New-Onset Ulcerative Colitis in a Young Caucasian Woman with Unclassified Arteritis

Takayasu arteritis is a rare disease mostly found in Asian populations. Cases have been reported in patients with inflammatory bowel disease, suggesting possible genetic linkage. The objective of this clinical case report is to highlight a rare finding of arteritis signs and symptoms in a 32-year-old Caucasian woman (likely early that it did not yet meet classification for official diagnosis as Takayasu arteritis) who subsequently was diagnosed with ulcerative colitis a few months later. The patient presented to the hospital with throbbing neck pain and tenderness around the area of her right carotid artery distribution, nonspecific visual changes, and bilateral upper extremity paresthesia, with significant findings of 50-69% right carotid artery stenosis on a recent outpatient carotid Doppler ultrasound. Based on additional laboratory, clinical, and advanced imaging findings at the hospital, a diagnosis of arteritis not yet classifiable as Takayasu arteritis was made, and the patient was treated with corticosteroids. Unfortunately, she developed bradycardia that was later attributed to the corticosteroid regimen and the medication was discontinued. By follow-up in the clinic, the patient’s carotidynia improved, but now, she reported a three-month history of bloody stools. Colonoscopy and pathology findings were consistent with ulcerative colitis, and the patient was started on mesalamine. The association of inflammatory bowel disease and Takayasu arteritis should not be overlooked, as future treatment methods and early, continuous surveillance may be critical in improving quality of life and avoiding serious complications.

Thoracic Endovascular Aortic Repair for a Ruptured Mycotic Aortic Pseudoaneurysm Secondary to Esophageal Carcinoma

A 47-year-old female presented to the emergency department with new episodes of hematemesis. She had a background of unresectable T4b + N1 + M0 esophageal squamous cell carcinoma. Contrast CT thoracic aorta diagnosed a ruptured mycotic aortic pseudoaneurysm of the descending aorta, forming a life threating aorto-esophageal fistula secondary to neoplasm. Due to the high risk of fatal haemorrhage, she underwent successful emergency thoracic endovascular aortic repair (TEVAR). Mycotic aortic pseudoaneurysms are a rare and often fatal complication of esophageal carcinomas. They represent a small subsection of aorto-esophageal fistulas. Early diagnosis with cross sectional imaging and vascular control of the sentinel bleed is essential for survival. TEVAR may be used as a bridge to palliative treatment in the case of unresectable esophageal carcinoma.

Treatment of Aortic and Iliac Artery Occlusion by Catheter Thrombolysis Combined with Catheter Thrombectomy and Aortic Bifurcation Endovascular Stent Reconstruction

Aortoiliac occlusive disease (AIOD) is an occlusive disease of the infrarenal aorta and iliac arteries usually caused by stenosis or occlusion at the end of the abdominal aorta-common iliac artery. Herein, we reported a case of Trans-Atlantic Inter-Society Consensus- (TASC-) D AIOD with pale, cool, and intangible dorsalis pedis artery treated with catheter thrombolysis combined with catheter thrombectomy and aortic bifurcation endovascular stent reconstruction, which proved to be safe, effective, and minimally invasive approach. In the present paper, we discussed the physical and imaging manifestations, as well as treatments.

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.

Superior Mesenteric Artery Syndrome: A Community Hospital Case Series

Superior mesenteric artery syndrome is an obstruction of the small bowel between the aorta and the superior mesenteric artery. Patients with this disease are initially managed medically and those patients who fail medical treatment require surgery. A retrospective case series of thirteen patients diagnosed with SMAS at Flushing Hospital, Flushing, NY, from 2011 to 2020 was performed. Descriptive statistics were used to summarize the characteristics of the entire cohort, and comparative statistics were used to compare the patients who failed medical treatment and required surgery to those who were successfully managed medically. Nine patients were managed conservatively and four patients required operative intervention. BMI was significantly lower in patients requiring operation compared to those who were successfully managed medically. This retrospective community hospital case series adds to the literature on SMAS and provides evidence of BMI as a potential predictor of requiring surgery in SMAS.

Balloon-Assisted Percutaneous Thrombin Injection for Treatment of Iatrogenic Left Subclavian Artery Pseudoaneurysm in a Critically Ill COVID-19 Patient

Background. Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up. Conclusion. This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Thrombosed Aneurysm of Superficial Epigastric Vein Simulating Inguinal Hernia: Report of Two Cases

Aim. Presentation of two cases of superficial epigastric vein aneurysm simulating inguinal hernia. To our knowledge, only one other case is reported in the literature. Case presentation. The first case was a 34-year-old female with left inguinal pain and swelling which was clinically diagnosed as inguinal hernia. The second case was a 28-year-old female with inguinal pain and swelling, depicted with triplex ultrasonography and computed tomography, and was suspected to have inguinal hernia or enlarged inguinal lymph node. During the surgical exploration, both patients were found to have thrombosed aneurysm of the superficial epigastric vein. During the surgical exploration, both patients were found to have thrombosed aneurysm of the superficial epigastric vein. The superficial epigastric vein was ligated, and the venous aneurysms ( 6 × 4 × 3 and 2 × 3 × 2.5 c m , respectively) were excised. Histological examination of the thrombosed aneurysm showed complete replacement of the vascular wall by fibrous tissue, thrombosis, and an inflammatory reaction. There were no postoperative complications, and both patients were discharged on the second postoperative day. The 3-month and 1-year follow-up examination, respectively, was uneventful. Conclusion. Although venous aneurysms in the inguinal area are rare, they should be included in the differential diagnosis of a groin swelling.

