Management of Renal Artery-Inferior Vena Cava Fistula Following Nephrectomy for Penetrating Trauma

Background: Renal artery to inferior vena cava fistula is a rare event postnephrectomy. We report a case of an adult male in whom a renal artery to inferior vena cava fistula was detected on non-invasive studies following nephrectomy for penetrating trauma. Case Report: A fistula between the right renal artery and inferior vena cava was confirmed with diagnostic angiography. The fistula was successfully embolized using microcoils. Discussion: This case highlights the importance of exploring retroperitoneal hematomas secondary to penetrating trauma.

Occam’s Razor and Managing Acute Thrombosis in the COVID-19 Era

The COVID-19 pandemic has profoundly influenced the practice of medicine in Australia over the last 24 months. Recently, the development of several vaccines to COVID-19 has been accompanied by reports of an associated rare syndrome of thrombosis and thrombocytopaenia (VITTS). The possibility of this rare disorder confronts all clinicians who deal with acute thrombosis, particularly given the prevalence of patients who have recently been immunised. However, VITTS remains rare, and we believe unnecessary focus on its potential diagnosis may distract from other more common causes of acute thrombosis. We discuss this with reference to a recent case at our institution.

A Popliteal Vein Aneurysm Accompanied by Lower Persistent Sciatic Vein

Popliteal venous aneurysms (PVAs) are rare. Surgical treatment is recommended because of the risk of deep vein thrombosis and fatal pulmonary embolism. A persistent sciatic vein (PSV) is also a rare anomaly. We report a case of a PVA accompanied by a lower PSV. A 70-year-old man was admitted due to left leg heaviness. He had undergone ablation of both great saphenous veins 6 years prior to the admission. Duplex ultrasound showed a PVA on his left leg, which was 3.2 × 2.4 cm in size. The patient was treated with tangential aneurysmectomy with lateral venorrhaphy. His symptom gradually resolved. He received warfarin at a therapeutic range for 3 months. Duplex ultrasound at 6 months later showed no evidence of any recurrent aneurysm or venous reflux. His follow-up has revealed no complications for 18 months. Surgical treatment and perioperative therapeutic anticoagulation are recommended for treating PVAs. Tangential aneurysmectomy with venorrhaphy is the most common and the simplest surgical method.

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).

Use of Suture-Mediated Closure Devices for Closure of Punctures in Prosthetic Patches or Grafts is Associated With High Rates of Technical Success and Low Complication Rates

Objectives Despite the increasing use of endovascular techniques in the management of peripheral vascular disease, there is little data on the safety of percutaneous closure devices in punctures of synthetic vascular material. Our paper sought to address this paucity in the literature by reviewing the incidence of complications occurring in patients in whom the ProGlide device was utilised to achieve haemostasis post-percutaneous puncture of vascular patches and graft materials. Methods A retrospective review of patient records was conducted at a tertiary referral centre. Patients who had undergone percutaneous punctures of prosthetic bypass grafts or patch angioplasties between January 2011 and December 2020 were identified from a prospectively collected database. Medical records and post-procedural imaging were reviewed to assess the occurrence of post-procedural complications such as pseudoaneurysms, puncture site stenosis and further interventions for access complications. Results A total of 73 punctures of prosthetic material were performed in 42 patients, of which 39 utilised ProGlides. Median age of included patients was 72 years. There was male predominance in the cohort (69.8%), and most punctures (87.3%) were through polyurethane patches. Device success rate was 95%, and no patients required open repair. There was a low incidence of complications, with no patients developing pseudoaneurysms, arteriovenous fistulas, ischaemic limbs or > 50% stenosis when either manual pressure or the ProGlide device was used to achieve haemostasis. Furthermore, there were no returns to theatre or further interventions performed for access site complications. Conclusion The use of the ProGlide closure device has a low incidence of complications and its safety appears to be equivalent to manual compression when used to achieve haemostasis in percutaneous punctures of synthetic vascular material in select patients. To our knowledge, this is the only article to date to assess the safety of the ProGlide in this setting.

