination antibiotics is required. For the treatment of Brucella-infected pseudoaneurysms, endovascular surgery can be both effective and safe.

Acute Aorto-Illiac Occlusion with Bilateral Limb Ischemia Underwent Direct Catheter Thrombolysis in Older Patient: A Case Report

Background: Peripheral arterial diseases could be a major burden for the health system with a wide clinical spectrum from asymptomatic to limb-threatening. Sudden onset of limb deteriorations represent a vascular emergency and need proper treatment for limb preservation and life-saving. It is still challenging to choose proper management to reduce morbidity and mortality, despite the various advance in diagnostic and therapeutic tools were available. Objective: This case report aimed to elaborate on the management of acute aorto-illiac occlusion with bilateral limb ischemia underwent direct catheter thrombolysis in an older patient. Case Presentation: A 70-years-old man came to our hospital with a chief complaint of leg pain in both of his legs, suddenly since 18 hours before admission. He had paresthesia and paralysis in both of his legs. And the Doppler ultrasonography result was occlusion proximal to the right and left common iliac artery. Then we performed percutaneous intra-arterial thrombolysis using streptokinase with a successful outcome of peripheral revascular- ization but with gastrointestinal bleeding as an adverse event. Conclusion: Despite the various advancement of diagnostic and therapeutic tools available today, Acute Limb Ischemia (ALI) still proceed to be related to increasing major amputation and mortality rates in 20% of patients, more often due to the existing comorbidities such as other atherosclerotic diseases.

Impact of statins on vascular scaffolds response in porcine carotid arteries

Surgical treatments of arterial occlusive disease with fully absorbable polymeric scaffolds, as a potential alternative to permanent metallic stents, are increasingly penetrating the clinical field. An addition part of the management of patients suffering from vascular diseases is the administration of statins. In this study, absorbable x-ray marked PLLA-based polymer scaffolds and permanent bare-metal stents (BMS) were implanted interventionally into both common carotid arteries (CCA) of 6 healthy female pigs via the left common iliac artery (8F-sheath). The pigs were administered dual antiplatelet drugs oral starting 3 days before the procedure until the end of the study. In Addition, the pigs received atorvastatin orally, beginning 5 days prior to surgery and lasting until the study ended. Stented CCA segments were explanted after 4 weeks, and processed for quantitative histomorphometry, and estimation of vascular inflammation and injury scores. Polymer scaffolds showed a decreased residual lumen area and higher stenosis after 4 weeks (6.41 ± 0.83 mm² and 40.52 ± 5.01%) as compared to the bare-metal reference stent (15.17 ± 0.896 mm² and 7.80 ± 0.88%). After 4 weeks, inflammation score were higher in the polymer group (1.30 ± 0.37) compared to the BMS group (0.42 ± 0.18). In contrast, the BMS showed a slightly elevated vascular injury score (0.85 ± 0.12), as compared to the polymer (0.60 ± 0.23) group. In this preclinical model, the new absorbable polymeric scaffolds showed similar technical feasibility and safety for vascular application as the permanent metal stents. Although no positive trends were observed with oral treatment with atorvastatin, further optimization with a dual-loaded coating is still reasonable. In addition, reduced strut thickness of the polymer scaffolds would have potential to positively impact tissue ingrowth between struts and should be considered in future work on stent design.

Clinical case of successful endovascular correction of an arterio-ureteral fistula

