Background: Chronic limb-threatening ischemia (CLTI) represents the most severe form of peripheral artery disease. While previous studies have focused on gender and racial disparities, there is lack of evidence regarding the impact of housing status. The aim of this analysis was to identify disparities in inpatient management and outcomes of CLTI based on housing status. Methods: In this retrospective, descriptive study, we analyzed patients admitted with CLTI who underwent revascularization, as identified by International Classification of Diseases, 10th Revision, Clinical Modification codes, between 2016 and 2021, using the National Inpatient Sample database. The patients were stratified by their housing status and a detailed, propensitymatched analysis was conducted to compare the demographics, comorbidities, mortality rates, types of intervention, resource utilization, and inpatient outcomes. Results: During the study, 2,667,294 patients were admitted with CLTI, and 17% (463,435) underwent revascularization. Among these, 0.4% (1,790) was unhoused. Males were overrepresented in the unhoused group (83.5% vs. 62.5%, P < 0.001). Unhoused patients were more likely to receive endovascular revascularization (adjusted odds ratio [AOR] 1.77, 0.45-0.90, P - 0.003) but less likely to undergo open surgical intervention (AOR 0.64, 0.45-0.90, P - 0.010). They were also more likely to undergo aortoiliac interventions, while housed patients underwent more distal interventions. The mean adjusted length of stay was 4 days longer and inflation-adjusted costs were $8,501 higher for unhoused patients (P < 0.001). Unhoused patients were also more likely to leave against medical advice and be transferred to skilled nursing facilities. Conclusions: This study highlights significant disparities in CLTI management and outcomes between housed and unhoused patients, underscoring the need for targeted interventions to address these inequities.

Background Delayed stent grafting for blunt thoracic aortic injuries (BTAIs) is current standard of care. However, given the heterogeneity of pseudoaneurysm presentations, it is currently unclear which severe BTAIs require more urgent intervention. We hypothesize that a Traumatic Aortic Disruption Index (TADI) calculation based on sagittal computed tomography angiography imaging measurements would correlate with urgency of stent grafting. Methods All patients at a level-1 trauma center with BTAIs over a 12-year period were identified. A TADI score was then calculated using the length of pseudoaneurysm (L), maximum width of pseudoaneurysm (W), and normal adjacent aortic diameter (NA). Patient presentation, injury characteristics, timing of stent grafting, and outcomes were then evaluated. Results Forty-two patients were diagnosed with BTAIs. Mean age was 37.6 years, with a median injury severity score (ISS) of 29. Overall mortality was 11.9%. TADI scores ranged from 3.6 to 158.6. Compared to patients with a TADI <28, patients with TADI >28 had similar median ISS scores (34 vs. 29, P = 0.16), and rates of both traumatic brain injury (TBI; 33.3% vs. 42.0%, P = 0.53) and nonaortic hemorrhage control procedures (44.4% vs. 33.3%, P = 0.3). TADI >28 patients had a lower initial mean systolic BP (98.5 vs. 121.9, P = 0.003), more severe hypotension (lowest systolic 77.0 vs. 91.2, P = 0.034), lower initial Glasgow Coma Scale (6 vs. 13, P = 0.039), higher mean admission lactate (4.6 vs. 3.3, P = 0.036), and higher overall mortality (23.8% vs. 0%, P = 0.048). Patients with TADI >28 received stent grafting at significantly shorter median time intervals from injury identification (median 4 hrs vs. 14 hrs, P = 0.001). Overall causes of mortality were aortic hemorrhage related (n = 3, 60%) and TBI (n = 2, 40%). Conclusions This simple-to-calculate index is independently correlated with mortality and urgency of stent grafting in blunt trauma patients with similar ISS. Patients with TADI scores >28 were more likely to undergo urgent stent grafting, thereby suggesting a trend in practice patterns with higher scores representing injuries that should be considered for expedited operative management. The TADI score should be validated in a larger sample of blunt trauma patients as an injury prioritization tool in the multisystem injured patient.

Intraoperative positioning system (IOPS; Centerline Biomedical, Inc) is a novel technology that allows for real-time intravascular navigation of endovascular devices using an electromagnetic field. In this report, we describe the use of IOPS for effective treatment of bilateral common iliac artery aneurysms with endovascular aortoiliac repair using iliac branch endoprostheses. Our experience suggests that this technology has the potential to reduce radiation and contrast use in endovascular procedures, although its application is currently limited. To the best of our knowledge, this is the first reported case of bilateral internal iliac cannulations for iliac branch endoprosthesis placement using IOPS.

