Thoracic endovascular aortic repair with the PETTICOAT (provisional extension to induce complete attachment) technique can cause persistent false lumen perfusion through distal re-entry tears, leading to late aneurysmal degeneration and challenging reinterventions. We report the use of renal artery covered stent placement to treat a persistent false lumen perfusion after PETTICOAT caused by a re-entry tear in a 57-year-old man with chronic type B aortic dissection. Preoperative assessment of the relationship between the re-entry tear and bare-stent struts enabled device delivery and false lumen exclusion, while preserving renal perfusion. This approach represents a feasible branch-preserving reintervention strategy after PETTICOAT.
Airway compression in older children is uncommon and becomes more challenging when thoracic deformities alter aortic anatomy. A 16-year-old girl with severe scoliosis and chronic bedridden status presented with progressive respiratory distress caused by compression of the left main bronchus between the ascending aorta and a right-sided descending aorta. Because conventional aortopexy alone was unlikely to achieve adequate decompression, aortic elongation with a prosthetic graft was performed to reposition the descending aorta posteriorly, followed by aortopexy. Postoperative imaging confirmed complete bronchial decompression, and the patient’s respiratory symptoms resolved.
We report a 36-year-old man with neurosarcoidosis who developed multiple pseudoaneurysms involving the superior mesenteric artery, infrarenal aorta, and bilateral iliac arteries. FDG-PET demonstrated no significant uptake within the aneurysmal segments. Given the complex vascular anatomy, a staged hybrid approach was undertaken. Initial treatment consisted of a hepatic artery-to-distal superior mesenteric artery bypass followed by plug embolization of the superior mesenteric artery aneurysms. Subsequently, aortoiliac reconstruction was performed with a left aorto-uni-iliac endograft, femoral–femoral bypass, and right external-to-internal iliac artery stenting. This case highlights a rare vascular manifestation of sarcoidosis.
Langerhans cell histiocytosis (LCH) is a rare histologic disorder, that can affect and damage any tissues and organ of the body.A 40-year-old man with multisystem LCH presented with a painful distal arm mass. Imaging demonstrated a 3.6-cm true distal brachial artery aneurysm and progressive hypermetabolic activity of the affected artery on retrospective review of serial positron emission tomography/computed tomography scans.The patient underwent aneurysm resection and arterial reconstruction using a reversed great saphenous vein bypass. Histopathology confirmed infiltration of the intima and media by Langerhans cells with elastic lamina destruction. Subsequent disease-specific therapy achieved complete metabolic response, and vascular reconstruction remains patent.
Inferior vena cava (IVC) injury during thoracic endovascular aortic repair (TEVAR) is exceedingly rare. We present an 80-year-old female who developed fatal IVC perforation at the iliac confluence during large-bore (24F) sheath insertion for TEVAR. Despite successful thoracic endograft deployment, the patient developed acute hypotension and hemorrhagic shock. Emergent exploratory laparotomy revealed hemoperitoneum from an IVC tear, likely caused by shearing forces transmitted through heavily calcified iliac arteries. This case highlights the importance of preoperative access planning in patients with small, calcified iliac vessels and maintaining low threshold for suspecting retroperitoneal venous injury when clinical findings differ from angiography results.
Aneurysm of the external jugular vein is rare, and a traumatic case with documented mechanism and pathology is exceptional. A woman in her 50s sustained a blunt injury to the left anterior neck from a kendo thrust (tsuki). One month later she developed a left cervical swelling. Ultrasonography and computed tomography showed a 2-cm saccular dilatation with a cranial filling defect, indicating partial thrombosis. After four months of observation, the aneurysm was resected at the patient's request. Histopathology showed segmental loss of elastic fibers and adventitial rupture without organized thrombus. Recognizing venous injury after a kendo thrust enables timely diagnosis.