<p>Arterio-ureteral fistulas are a pathological condition characterised by the appearance of a defect between the blood vessels and adjacent distal segments of the ureter. Arterio-ureteral fistulas are relatively rare and potentially life-threatening, since they are associated with a high risk of developing haemorrhagic shock against the background of recurrent massive haematuria.<br />This study describes the successful endovascular treatment of arterio-ureteral fistulas in a 51-year-old female patient. Evisceration of the pelvic organs was performed, followed by uretero-cutaneostomy and colostomy. Ureteral stents were installed to improve the outflow of urine and prevent ureteral stenosis. After stent removal, episodes of recurrent profuse bleeding from uretero-cutaneostomy occurred. On admission, multi-spiral computed tomography with angiography of the iliac arteries was performed. Extravasation of the contrast agent was not detected; however, external compression of the left common iliac artery by the left ureter was identified. After further examination, a balloon-expandable stent-graft was implanted into the left common iliac artery. The postoperative period thereafter was uneventful.<br />This clinical case demonstrates the highly efficient endovascular treatment of the presented pathology and exemplifies the need for an integrated and multidisciplinary approach in the diagnosis and treatment of arterio-ureteral fistulas. Minimally invasive techniques can reduce surgical trauma and quickly isolate pathological blood discharge from the artery into the ureter. The advantages and disadvantages of endovascular technologies in the treatment of the presented pathology are also discussed.</p><p>Received 16 February 2021. Revised 11 March 2021. Accepted 12 March 2021.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> The authors declare no conflicts of interests.</p><p><strong>Contribution of the authors</strong><br />Drafting the article: A.G. Vanyurkin, A.N. Kazantsev<br />Critical revision of the article: M.A. Chernyavsky, N.V. Susanin, M.S. Mosoyan<br />Surgical treatment: M.A. Chernyavsky, A.G. Vanyurkin, N.V. Susanin<br />Final approval of the version to be published: M.A. Chernyavsky, M.S. Mosoyan, A.G. Vanyurkin, N.V. Susanin, A.N. Kazantsev</p>

Differential Diagnosis between Marfan Syndrome and Loeys–Dietz Syndrome Type 4: A Novel Chromosomal Deletion Covering TGFB2

Marfan syndrome (MFS) and Loeys–Dietz syndrome type 4 (LDS4) are two hereditary connective tissue disorders. MFS displays ectopia lentis as a distinguishing, characterising feature, and thoracic aortic ectasia, aneurysm, dissection, and systemic features as manifestations overlapping with LDS4. LDS4 is characterised by the presence of hypertelorism, cleft palate and/or bifid uvula, with possible ectasia or aneurysms in other arteries. The variable age of onset of clinical manifestations makes clinical diagnosis more difficult. In this study, we report the case of a patient with Marfan syndrome diagnosed at our centre at the age of 33 on the basis of typical clinical manifestations of this syndrome. At the age of 38, the appearance of ectasia of the left common iliac artery and tortuosity of the iliac arteries suggested the presence of LDS4. Next Generation Sequencing (NGS) analysis, followed by Array-CGH, allowed the detection of a novel chromosomal deletion including the entire TGFB2 gene, confirming not only the clinical suspicion of LDS4, but also the clinical phenotype associated with the haploinsufficiency mechanism, which is, in turn, associated with the deletion of the entire gene. The same mutation was detected in the two young sons. This emblematic case confirms that we must be very careful in the differential diagnosis of these two pathologies, especially before the age of 40, and that, in young subjects suspected to be affected by MFS in particular, we must verify the diagnosis, extending genetic analysis, when necessary, to the search for chromosomal alterations. Recently, ectopia lentis has been reported in a patient with LDS4, confirming the tight overlap between the two syndromes. An accurate revision of the clinical parameters both characterising and overlapping the two pathologies is highly desirable.

Paraganglioma of the left common iliac artery: case report and review of the literature

Paraganglioma is a neoplasm derived from the neural crest of the neuroendocrine system. Head and neck account for its more frequent localizations. Parasymphatic paraganglioma have been encountered at cauda equina and iliac vessels. A 37–year old female patient with abdominal pain diagnosed as adnexal mass was surgically operated on at the SMS medical college and research group in Jaipur, Rajasthan, India. During surgery, a retroperitoneal mass was found located lateral to the common left iliac artery. It was completely resected. Microscopic study established characteristics of paraganglionoma. Patient outcome was good. Scanning for other tumour site was negative.

