•Brachial artery mycotic aneurysm (BAMA) secondary to infective endocarditis.•Only case reported to be caused by haematogenous spread of Enterococcus faecalis.•BAMAs are rare and can be potentially limb or life threatening.•One must acknowledge bacterial endocarditis as a cause of BAMA.•Prompt diagnosis and intervention are essential for good outcomes.
•Iatrogenic aortic injuries during non-aortic related procedures are rare.•Such injuries can be catastrophic.•Most reported injuries involve orthopaedic hardware from spine surgery.•This is a case of thoracostomy tube placement leading to acute aortic injury.•Endovascular aortic endografts have simplified treatment of acute aortic injuries.
An 82 year old male presented eight years after left popliteal endovascular aneurysm repair (PEVAR) for a 58 mm popliteal artery aneurysm (PAA) using 10 mm Viabahn endoprostheses (WL Gore and Associates, Flagstaff, USA). He had undergone prior contralateral bypass for chronic limb threatening ischaemia due to an occluded PAA in 2010 (patent). He took up cycling after this, resulting in multiple redo PEVAR episodes to treat migration (2011, stent graft extension) and fracture (2014, relined), with eventual graft failure and fractures with no endoleak noted (Fig. 1), diagnosed when he presented with left calf pain (deep vein thrombosis excluded). Throughout there was continued PAA shrinkage (currently 47 mm). As there was now new PAA formation distal to the distal landing zone of the stent graft, this was treated with a reversed great saphenous vein bypass graft which remains patent at six months. This report indicates that PEVAR endografts can be maintained for a reasonably long time despite repeated complications.
Post-endarterectomy pseudoaneurysms (PEPA) are a rare complication of carotid endarterectomy (CEA), but are associated with high morbidity risk. Therefore, once they are diagnosed, treatment is urgent to prevent possible complications such as rupture, embolisation, thrombosis, or airway and cranial nerve compression. In this video, the surgical procedure is shown in a case of PEPA 10 years after CEA with patch angioplasty, which was successfully managed by surgical excision and interposition of great saphenous vein graft. Follow up duplex examination at six months was normal, with patency of the vein graft. This case reiterates the importance of open surgery as the treatment of choice for this difficult clinical setting.
We read the commentary from Alric and Canaud1Alric P. Canaud L. Is chimney EVAR an acceptable endovascular technique?.EJVES Short Rep. 2019; 42: 43https://doi.org/10.1016/j.ejvssr.2019.01.001Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar regarding our case of a symptomatic patient unfit for open repair symptomatic with persistent gutter related type Ia endoleak after chimney endovascular aneurysm repair (ch-EVAR).2Ballesteros-Pomar M. Taneva G.T. Austermann M. Fernández-Samos R. Torsello G. Donas K.P. Successful management of a type B gutter related endoleak after chimney EVAR by coil assisted onyx embolisation.EJVES Short Rep. 2019; 42: 38-42https://doi.org/10.1016/j.ejvssr.2018.12.002Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The goal of our case presentation was to provide information about possible solutions for suboptimal performance, as a lesson learned after 10 years of clinical experience and treatment of more than 250 cases by ch-EVAR.3Donas K.P. Lee J.T. Lachat M. Torsello G. Veith F.J. Dalman R.L. et al.Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry.Ann Surg. 2015; 262: 546-552https://doi.org/10.1097/SLA.0000000000001405Crossref PubMed Scopus (221) Google Scholar, 4Donas K.P. Torsello G.B. Piccoli G. Pitoulias G.A. Torsello G.F. Bisdas T. et al.The PROTAGORAS study to evaluate the performance of the Endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique.J Vasc Surg. 2016; 63: 1-7https://doi.org/10.1016/j.jvs.2015.07.080Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar As the authors published when they reported on the role of physician modified endografts “to break the rules you must first master them.”5Canaud L. Gandet T. Ozdemir B.A. Sfeir J. Alric P. Commentary: physician-modified thoracic stent-graft: to break the rules you must first master them.J Endovasc Ther. 2018; 25: 464-465https://doi.org/10.1177/1526602818779394Crossref PubMed Scopus (1) Google Scholar And, in this context, we believe that presentation of successful management of challenging cases with persistent post-operative flow to the aneurysm sack is of particular importance, having as a sustained goal of optimising the outcome in favour of the patient. The authors are wondering whether ch-EVAR is in general, an alternative option. The answer could be very easily given from recommendation 97 of the European Society for Vascular Surgery (ESVS)'s newest guidelines regarding juxtarenal aneurysms.6Wanhainen A. Verzini F. Herzeele I Van Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg 2019. 2018; https://doi.org/10.1016/j.ejvs.2018.09.020Abstract Full Text Full Text PDF Scopus (1165) Google Scholar It is stated that ch-EVAR can be considered as an alternative option when fenestrated endografting (f-EVAR) is not indicated or not available. The level of evidence (C) is the same as for f-EVAR,6Wanhainen A. Verzini F. Herzeele I Van Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg 2019. 2018; https://doi.org/10.1016/j.ejvs.2018.09.020Abstract Full Text Full Text PDF Scopus (1165) Google Scholar and our case is in full alignment with this recommendation. There is no evidence in the new guidelines supporting other alternative therapies rather than chimney grafts as the authors of the commentary suggested. In summary, the use of chimney grafts is no longer a matter of faith but a fact. The evidence in the literature supports its complementary role for the treatment of juxtarenal aneurysms and in agreement with that the ongoing ENCHANT Study as a fully prospective multicentre trial of ch-EVAR (clinicaltrials.gov identifier: NCT03320252) will provide further evidence bringing the technique to a higher level of evidence (B) than f-EVAR (C). Do we want to keep looking at the tree and not the forest?