Objective Endograft explantation is associated with high morbidity and mortality, driven in part by uncontrolled shear-mediated aortic injury. We evaluated whether a mechanism-based explantation device could reduce this injury and improve procedural performance. Methods In a controlled simulation using a multilayered 3D-printed aortic model, 25 vascular trainees and surgeons performed endograft explantation using both a conventional syringe technique and a novel device (EndoEx). Outcomes included quantitative intimal injury, procedural time, and validated usability metrics. Results The EndoEx device reduced intimal injury by approximately 90% compared with the syringe technique (0.94% vs 9.56%, p<0.001), representing near-elimination of shear-mediated disruption. Procedural time was modestly longer (+32 seconds, p<0.05). EndoEx demonstrated superior usability across all domains, including ease of use, safety perception, and overall cognitive load (p<0.05). Conclusions In this controlled simulation, a mechanism-based explantation strategy (EndoEx) drastically reduced shear-mediated aortic injury while improving operator control. These findings support further in vivo evaluation and establish a mechanistic foundation for a device-based approach to EVAR explantation that warrants clinical validation.
Objective To compare the outcomes between surgical and conservative treatment of aorto-esophageal fistula after descending aortic repair. Methods Between January 2019 and January 2024, we treated 35 patients with aorto-esophageal fistula after descending aortic repair. Patients were assigned to conservative (n = 14) or surgical (n = 21) management. Surgical strategies included in situ descending thoracic aortic replacement (n = 2); two-stage aortic surgery with (n = 12) or without (n = 4) esophageal repair—first stage: combined median sternotomy and upper midline laparotomy with a four-branch Dacron graft interposition between the ascending and abdominal aortas, debranching of the supra-aortic trunks, and aortic arch transection proximal to the innominate artery; second stage: left intercostal thoracotomy with excision of the infected descending aorta, stent graft, and surrounding mediastinal tissue; single-stage aortic surgery (n = 1); and isolated esophageal repair (n = 2). Results Mean age was 54.5 ± 10.2 years, and 31 (88.6%) patients were male. Prior aortic repair included thoracic endovascular aortic repair in 27 (77.1%), total arch repair in 2 (5.7%) and combined total arch repair with thoracic endovascular aortic repair in 6 (17.1%).Early mortality was 50.0% (7/14) in the conservative group versus 14.3% (3/21) in the surgical group (P = 0.053). Causes of early death primarily included aortic rupture and sepsis with multiorgan failure. follow-up was 100% complete at median 30 months (interquartile range 3.3–74). All conservatively managed patients died within 1.5 years. Late death occurred in 6 patients of the surgical group (28.6%), and all survivors successfully resuming normal oral feeding. The 1-, 3-, and 5-year survival rates were significantly higher in the surgical group (71.4%, 58.4%, and 48.7%) compared to the conservative group (14.3%, 0%, and 0%; P < 0.001). Notably, patients undergoing two-stage aortic surgery achieved a favorable 5-year survival of 65.6%. Conclusions The two-stage aortic surgery with esophageal repair yielded favorable outcomes in the management of aorto-esophageal fistula secondary to descending aortic repair.
Short common iliac artery anatomy may preclude iliac branch device use during fenestrated or branched aortic repair. We describe two patients treated with a low-profile, short-tip distal branched custom-made device based on an aorto-uni-iliac configuration and combined with fenestrated or branched repair. The device incorporated iliac side branches to preserve bilateral internal iliac artery perfusion. In aneurysmal anatomy, complete release caused loss of ipsilateral branch access, requiring through-and-through control and balloon-assisted luminal modulation. In chronic dissection, staggered release preserved a working lumen but required adjunctive balloon dilatation. Device configuration, orientation, luminal constraint, and release sequence were critical to technical success.
Bilateral lower-limb arterial lesions after minor trauma are rare and suggestive of vascular Ehlers-Danlos syndrome (vEDS). A 40-year-old man developed bilateral anterior tibial artery (ATA) pseudoaneurysms after being kicked. The right limb, complicated by compartment syndrome, was treated by ATA ligation with aneurysm incision and hematoma evacuation; the left, by coil embolization. COL3A1 sequencing was negative, but multiplex ligation-dependent probe amplification revealed a monoallelic whole-exon deletion, confirming vEDS. Hybrid management is safe in vEDS, and copy-number analysis is essential when sequencing is negative but suspicion persists.