Unusual Endovascular Treatment of Iliac Occlusive Disease With a Physician-Modified Endograft to Preserve a Transplant Renal Artery

Purpose: We describe the feasibility and early results of iliac stenting using a physician-modified endograft (PMEG) to preserve a transplant renal artery in patient with iliac occlusive disease. Case Report: A 70-year-old male patient, with sub-occlusive left common iliac artery stenosis at the level of the transplanted kidney arterial anastomosis, presented with left critical limb ischemia (CLI) and pseudo-transplant renal artery stenosis (pseudo-TRAS) symptoms. He was treated with a physician-modified fenestrated covered stent introduced percutaneously via ipsilateral femoral artery after failure of simple angioplasty (percutaneous transluminal angioplasty, PTA). The modified graft was created by performing a square fenestration graftotomy on a Medtronic iliac limb stent graft (Medtronic Cardiovascular, Santa Rosa, CA, USA). The procedure was technically successful with no intraoperative complications. Procedural time was 110 minutes, including 35 minutes for device modification. On short-term follow-up, the patient had early improvement of renal function and resolution of CLI. The iliac and transplant renal artery remained patent with no sign of stent migration or kinking on 6 months surveillance computed tomography angiography and 1 year color Doppler ultrasonography. Conclusion: Use of PMEG to preserve visceral branches in occlusive iliac disease is a feasible endovascular technique with encouraging technical success and satisfying early results.

Our clinical experiences of vascular injuries due to lumbar disc surgeries

Objectives We aimed to evaluate emergency vascular complications of the lumbar disc reconstructive surgery in this study. Method Between March 2006 and February 2020, nine patients (six males and three females; mean age: 53.4 ± 9.6 years; range: 38–64 years) who underwent emergent vascular intervention during lumbar spinal disc reconstructive surgery in our clinic were included in this retrospective study. Result The left common iliac artery injury, the left common iliac artery and left common iliac vein injuries, bilateral common iliac artery and abdominal aortic injuries, and vena cava inferior injury with left common iliac vein and right common iliac vein injuries were detected in two, three, two, and two patients, respectively. In addition, 16 mm Dacron tube graft interposition and graft patch plasty were performed in one and two patients who had an abdominal aortic injury, respectively. Also, 8 mm polytetrafluoroethylene straight graft interposition was performed in two patients with left common iliac artery injury, and lateral wall repair was performed in other patients. Graft patch plasty and 8 mm polytetrafluoroethylene graft interposition were performed in one patient with vena cava inferior injury and left common iliac vein injury, respectively. Also, lateral wall repair was performed in other patients with venous injuries. Deep venous thrombosis had developed in three patients, and one patient of these had a pulmonary embolism. Conclusion The incidence of vascular injury after the lumbar disc surgery is relatively low; however, the emergency vascular operation should be performed as soon as possible.

Differentiation of vascular claudication due to bilateral common iliac artery stenosis versus neurogenic claudication with spinal stenosis

Background: Differentiating between neurogenic and vascular claudication may be difficult. Vascular claudication due to aortic and iliac artery occlusions may present as low back, hip, and buttock pain while walking short distances. These findings are often very similar to those seen for neurogenic claudication attributed to lumbar stenosis. Case Description: A 68-year-old female presented with low back, right hip, and groin pain while walking short distances. She had previously undergone lumbar and cardiac surgery. Now, with negative repeated lumbar studies, the CT angiogram (CTA) revealed a dense calcified plaque in the right common iliac artery resulting in 90% stenosis at its origin and <50% stenosis of the left common iliac artery. Once bilateral common iliac artery kissing stents were placed, the patient’s symptoms resolved. Conclusion: Spine surgeons should be aware that vascular and neurogenic claudication may mimic each other. Obtaining MR studies of the lumbar spine and EMG/NCV, along with the appropriate vascular studies (CTAs), help differentiate between the two, and result in the appropriate operative choices.