Delayed stent grafting of blunt thoracic aortic (grade 3) pseudoaneurysms (BTAPs) is a standard practice, allowing focus on more acute life-threatening injuries. Which severe BTAPs require urgent intervention is currently unclear. We hypothesize that a Traumatic Aortic Disruption Index (TADI) based on sagittal computed tomography (CT) imaging would predict urgency of stent grafting in polytrauma patients. All BTAPs at a level-1 trauma center over 12-years were identified. TADI score was calculated utilizing pseudoaneurysm length (L), maximum injury width (W), and normal adjacent aortic diameter (NA) on a CT image (Fig 1). Patient presentation, timing of stent grafting, and outcomes were then evaluated. Forty-two patients were diagnosed with BTAP. Mean age was 37.6 years, with median injury severity score (ISS) of 29. Overall mortality was 11.9% (aorta-related, n = 3; 60%; traumatic brain injury [TBI], n = 2; 40%). TADI scores ranged from 3.6 to 158.6. Compared with patients with TADI <28 (n = 21), patients with TADI >28 (n = 21) had similar median ISS scores (34 vs 29; P = .16) and rates of both TBI (33.3% vs 42.0%; P = .53) and non-TEVAR hemorrhage control procedures (44.4% vs 33.3%; P = .3). However, patients with TADI >28 had lower presentation mean systolic blood pressure (98.5 mmHg vs 121.9 mmHg; P = .003) and higher overall mortality (23.8% vs 0%; P = .048). Patients with TADI >28 received stent grafting at significantly shorter time intervals (median 4 vs 14 hours; P = .001). In subgroup analysis of patients with TBI (n = 16), overall median time from injury to stent grafting was 5 hours. Patients with TADI>28 and TBI received stent grafting at significantly shorter time intervals than patient with TADI <28 and TBI (median 3 vs 10 hours; P = .026). This simple-to-calculate score predicted mortality and urgency of stent grafting in polytrauma patients with similar ISS and rates of TBI. TADI should be validated in a larger prospective study as an injury prioritization tool in trauma patients with BTAPs.

Background: Arterial axillosubclavian injuries (ASIs) are currently managed with open repair (OR) and endovascular stenting (ES). The long-term prognosis of patients with these and associated brachial plexus injuries is poorly understood. We hypothesize that OR and ES for ASI have similar long-term patency rates and that brachial plexus injuries would confer high long-term morbidity. Methods: All patients at a level-1 trauma center who underwent procedures for ASI over a 12year period (2010 to 2022) were identified. Long-term outcomes of patency rates, types of reintervention, rates of brachial plexus injury, and functional outcomes were then investigated. Results: Thirty-three patients underwent operations for ASI. OR was performed in 72.7% (n = 24) and ES in 27.3% (n = 9). ES patency was 85.7% (n = 6/7) and OR patency was 75% (n = 12/16), at a median follow-up of 20 and 5.5 months respectively. In subclavian artery injuries, ES patency was 100% (n = 4/4) and OR patency was 50% (n = 4/8) at a median followup of 24 and 12 months respectively. Long-term patency rates were similar between OR and ES (P = 1.0). Brachial plexus injuries occurred in 42.9% (n = 12/28) of patients. Ninety percent (n = 9/10) of patients with brachial plexus injuries who were followed postdischarge had persistent motor deficits at median follow-up of 12 months, occurring at significantly higher rates in patients with brachial plexus injuries (90%) compared to those without brachial plexus injuries Conclusions: Multiyear follow-up demonstrates similar OR and ES patency rates for ASI. Subclavian ES patency was excellent (100%) and prosthetic subclavian bypass patency was poor (25%). brachial plexus injuries were common (42.9%) and devastating, with a significant portion of patients having persistent limb motor deficits (45.8%) on long-term follow-up. Algorithms to optimize brachial plexus injuries management for patients with ASI are high-yield, and likely to influence long-term outcomes more than the technique of initial revascularization.

We have described the utility of a three-dimensionally (3D) printed model in the surgical repair of an extensive mycotic superior mesenteric artery (SMA) aneurysm. A 62-year-old woman with no pertinent medical history had presented with a 2-week history of fever, abdominal pain, and diarrhea. Laboratory analysis demonstrated leukocytosis. Computed tomography angiography (CTA) revealed an SMA mycotic aneurysm with degeneration along its entire length and endometrial/myometrial inflammation. After obtaining blood cultures, endometrial biopsy, and initiating broad-spectrum antibiotics, the patient was scheduled for urgent aneurysm repair because of the risk of rupture.

