Chronic infrarenal aortic occlusion is an advanced manifestation of atherosclerotic disease associated with significant morbidity. Open surgical reconstruction remains the historical gold standard. Endovascular recanalization has emerged as a viable alternative in selected patients, although the technical success rate remains low and the risk of complications high. Herein is presented a case of an 81-year-old gentleman with symptomatic, chronic, infrarenal aortic occlusion that was successfully treated with balloon angioplasty and implantation of a covered balloon expandable stent.
Objectives Thoraco-abdominal aneurysms carry high mortality and morbidity with open repair. Current endovascular strategies include custom made devices that require several weeks to be constructed. Physician modified grafts or laser fenestrations lack quality control and are associated with a learning curve. Recent publication of the 1 year PIVOTAL data support the use of an off-the-shelf, GORE TAMBE device in pararenal and extent 4 thoraco-abdominal aneurysms. We describe our experience with this device in patients with anatomy outside of this criteria. Methods We retrospectively reviewed our experience with seven cases of thoraco-abdominal aneurysms extending beyond the para-renal or extent 4 anatomy at a single, high-volume Canadian center. Results Patients with varying aortic aneurysm anatomy, including extent I, extent V, and previous open thoraco-abdominal aortic repair, were treated with the Gore TAMBE with technical success. There was no procedure-related mortality. There was one case of spinal cord ischemia resulting in paraplegia, and one case of post-operative stroke resulting in hemiplegia. Conclusion Early experience with the use of TAMBE in conjunction with proximal TEVAR to treat thoraco-abdominal aneurysms, that extend beyond the pararenal and extent 4 aneurysms treated in the PIVOTAL trial, is encouraging and warrants further investigation.
An 85-year-old man developed a device-related infected femoral pseudoaneurysm after carotid artery stenting. Because rupture was feared, initial treatment consisted of minimal skin incision drainage and empiric intravenous antibiotics. After improvement in inflammatory markers and general condition, a salvage bypass from the distal external iliac artery to the mid-superficial femoral artery was created with a reversed great saphenous vein graft via a retroperitoneal trans-inguinal-ligament lateral groin route, followed by excision of infected arterial segments, serial debridement, and delayed contralateral rectus abdominis muscle flap coverage. At 16 months, bypass patency, limb perfusion, and infection control were maintained.
Objective : Carotid artery entrapment is a rare phenomenon often caused by anatomic abnormalities. This case series describes two patients with carotid artery entrapment who presented with atypical pathologies. Methods : First patient was a 62-year-old female with severe, presyncopal symptoms when rotating head. CTA revealed near-complete occlusion of the ICA by the superior cornu of the thyroid cartilage. Second patient is a 66-year-old female with transient dysarthria found on CTA to have a dynamic hyoid bone that changed position in relation to the ICA with head rotation. Both opted for surgical management in conjunction with otorhinolaryngology. Results : In case 1, an elongated suspensory, calcified thyrohyoid ligament, and an elongated superior cornu were identified extending across the internal carotid artery. Post-operative CTA neck showed patent right ICA in symptomatic and asymptomatic position. In case 2, the thyrohyoid ligament and hyoid bone extended across the left ICA. CTA neck showed improved luminal caliber of the left internal carotid. Discussion : Carotid artery entrapment is a rare condition with diverse pathology. We describe two unique compressions of carotid arteries by the lateral thyrohyoid ligament, superior cornu impingement, and/or the hyoid bone where surgical resection was an effective treatment due to the mechanical nature of the compressions.
We report an 82-year-old man presenting with severe systemic inflammation six years after permanent inferior vena cava (IVC) filter placement. Computed tomography revealed a 66-mm saccular infected abdominal aortic aneurysm immediately adjacent to the filter. Following 36 days of targeted antibiotics, he underwent open surgical repair via a suprarenal cross-clamp due to dense periaortic fibrosis. To minimize the risk of catastrophic venous hemorrhage, surgical extraction of the filter was avoided, maintaining the option of future endovascular (catheter) retrieval if necessary. Histopathology confirmed severe chronic inflammatory cell infiltration traversing the aortic wall, representing a modified healing phase of the infection following the prolonged antibiotic course. This case highlights that the long-term presence of permanent IVC filters might be associated with a vulnerability to adjacent regional aortic wall infections.
Background: Aortic endograft infection is uncommon, and fastidious organisms may escape routine culture. Case: A 58-year-old man presented 15 months after urgent EVAR with fever, anemia, and an inflammatory syndrome. CTA and FDG PET/CT supported endograft infection, whereas blood and operative cultures were negative. Complete explantation and in situ aorto-bi-iliac reconstruction were performed. Broad-range 16S rRNA gene analysis identified Helicobacter bilis. Doxycycline was continued for six weeks after surgery, with no recurrence at one year. Conclusion: Molecular testing aids culture-negative diagnosis, but complete surgical source control remains essential.