Hybrid Percutaneous Brachiofemoral Shunt and Open Abdominal Aortic Aneurysm Repair in a Kidney Transplant Recipient

Abdominal aortic aneurysm (AAA) repair in kidney transplant recipients may cause ischemia in the transplanted kidney. As a result, various techniques have been described for protection of the renal allograft during AAA repair including temporary shunt, extracorporeal bypass, cold renal perfusion, endovascular aortic aneurysm repair (EVAR), and operation without renal allograft protection. We successfully treated a 56-year-old man, a case of kidney transplantation with AAA, using a temporary hybrid percutaneous brachiofemoral shunt using vascular prosthesis with a long 7-French (Fr) catheter sheath introducer (CSI) in the aortic arch via the right brachial artery and 8 Fr CSI in the right femoral artery that were connected together with a 7 Fr guiding catheter, before aortic cross-clamping and repair of AAA using a Dacron tube graft. The patient recovered well from the surgery without any complication and was discharged on the 6th postoperative day. To our knowledge, this is the first report of using a temporary hybrid percutaneous brachiofemoral shunt for renal allograft protection in AAA repair surgery in a patient with kidney transplantation, and we think that this temporary shunt is an easy, safe, and rapid method for renal allograft protection from ischemia.

Acute Pulmonary Embolism Associated with Low-Dose Olanzapine in a Patient without Risk Factors for Venous Thromboembolism

Background. Olanzapine is a second-generation antipsychotic drug commonly prescribed for certain mental/mood conditions such as schizophrenia and bipolar disorders. This agent has been considered a precipitating factor for venous thromboembolism formation. Most of the cases previously reported were associated with high-dose olanzapine therapy or in patients with high-risk factors for the development of thromboembolism. Case Presentation. We report a patient who developed pulmonary embolism after a long course of low-dose olanzapine. A 66-year-old female patient suffering from insomnia had been prescribed olanzapine 2.5 mg and paroxetine 10 mg for two years. The patient suddenly developed a syncopal episode at home and was immediately brought to the hospital. The diagnosis of pulmonary embolism was made by chance during the computerized tomography of coronary arteries. The patient made a full recovery under conventional treatment and was discharged in stable condition. The thoracic computed tomography taken two months after discharge showed a completely normal pulmonary arterial tree. Conclusion. Olanzapine-associated pulmonary embolism is a rare entity and might be missed if the physician in charge is not vigilant and well informed. Even low-dose olanzapine can be associated with pulmonary embolism in patients with low classic risk factors if the treatment is prolonged. Pulmonary embolism should be sought in patients taking olanzapine even though the presenting manifestations are nonspecific.

Off-Label Use of a Double-Layer Micromesh Carotid Stent for Hybrid Treatment of Popliteal Artery Aneurism Complicated by Chronic Distal Embolization

We report our initial experience in off-label use of the double-layer micromesh (DLM) Roadsaver® stent for the hybrid treatment of a fusiform popliteal artery aneurism complicated by distal embolization and chronic limb threatening ischemia in a COVID-19-positive young male. A 36-year-old male patient was admitted with chronic limb threatening ischemia of the left lower limb. The duplex ultrasound and computer tomography angiography (CTA) demonstrated a fusiform popliteal artery aneurism with a maximal diameter of 14 mm and distal occlusion of peroneal and both tibial arteries. Urgent hybrid intervention was performed, starting with an open thrombectomy from the distal posterior tibial artery via a retromalleolar access followed by percutaneous deployment of the DLM Roadsaver® stent (Terumo, Tokyo, Japan) for the exclusion of the popliteal artery aneurism. The flow diverting effect was observed immediately with contrast stagnation in the asymmetrical part of the aneurism sac (grade C2 of the O’Kelly-Marotta flow diversion scale). The procedure was uneventful, with the regaining of an adequate foot perfusion and palpable pulse at the posterior tibial artery. On the 2nd postoperative day, the patient was diagnosed with a symptomatic form of COVID-19 infection and transferred to a dedicated facility. At a one-month follow-up, the patient had no symptoms of limb ischemia and CTA showed complete thrombosis of the aneurism sac, absence of endoleaks, and patency of the treated arterial segment. This case demonstrates the possibility of off-label use of the DLM Roadsaver® stent for hybrid treatment of popliteal artery aneurism complicated by distal embolization and critical limb ischemia.