Unique Association of Aortopulmonary Window With Anomalous Origin of Left Coronary Artery From Pulmonary Artery in an Infant: A Blessing in Disguise?

Aortopulmonary window (APW) seen in association with anomalous origin of left coronary artery from pulmonary artery (ALCAPA) is extremely uncommon. When faced with this combination, ALCAPA usually goes undetected since most of the clinical and echocardiographic features of ALCAPA, including ventricular dysfunction are absent due to co-existent pulmonary hypertension. Herein we report a 5-month-old child with a large APW in whom a preoperative computed tomography angiogram facilitated the diagnosis of ALCAPA. The case is described for its rarity and the challenges faced during management. Also, it is extremely crucial that this coronary anomaly is identified and corrected during surgery, since failure to do so results in unforeseen postoperative ventricular dysfunction.

The “needle re-entry” technique for infrainguinal arterial calcified occlusive lesions

Background Vascular calcification is a predictor of poor clinical outcome during and after endovascular intervention. Guidewire crossing techniques and devices have been developed, but chronic total occlusions (CTOs) with severe calcification often prevent subintimal re-entry. We propose a novel guidewire crossing approach combined needle rendezvous with balloon snare technique, named the “needle re-entry” technique, for treatment of complex occlusive lesions. Main text A 73-year-old female with severe claudication in her right calf with ankle brachial index of 0.62, and a computed tomography angiogram showed a long occlusion with diffuse calcification in superficial femoral artery. She was referred to our department to have peripheral interventions. Since the calcified vascular wall of the lesion prevented the successful re-entry, the “needle re-entry” was performed. First, a retrograde puncture of the SFA, distally to the occlusion, was performed and an 0.018-in. guidewire with a microcatheter was inserted to establish a retrograde fashion. Second, an antegrade 5.0-mm balloon was advanced into a subintimal plane and balloon dilation at 6 atm was maintained. Third, an 18-gauge needle was antegradely inserted from distal thigh to the dilated 5.0-mm balloon. After confirming a balloon rupture by the needle penetration, we continued to insert the needle to meet the retrograde guidewire tip. Then, a retrograde 0.014-in. guidewire was carefully advanced into the needle hole, named the “needle rendezvous” technique. After further guidewire advancement to accomplish a guidewire externalization, the needle was removed. Finally, since the guidewire was passing through the 5.0-mm ruptured balloon, the balloon was withdrawn, and the guidewire was caught with the balloon and successfully advanced into the antegrade subintimal space, named the “balloon snare” technique. After the guidewire was advanced into the antegrade guiding sheath and achieved a guidewire externalization, an endovascular stent graft and an interwoven stent were deployed to cover the lesion. After postballoon dilation, an angiography showed a satisfactory result without complications. No restenosis, reintervention, and limb loss have been observed for one year follow-up period after this technique. Conclusions The “needle re-entry” technique is a useful guidewire crossing technique to revascularize femoropopliteal complex CTOs with severe calcification which prevent the achievement of guidewire crossing with the conventional procedures.

Management of significant atherosclerotic carotid artery disease: review of literature

Stroke is the third leading cause of death and disability in the world. Carotid artery stenosis due to atherosclerosis accounts for 20 to 30% of all strokes. The patients can be asymptomatic or present with a transient ischemic attack or stroke. Diagnosis is based primarily on imaging modalities like carotid Doppler, CT (Computed tomography) angiogram, MR (Magnetic resonance) angiogram or DSA (Digital subtraction angiogram). Treatment options include optimal medical therapy, carotid endarterectomy-touted as the gold standard for treating significant carotid stenosis; and carotid artery stenting, whose safety and efficacy have undergone significant improvements due to technological advances in the field. We presented a review of the literature outlining the various aspects of atherosclerotic carotid stenosis and the findings of several randomized controlled trials conducted to settle the debate between endarterectomy and stenting for carotid stenosis.