Introduction Aberrant right subclavian artery may cause dysphagia lusoria due to retroesophageal compression. Report We report a 45-year-old man with progressive solid-food dysphagia and retrosternal discomfort caused by a retroesophageal aberrant right subclavian artery without Kommerell diverticulum. He underwent single-stage hybrid repair with right carotid-subclavian bypass, thoracic endovascular aortic repair covering the aberrant vessel origin, Amplatzer Vascular Plug occlusion, and additional surgical ligation proximal to the vertebral artery origin. This dual-site, triple-modality exclusion strategy was selected to prevent persistent retrograde perfusion of the retroesophageal segment. Discussion Dysphagia resolved completely, and one-month computed tomography angiography confirmed bypass patency, complete thrombosis of the excluded segment, and absence of endoleak. This case highlights a practical hybrid strategy for complete exclusion of the aberrant right subclavian artery and prevention of persistent retrograde perfusion.
We present a case series describing the off-label use of prolonged remimazolam infusions for intraoperative sedation for vascular surgery procedures in three patients with severe cardiac dysfunction. All patients had a history of heart failure with reduced ejection fraction (25%–35%) and underwent minor vascular procedures under sedation. In each case, remimazolam was used as the primary agent, with infusion durations exceeding the FDA-approved 30-minute limit: 40, 103, and 94 minutes, respectively. Adjunctive medications were minimal—one patient received only 25 mcg of fentanyl, and another required low-dose vasopressors without significant blood pressure fluctuation. All three patients tolerated the sedation without complications, and no postoperative respiratory or hemodynamic instability was observed. These findings highlight the potential utility of remimazolam for extended intraoperative sedation in high-risk cardiac patients, especially those with limited hemodynamic reserve, undergoing vascular surgery procedures. Further prospective studies are warranted to evaluate the safety and efficacy of longer-duration remimazolam infusions in this patient population.
Intravenous leiomyomatosis is characterized by the growth of leiomyomatous tissue within the venous walls. It is rare but can have devastating consequences when extending into cardiac chambers.A 45-year woman presented with abdominal pain and thrombosis of left ovarian vein extending to the renal vein. Intravenous leiomyomatosis was suspected on imaging, due to the association with uterine myomas. Left nephrectomy with complete hysterectomy, right salpingectomy and left adnexectomy were performed. Follow-up at one-year was uneventful. Even rare, vascular surgeons should include intravenous leiomyomatosis in their differential diagnosis of venous thrombosis in a reproductive or premenopausal woman regardless of symptoms.
Background Aortic arch aneurysms remain challenging to treat because of their proximity to the supra-aortic branches and the need to preserve cerebral perfusion. Conventional open total arch replacement may be associated with considerable perioperative risk in selected patients. Hybrid repair, consisting of surgical supra-aortic debranching followed by thoracic endovascular aortic repair (TEVAR), may provide an alternative treatment strategy when adequate landing zones cannot be achieved with standard TEVAR alone. Case Presentation A 61-year-old man presented with chest pain radiating to the back. Computed tomography angiography demonstrated a symptomatic saccular aortic arch aneurysm extending into the descending thoracic aorta, with a maximal diameter of 70.1 mm and involvement of the origins of the supra-aortic vessels. Because of hypertension, diabetes mellitus, and active smoking, the patient was considered to have an increased risk for conventional open total arch replacement. He had no history of previous cardiac, thoracic, or vascular surgery. A two-stage hybrid strategy was selected. First, supra-aortic debranching was performed through a median sternotomy using Dacron grafts to revascularize the brachiocephalic trunk, left common carotid artery, and left subclavian artery. Four weeks later, after computed tomography angiography confirmed graft patency, TEVAR was performed using the surgically created proximal landing zone. The postoperative course was uneventful. One-month follow-up imaging demonstrated patent debranching grafts, stable endograft position, complete aneurysm exclusion, and no detectable endoleak. Conclusion Two-stage hybrid repair may be a feasible option for selected patients with complex aortic arch anatomy who are considered to be at increased risk for conventional open repair. This case demonstrates a favorable early clinical and radiological outcome. Longer follow-up is required to assess long-term durability.