Acute kidney injury remains a relevant complication of open aortic surgery requiring suprarenal cross-clamping. We describe a simplified extracorporeal shunt configuration for temporary selective renal blood perfusion using devices routinely available in vascular operating rooms. Brachial arterial inflow is connected to a 9F Pruitt–Inahara shunt, whose limbs are positioned within the renal artery ostia. In our initial experience of five consecutive patients, technical success was achieved in all cases, with no postoperative deterioration in renal function or need for renal replacement therapy. This technique provides a practical and reproducible adjunct for selected open aortic procedures.
Objective To evaluate whether a structured, physiology-first surveillance protocol improves arteriovenous fistula (AVF) clinical maturation rates and reduces time to cannulation readiness compared with standard postoperative observation. Methods Two consecutive cohorts of surgically created AVFs by a single surgeon at a community-based center were compared: a standard observation cohort (January–May 2025; 64 created, 58 analyzable), and a physiology-first cohort (June 2025–March 2026; 52 created, all analyzable) managed with a structured protocol featuring standardized 2.7-mm anastomosis, day-of-creation (DOC) baseline flow documentation, structured ultrasound surveillance at weeks 2 and 4, and defined failure-to-progress intervention triggers and procedure. Salvage intervention for both cohorts included kinetic endovascular microincision creation followed by angioplasty with a drug-coated balloon. Results Overall maturation increased from 75.9%(44/58) to 92.3% (48/52; P=0.022). Unassisted maturation rose from 53.4%(31/58) to 69.2% (36/52). The overall median time to clinical maturation decreased from 49 days (IQR 42–68) to 30 days (IQR 26–43; P <0.001). Salvage intervention success was comparable between cohorts. DOC flow documentation increased from 0% to 100% and no steal syndrome was observed (0/52) with the new physiology-first protocol. Conclusions As a quality-improvement evaluation, the physiology-first protocol generated a clear and consistent signal of improved maturation outcomes: access failure decreased, unassisted maturation increased, overall maturation increased and median time to cannulation readiness decreased. These findings support adopting the protocol as a meaningful adjunct to care and warrant multi-center evaluation.
Takayasu arteritis (TA) is a rare large-vessel vasculitis that predominantly affects the aorta and its major branches. While stenotic lesions and fibrotic wall thickening are common, extensive aortic calcification with mesenteric involvement is exceedingly rare. Diffuse calcification of the aorta poses significant challenges for both open and endovascular treatment. We report a case of TA with near-circumferential calcification of the entire aorta and most visceral branches, successfully managed with intravascular lithotripsy.
Percutaneous transmural arterial bypass (PTAB), or DETOUR, is a technique for treatment of femoropopliteal occlusive disease with endovascular, extra-anatomic bypass stent-grafting(1, 2). While studies show promise, reports on the management of infection and structural failure of the PTAB stentgraft system are lacking. We describe an 80-year-old man who developed an enlarging infected femoral artery pseudoaneurysm, arteriovenous fistula, and deep venous thrombosis following PTAB. Removal of the stents was performed using total vascular isolation of the limb with open arterial exposure and clamping, Esmarch exsanguination of the venous system and iliofemoral reconstruction with rifampin-soaked Dacron and vascularized soft tissue coverage.
We report a patient who developed an acute Stanford type B aortic dissection four days after a thoracoabdominal multibranch endoprosthesis (TAMBE) repair for a ruptured thoracoabdominal aortic aneurysm. The dissection caused complete endograft collapse and profound malperfusion. Emergent salvage endovascular repair successfully re-expanded the graft; however, the patient ultimately died due to the severity of their systemic injuries. This case highlights the potential for acute type B dissection to occur in a recently stented thoracic aorta following TAMBE repair and emphasizes the need for urgent recognition of malperfusion and meticulous CT evaluation of the aortic injury pattern.