Portal Steal Syndrome From a Large Linton’s Splenorenal Shunt after Liver Transplantation: Successful Endovascular Management Through Off-Label Application of a 30 mm Amplatzer Cardiac Plug

A 34-year-old patient underwent liver transplantation for progressive hepatic failure in the setting of congenital hepatic fibrosis. In past medical history, the patient had undergone splenectomy with proximal Linton’s splenorenal surgical shunt creation for symptomatic portal hypertension with hypersplenism. The patient developed an early allograft dysfunction, with radiologic evidence of a reduced portal flow associated to portal steal from the patent surgical shunt. The patient was successfully treated through endovascular placement of a 30 mm Amplatzer cardiac plug at the origin of the splenic vein.

Partial Splenic Embolization for the Management of Severe Refractory Thrombocytopenia in Antiphospholipid Syndrome: A Case Report and Literature Review

Antiphospholipid syndrome is an autoimmune condition characterized by arteriovenous thromboembolic events. Thrombocytopenia is a common finding among these patients and is typically of mild severity not requiring any treatment. However, severe cases of thrombocytopenia should be treated. Steroids, intravenous immune globulin (IVIG), and immunomodulatory agents are the first-line treatment options, and surgical splenectomy is usually reserved for more severe and refractory cases of thrombocytopenia. Herein, we report the case of a 30-year-old man with primary antiphospholipid syndrome and severe thrombocytopenia. The patient’s thrombocytopenia had been refractory to almost all the medical managements, and surgical splenectomy could not be an option due to the patient’s high-risk condition for surgery. The patient was successfully managed by partial splenic embolization (PSE) which was a unique application of this technique.

Carotid-Axillary Bypass and Debridement for a Mycotic Aneurysm of the Left Subclavian Artery

Mycotic subclavian aneurysms are rare, and their presence typically mandates urgent repair due to the associated high risk of rupture and mortality. A multi-disciplinary team effort is of utmost importance in ensuring favorable results. In this case report, we present a 79-year-old male with a rapidly enlarging mycotic left subclavian artery aneurysm secondary to a retrosternal abscess and left sternoclavicular septic arthritis, who underwent aneurysmal exclusion, a left carotid-left axillary bypass and pectoralis muscle flap coverage with a good outcome.

The Outcome of Catheter-Directed Thrombolysis in COVID-19-Associated Deep Vein Thrombosis

Introduction Published evidence of venous thrombotic complications of COVID-19 is lacking from India. This case series consists of twenty-nine adult patients who were COVID -19 positive and treated for Deep Vein Thrombosis (DVT) during the second wave of the COVID-19 pandemic, in India. The study was aimed at analyzing patient demographics of patients with DVT and the outcome of Catheter-Directed Thrombolysis (CDT) in COVID positive patients. Material and Methods: Patients who developed DVT while or after being COVID positive were managed between February and April 2021 at the institution of the first two authors and were included in this retrospective study. Demographic, clinical data, laboratory data, and treatment given were analyzed. All patients were followed up for 3 months with a Villalta score. Results: There were a total of 29 patients (12 male and 17 female) included in the study with a mean age of 47 ± 17 years. The average time of presentation from being COVID positive was 17.8 ± 3.6 days and one patient developed DVT after becoming Covid negative. All but one patient had lower limb involvement, with 42.8% having proximal and 57.2% distal DVT. All patients with Iliofemoral and two with Femoropopliteal DVT were treated with catheter-di thrombolysis and the other 15 patients were managed with anticoagulation alone. No re-thrombosis was observed in the thrombolysis group. Overall average Villalta score at 3 months was 10.7 ± 2.1 with a score of 10.58 ± 2.1 in the anticoagulation-only group and 10.85 ± 2.3 in the CDT group. Conclusion: COVID-19 seems to be an additional risk factor in the development of DVT. The outcome of such patients, treated by thrombolysis appears to be similar to non-COVID patients. In this, observational experience of the authors suggests that CDT could be offered to COVID positive patients with symptomatic Iliofemoral DVT with good outcomes and an acceptable post-intervention Villalta score.

Aortic Intramural Hematoma due to Intercostal Artery Aneurysms

Background Intercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.