Pseudoaneurysms of the dorsalis pedis artery (DPA) are exceedingly rare, accounting for <0.5% of all peripheral arterial aneurysms. Surgical management for symptomatic patients is the current standard of care.We report the case of a 67-year-old woman who presented with a DPA pseudoaneurysms secondary to a previous trauma. She underwent surgical excision with bovine pericardial patch angioplasty of the DPA. Postoperatively, she maintained a palpable distal pulse.This case highlights the importance of individualized management. To our knowledge, this is the first reported case of DPA pseudoaneurysm treated with bovine pericardial patch angioplasty, adding a novel reconstructive option.
Introduction Neurofibromatosis type 1 is commonly associated with cutaneous and neurological features; however, NF1-related vasculopathy can lead to rare, life-threatening complications such as spontaneous hemothorax. This case highlights an unusual presentation of arterial rupture causing massive hemothorax and contributes to the limited literature on its diagnosis and management. Case Presentation A 50-year-old male with known NF1 presented with sudden-onset chest pain, collapse, and hemodynamic instability. Imaging revealed a massive left-sided hemothorax with active arterial extravasation from a branch of the thyrocervical trunk. The patient was managed with a massive transfusion protocol followed by urgent transcatheter arterial embolization, which successfully achieved hemostasis. He showed progressive clinical improvement in the intensive care unit and was discharged in stable condition. Conclusion Spontaneous hemothorax in NF1 is a rare but critical emergency requiring prompt recognition and rapid multidisciplinary intervention. Early imaging and endovascular embolization can be life-saving, emphasizing the need for heightened clinical awareness and timely management in such cases.
Renal artery aneurysms (RAAs) are rare in comparison to other arterial aneurysms. However, they have great clinical importance due to their natural history leading to serious complications. The restoration of anterograde flow is the conventional standard for elective treatment of RAAs in contemporary practice. Several open and endovascular procedures meet this criterion. The choice of RAA treatment depends on their anatomy and location, associated vascular procedures, as well as on patients comorbidities and life expectancy. Our case report includes an open repair of an RAA that involved the distal segment of the renal artery. This approach represents an efficient and safe treatment option if it is performed by an experienced vascular surgeon. Open repair of RAAs is especially recommended in children and young patients.
Background Endovascular aneurysm repair (EVAR) is widely accepted as a less invasive treatment for abdominal aortic aneurysms. However, in patients with hostile anatomy, rare but catastrophic complications such as shower embolism may occur. The underlying mechanisms remain poorly understood. Case A 73-year-old man with a 56-mm infrarenal abdominal aortic aneurysm underwent elective EVAR. Preoperative imaging demonstrated a shaggy aorta, a very short proximal neck, and severe stenosis of the left common iliac artery. An AFX2 unibody endograft was selected to minimize wire manipulation and avoid proximal ballooning. During the procedure, intraoperative aortography showed contrast reflux toward the proximal aorta. Postoperatively, the patient developed acute paraplegia and multi-organ ischemia. Results Computed tomography angiography revealed multiple infarctions in the kidneys, spleen, liver, together with poor enhancement of the gallbladder and descending colon wall, without occlusion of major visceral arteries, suggesting diffuse microembolization. A minor Type Ia endoleak, not detected intraoperatively, was retrospectively identified. Surgical exploration confirmed extensive intestinal and gallbladder necrosis. Histopathology demonstrated fresh, unorganized thrombi without identifiable cholesterol clefts. Despite aggressive supportive management, the patient died shortly after reoperation. Conclusion This case suggests that transient outflow obstruction during EVAR may have increased intra-aneurysmal sac pressure, promoting thrombus fragmentation and fatal shower embolism. Recognition of impaired distal outflow as a potential trigger for embolic complications may be critical when performing EVAR in anatomically high-risk patients.
A 56-year-old right-handed man presented with a painful, progressively enlarging pulsatile mass in the palm associated with paresthesia in the ulnar nerve distribution, reproduced by a positive Tinel’s sign at Guyon’s canal, without objective motor deficit. Initial clinical suspicion included a soft tissue tumor. On physical examination, the lesion was tender and pulsatile. Doppler ultrasound and magnetic resonance angiography confirmed a saccular pseudoaneurysm of the ulnar artery. Surgical treatment consisted of pseudoaneurysm resection and direct microsurgical repair of the arterial defect under magnification. Complete excision and restoration of arterial continuity were achieved without intraoperative complications. The postoperative course was uneventful, with progressive resolution of neurological symptoms. At two months, the patient had returned to normal activities, with preserved hand function and confirmed arterial patency on ultrasound. Ulnar artery pseudoaneurysms are rare and may present as palmar masses, leading to diagnostic delay. A high index of suspicion and appropriate imaging are essential for accurate diagnosis.Type of Study / Level of Evidence: Case report; Level V evidence.