A Rare Case of Aortoenteric Graft Erosion Presenting as Candida glabrata Fungemia

Background. An aortoenteric fistula (AEF) describes a communication of the aorta or aortic graft with an adjacent loop of the bowel. Aortic graft erosion is a rare complication of abdominal aortic aneurysm repair. We describe a case of a patient presenting with sepsis from Candida glabrata fungemia secondary to aortoenteric erosion without any symptoms or signs of gastrointestinal bleeding. This is a unique case of Candida glabrata fungemia from aortoenteric graft erosion. Case Summary. This patient is a 75-year-old male with a history of a prior aortobifemoral bypass graft in 2005. He presented with complaints of right paraspinal pain and chills. He had no symptoms of gastrointestinal bleeding or abdominal pain. His white blood cell count was 25,600/mcl (4,000–11,000/mcL) with left shift. The erythrocyte sedimentation rate was 11 mm/hr (0-38 mm/hr), and C-reactive protein was 95.5 mg/L (<=10.0 mg/L). Blood cultures were obtained and eventually grew Candida glabrata. A computed tomography angiogram (CTA) of abdomen and pelvis demonstrated inflammation surrounding the graft concerning for graft infection with additional inflammatory changes tracking down both femoral limbs. He underwent staged bilateral femoralaxillary bypass followed by the excision of aortobifemoral bypass. Conclusion. Patients with aortoenteric erosion can present with sepsis in absence of gastrointestinal bleeding. Emergent computed tomography angiogram (CTA) of abdomen and pelvis should be performed to assess for aortic graft erosion or fistula. Empiric treatment with antibiotics should include antifungal agent like micafungin until the final culture is reported. The definite management is an extra anatomic bypass, followed by graft excision.

Salvage of a megafistula causing high-output cardiac failure in a young adult with aneurysmorrhaphy and banding

We present the case of a 21-year-old male with significant lengthening and aneurysmal degeneration of his brachiocephalic arteriovenous fistula resulting in a megafistula and high-output cardiac failure. A computed tomography angiogram showed narrowing at the cephalic arch. Further evaluation during the operation revealed kinking and elongation of the fistula in addition to compression of the cephalic arch in the deltopectoral groove leading to outflow obstruction. The aneurysmal fistula was treated successfully with aneurysmorrhaphy of the remaining conduit and banding of the inflow. This case demonstrates a unique etiology of venous outflow obstruction for a fistula and describes the surgical approach to its treatment in a young patient suffering from cardiac failure.

Abstract 1122‐000205: Bilateral ACA Stroke ‐ A Case Report of an Unusual Presentation

Introduction : Bilateral ACA strokes are rare, with one stroke registry reporting 2 cases out of 1490 strokes (1). These strokes are even less common in the absence of anatomic variants, such as an azygos ACA. Diagnosis may be difficult given the variability in clinical presentation. Methods : This is a case report. Results : A 51‐year‐old right handed man with no cerebrovascular risk factors on no antithrombotic medications presented two hours from last known well with complaints of generalized weakness, inability to speak or move, and feeling numb all‐over during intercourse. He reported rapid improvement in symptoms. Emergency room exam was notable for right leg weakness (3/5) and left leg plegia with intact sensation. Hoover’s sign was positive in the left leg and the patient was able to bear some weight while standing with a two‐person assist. A computed tomography angiogram (CTA) of his head and neck was preliminarily interpreted as normal. No azygos ACA or single internal carotid artery origin for the ACAs were present. His exam improved to an isolated left foot dorsiflexor and plantar flexor weakness. The decision was made not to use thrombolytics based on his symptoms and exam which were improving and not entirely consistent with acute stroke. Brain magnetic resonance imaging demonstrated bilateral parasagittal acute strokes. It was later noted the that non‐contrast head CT demonstrated bilateral hyperdense ACAs. Conclusions : This case demonstrates the difficulty in diagnosing bilateral ACA infarcts in a previously healthy adult in the setting of whole‐body numbness and positive Hoover’s sign. In retrospect, his transient inability to speak or move may have been transient akinetic mutism or callosal disconnection syndrome. Additionally, this case emphasizes the importance of evaluating for the hyperdense ACA sign (2) in patients complaining of bilateral leg weakness.

922 Pre-Operative Chest X-Ray Prior To Aneurysm Surgery Is Unnecessary

Aim Over 4100 elective abdominal aortic aneurysm (AAA) cases are performed each year in the UK. In our tertiary centre the anaesthetic pre-operative protocol for these patients includes a chest x-ray (CXR), because some risk factors for aneurysmal disease (smoking, older age) cross over with those for lung cancer. This study was performed to see if the CXR changed management in AAA patients. Method A retrospective radiology review of 191 consecutive patients who had an elective AAA repair at one unit in 2017-2018 was carried out. Computed tomography angiogram (CTA) and CXR findings were compared. Where an abnormality was reported, patient records were reviewed and the impact of the abnormal result on the patient journey assessed. Results Of 191 patients, 148 had pre-op CXRs. Of the CXRs, 60 reported abnormalities, most of which were minor (cardiomegaly, atelectasis, reticular shadowing). Of the 60, 28 had no lung abnormalities on CTA, 18 had not had a reported CTA, 8 corresponded with the CTA and 6 had a different chest abnormality reported on the CTA. 2 patients had CTs of the chest following CXR findings and no patients had an operation cancelled or delayed due to findings on CXR. Conclusions Each CXR costs around £20 including reporting and administration time. In addition, there is inconvenience to the patient and additional radiation dose. None of the pre-operative CXRs resulted in a change to patient operative management therefore the requirement for pre-operative CXR was removed from the units’ protocol.