As large-bore mechanical thrombectomy is increasingly utilized to treat deep vein thrombosis (DVT), uncommon device-related adverse events, including catheter deformation, fracture, and retained intravascular foreign bodies, may be encountered. This case describes a 60-year-old man with right lower extremity DVT and pulmonary embolism (PE) in whom a Lightning Bolt 7 catheter (Penumbra) fractured during aspiration thrombectomy, resulting in a retained catheter fragment within the femoral vein that was refractory to snare retrieval attempts. During a subsequent procedure, the ClotTriever BOLD Thrombectomy System (Inari Medical), was utilized to successfully achieve simultaneous extraction of the embedded catheter fragment in its entirety and acute thrombus, restoring inline venous flow. This case highlights a salvage strategy using a large-bore, mechanically distinct thrombectomy device to retrieve a retained catheter fragment while simultaneously treating acute DVT.
Left ventricular assist device (LVAD) outflow graft obstruction (OGO) is an uncommon but serious late complication requiring individualized treatment. We describe a 71-year-old HeartMate 3 recipient with long-segment OGO stenosis more than 3 years after implantation. Because surgical revision was high risk, overlapping self-expanding venous stents were implanted percutaneously, with brief LVAD deactivation enabling controlled proximal deployment near the pump. Imaging confirmed restored graft patency and improved flow. A later distal thrombotic stenosis was managed conservatively with intensified anticoagulation. Percutaneous stenting with tailored procedural safeguards can safely treat complex late LVAD OGO in selected patients.
Introduction The DeBakey CV Education YouTube channel was established to provide free, high-quality cardiovascular education to a global audience of healthcare professionals and trainees. As digital learning increasingly supplements traditional surgical training, video-based platforms offer scalable, accessible solutions to overcome geographic, financial, and learning disparities in medical education. Methods We conducted a descriptive evaluation of the DeBakey CV Education channel from October 2015 to July 2025 using YouTube analytics platform metrics and playlist-level data across six representative content series. Production workflows from intraoperative video capture to multimedia editing and publication are described in detail. Faculty perspectives, gathered through semi-structured interviews, provided contextual support for the quantitative findings. Results Over ten years, the channel has accumulated 23 million views, 85 million watch minutes, and 132,000+ subscribers across more than 3,000 videos. Selected playlists demonstrated high engagement, with average view durations exceeding 4.7 minutes and viewer retention rates above 55%. The channel achieved viewership in over 175 countries, with the United States and India consistently leading in total views. After 2021, India's annual viewership markedly increased, surpassing the United States for that year and maintaining a consistent second place position for the remainder of the analysis period. Pakistan, the United Kingdom, and the Philippines also demonstrated steady international engagement. Faculty were also interviewed to provide additional perspective on the educational value and impact of the platform. Conclusion The DeBakey CV Education channel exemplifies a scalable, sustainable model for open-access education. Through content creation, editorial review, and public dissemination, the platform supports mentorship and equitable learning across geographically and economically diverse settings. Future directions include interactive content formats and prospective validation of learning outcomes.
Vascular invasion is a common feature of renal cell carcinoma and intraoperative thrombus embolization during surgical resection, while rare, is a devastating complication. Temporary inferior vena cava filters have been employed in certain cases to provide protection from thrombi in large vessel oncologic surgeries; however, the Protrieve system (Stryker-Inari Medical, Irvine, California, USA) has not been well studied in this context. We report two cases in which intraoperative deployment of the Protrieve sheath effectively captured embolized tumor thrombus.
Endovascular exclusion of the false lumen (FL) in chronic type B aortic dissection is challenging when visceral branches depend on FL perfusion. We report a case of chronic type B aortic dissection in which the superior mesenteric artery (SMA) originated from the FL with concomitant celiac artery occlusion. Antegrade SMA perfusion was restored by balloon angioplasty and bridging stent grafting across a pinhole re-entry, followed by thoracic endovascular aortic repair with a fenestrated stent graft to seal the proximal entry. Follow-up imaging demonstrated complete FL thrombosis, favorable aortic remodeling, and preserved SMA perfusion. This case highlights the importance of tailored procedural sequencing.