In the case of carotid artery disease, improved evaluation of plaque morphology and better characterization of stenotic disease, particularly highly calcific or heterogenous lesions, is extremely important in making appropriate patient care decisions in the treatment of both symptomatic and asymptomatic disease. We present three cases here wherein repeating a CT angiogram with higher quality, photon-counting detector CT resulted in a more accurate measured degree of stenosis, more appropriate patient counseling, and a change in clinical management.
Thoracoabdominal aortic aneurysms (TAAA) with chronic dissection and complex visceral involvement are difficult to treat, particularly in older patients with severe comorbidities. Although advances in fenestrated and branched endovascular techniques have expanded treatment options, cases with highly complex anatomy remain challenging. An 83-year-old man with TAAA, chronic abdominal aortic dissection, complete occlusion of the celiac and superior mesenteric arteries, duplicated left renal arteries, and severe chronic obstructive pulmonary disease (COPD) was considered unsuitable for open repair because of his pulmonary status. A custom fenestrated thoracic endovascular aortic repair (F-TEVAR) with two renal fenestrations was deployed in the false lumen under intravascular ultrasound (IVUS) guidance. The right renal artery was reconstructed with a covered stent, and both left renal arteries were preserved through fenestrations. Endovascular aortic repair (EVAR) was subsequently extended from the descending thoracic to the abdominal aorta,intentionally maintaining dual-lumen perfusion. The distal landing zone was placed just above the inferior mesenteric artery (IMA) to preserve mesenteric inflow. Dual-lumen preservation, renal reconstruction, and IMA protection were essential for maintaining organ perfusion, while IVUS guidance and preoperative pulmonary rehabilitation contributed to procedural safety.
Background Visceral artery pseudoaneurysms (PSA) carry high morbidity. While endovascular interventions are preferred, open surgical revascularization remains essential when anatomical constraints preclude stenting. Methods A 39-year-old male presented with epigastric pain, hematochezia, and syncope. CT angiography revealed a 3.5 cm pseudoaneurysm of a replaced right hepatic artery (RRHA). Results Due to the small vessel diameter (<4 mm) and critical need to preserve hepatic perfusion, endovascular stenting was deemed high-risk. He underwent open distal ligation and splenic artery to RRHA bypass using a great saphenous vein graft. Postoperative imaging confirmed pseudoaneurysm thrombosis and patent revascularization. Conclusion Open surgical bypass remains a vital strategy for hepatic artery pseudoaneurysms. It ensures definitive exclusion and preserves end-organ perfusion in patients with challenging vascular anatomy where endovascular options are unsafe.
Introduction Superior mesenteric vein aneurysms are extremely rare, with limited cases reported. Management is individualized, ranging from observation to surgery, as no standardized guidelines exist. This report contributes to defining intervention strategies when expansion increases rupture risk. Case presentation An 81-year-old woman with diabetes, hypertension, coronary artery disease, and atrial fibrillation presented with 3–4 months of progressive upper abdominal and back pain, distension, and bloating. Five years earlier, a 2.5 cm superior mesenteric vein aneurysm had been incidentally identified on CT. Current imaging showed enlargement to 4 cm with compression of the pancreatic duct causing dilation. The patient underwent aneurysmectomy via midline incision, resulting in symptom resolution on follow-up. Conclusion Management of superior mesenteric vein aneurysms depends on size, growth, thrombosis, and symptoms. Conservative management is often used for stable, asymptomatic cases, but clear guidelines are lacking due to limited understanding of risk factors for expansion, thrombosis, and rupture. A review of English-language literature since 1982 identified 24 reported cases; this case brings the total to 25. Analysis of presentations and management approaches aims to inform future strategies. This report underscores the need for standardized treatment guidelines for both asymptomatic and symptomatic patients.
The femoral vein is classically described as the direct continuation of the popliteal vein, passing through the adductor hiatus to enter the adductor canal where it courses anteromedial to the adductor magnus alongside the femoral artery. Although several variations of the femoral vein have been reported, these typically involve duplication or differences in venous confluence while preserving the expected anterior compartmental position. During routine cadaveric dissection of the thigh of a 76-year-old female donor, an unusual anatomical variant was identified in which the femoral vein coursed posterior to the adductor magnus rather than entering the adductor canal with the femoral artery. The vessel remained a single continuous vein without duplication and resumed its normal anatomical relationship proximally within the femoral triangle. To our knowledge, this posterior trajectory of the femoral vein relative to the adductor magnus has not been previously reported. Recognition of this variant is clinically important because diagnostic imaging, venous access, and surgical exposure of the femoral vessels rely on predictable anatomical relationships within the adductor canal. Documentation of rare venous variants expands current anatomical knowledge and may help prevent diagnostic errors or procedural complications when expected vascular relationships are not encountered.