Pseudoaneurysm of the uterine artery post loop electrosurgical excision procedure

Background The formation of a uterine artery pseudoaneurysm is rare and isolated cases have been reported in the existing literature following caesarean sections, curettages and cone biopsies. There has been no report of pseudoaneurysm formation following a loop electrosurgical excision procedure. Vaginal bleeding could potentially be life threatening if this diagnosis is not considered following cervical instrumentation or surgery. Management options range from haemostatic sutures, image-guided embolisation to surgical repair. We report the diagnosis and management of a case of uterine artery pseudoaneurysm after a loop electrosurgical excision procedure. Case presentation A 37-year-old woman was diagnosed with cervical intraepithelial neoplasia grade 3 (CIN3) and underwent a therapeutic loop electrosurgical excision procedure. One month after the procedure, the patient presented to the emergency department with repeated episodes of sudden-onset heavy vaginal bleeding associated with hypotension and syncope. A computed tomography angiogram was performed, which demonstrated a pseudoaneurysm of the right uterine artery. Following the diagnosis, image-guided embolisation was performed successfully. Post-embolisation angiograms showed successful embolisation of the pseudoaneurysm and the patient had no further episodes of bleeding. Conclusions Loop electrosurgical excision procedures are generally safe but rarely, can be complicated by the formation of uterine artery pseudoaneurysms. The depth of the loop electrosurgical excision procedure and vascular anatomy should be considered to prevent such complications. A computed tomography angiogram appears to be ideal for diagnosis. Image-guided embolisation is safe and effective as a therapeutic measure, with minimal morbidity.

Arteriovenous Malformations in Proximal Part of Ileum: A Case Report

Arteriovenous malformations in the ileum are a rare cause of gastrointestinal bleeding in young adults with few reported cases and pose difficulty in diagnosing. They usually present with chronic gastrointestinal bleed. A 30-year-old woman presented with an acute episode of hematochezia with a history of intermittent melena for 1.5 years. Complete blood count revealed a low hemoglobin level of 3.5g/dl and hypochromic microcytic anemia. Oesophago-gastro-duodenoscopy was normal; however, a colonoscopy revealed the terminal ileum and colon filled with blood. Computed tomography-Angiogram showed local intraluminal contrast extravasation in the ileum. Explorative laparotomy and on-table enteroscopy were performed identifying a small elevated, pigmented, and eroded mucosa (5 to 6 mm) in proximal ileum; resection and primary anastomosis were performed. The patient was followed after surgical resection and her symptoms improved dramatically with no additional episodes of melena and with the normalization of hemoglobin.

Case Report: Duodenoscopy diagnosis of a secondary aorto-duodenal fistula: A case report and review of literature.

Secondary aorto-enteric fistula (SAEF) is a rare life-threatening complication occurring in patients with previous infrarenal aortic prosthetic reconstruction. The main symptom is a gastrointestinal bleeding. Its diagnosis is challenging due to the lack of a specific clinical signs. The failure of early diagnosis and treatment of this entity can lead to fatal issue. Actually, the abdominal computed tomography angiogram represents the principal exploration to confirm the diagnosis, but it is associated with a moderate specificity and sensibility. Duodenoscopy can highlight the communication between the duodenum and the prosthetic graft, but it is often inconclusive. We report in this manuscript a case of secondary aorto-enteric fistula revealed by occult gastrointestinal bleeding in an elderly patient who is admitted for severe anemia. The SAEF diagnosis was suspected by the computed tomography scan and confirmed by the duodenoscopy showing an exceptional image of Dacron graft protruding in the third duodenum lumen. Unfortunately, the patient died from cataclysmic shock before intervention. We overview also the rare previous published case reports concerning the endoscopic images of secondary aortoenteric fistula and we contrast our findings with those reported in the literature.