OBJECTIVE:Compare the effects of preoperative embolization for carotid body tumor resection on surgical outcomes to carotid body tumor resections without preoperative embolization.METHODS:Single-center retrospective review of all consecutive patients who underwent carotid body tumor resection from 2001 to 2019. Surgical outcomes with emphasis on operative time (estimated blood loss and cranial nerve injury) of patients undergoing carotid body tumor resection following preoperative embolization were compared to those undergoing resection alone using unpaired Student's t-test and Fisher's exact test.RESULTS:Forty-six patients (15% male, mean age 50 ± 15 years) underwent resection of 49 carotid body tumors. Patients undergoing preoperative embolization (n = 20 (40%)) had larger mean tumor size (4.0 ± 0.7 vs 3.2 ± 1 cm, p = 0.006), increased Shamblin II/III tumor classification (18 (90%) vs 22 (76%), p < 0.001), operative time (337 ± 195 vs 199 ± 100 min, p = 0.004), and cranial nerve injuries overall (8 (40%) vs 2 (10%), p = 0.01) compared to patients undergoing resection without preoperative embolization (n = 29 (60%)). In subgroup analysis of Shamblin II/III classification tumors (n = 40), preoperative embolization (n = 18) was associated with increased tumor size (4.1 ± 0.6 vs 3.5 ± 0.9 cm, p = 0.01), operative time (351 ± 191 vs 244 ± 105 min, p = 0.02), and cranial nerve injury overall (8 (44%) vs 2 (9%), p = 0.03) compared to resections alone (n = 19). In further subgroup analysis of large (⩾ 3 cm) tumors (n = 37), preoperative embolization (n = 18) was associated with increased operative time (350 ± 191 vs 198 ± 99 min, p = 0.006) and cranial nerve injury overall (8 (44%) vs 2 (11%), p = 0.03) compared to resections alone (n = 19). There were no significant differences in estimated blood loss, transfusion requirement, or hematoma formation between any of the embolization and non-embolization subgroups.CONCLUSION:After controlling for tumor Shamblin classification and size, carotid body tumor resections following preoperative embolization were associated with increased operative time and inferior surgical outcomes compared to those tumors undergoing resection alone. Nonetheless, such results remain susceptible to the confounding effects of individual tumor characteristics often used in the decision to perform preoperative embolization, underscoring the need for prospective studies evaluating the utility of preoperative embolization for carotid body tumors.

Background: Recently, there has been an abundance of encouraging data regarding the creation of percutaneous arteriovenous fistulas. Despite promising data regarding their clinical maturation, a paucity of data exists which provides direct comparison between percutaneously created AVFs (pAVF) and open surgically created AVFs (sAVF). This study has 2 primary objectives: First, to compare clinical outcomes of pAVFs to sAVFs, with emphasis on clinical maturation and frequency of postoperative interventions to facilitate maturation. Second, to contribute toward the evidence-based incorporation of the pAVF procedure into the hemodialysis access algorithm. Methods: A single-center retrospective review was performed on all consecutive patients undergoing surgically created brachiocephalic arteriovenous fistula (BC-AVF, sAVF group) from January 1, 2018 to December 31, 2018 and Ellipsys-created percutaneous arteriovenous fistula (pAVF group) from January 1, 2019 to December 31, 2019. Comparative analysis between groups was performed. Results: A total of 24 patients underwent Ellipsys-created pAVF with mean age of 56.7 +/- 22.6 years (12 males [50%], 12 females [50%]) and 62 patients underwent surgically created BC-AVF with mean age of 62.5 +/- 13.2 years (32 males [52%], 30 females [48%]). Both the pAVF and sAVF groups had comparable mean operating times (60 +/- 40 vs. 56 +/- 25 min, P = 0.67) and frequency of procedural technical success (23 [96%] vs. 62 [100%], P = 0.28), respectively. The pAVF group had a lower clinical maturation rate (12 [52%] vs. 54 [87%], P = 0.003) and a higher primary failure rate (9 [39%] vs. 6 [10%], P = 0.003) when compared to the sAVF group. The pAVF group had an increased overall rate of undergoing a postoperative intervention (18 [78%] vs. 13 [21%], P < 0.001), as well as an increased number of total postoperative interventions (1.1 +/- 0.9 vs. 0.3 +/- 0.6 interventions, P < 0.001) compared to the sAVF group. Percutaneous transluminal angioplasty of the juxta anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency when compared to the sAVF group rate (13 [57%] vs. 5 [8%], P < 0.001). Conclusions: In our single-center retrospective review, patients undergoing Ellipsys-created pAVF in the first year following introduction of percutaneous endovascular had inferior rates of clinical maturation and underwent more postoperative interventions when compared to historical patients undergoing surgically created BC-AVF. Outcome discrepancies compared to previously reported Ellipsys data demonstrate a need for further studies examining the practical translatability of the pAVF.

Objective: The objective of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients. Methods: A retrospective study at a single institution of 28 patients that presented with submassive pulmonary embolism from July 2016 to September 2019 was performed. All patients were diagnosed using chest computed tomography demonstrating a pulmonary embolism and abnormal right ventricular to left ventricular ratio. Patients with severe right heart dysfunction (right ventricular to left ventricular ratio ⩾1.4) were protocolized to receive catheter-directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA, United States). Transthoracic echocardiogram was performed after 24 hours to assess right ventricular function and determine the need to continue thrombolysis. Patients after discharge then received follow-up echocardiograms at 6 weeks to determine new post-treatment baseline. Results: The mean patient age was 54.6 years, mean body mass index was 35.0, and mean right ventricular to left ventricular ratio on admission computed tomography imaging was 1.70. Interval mean right ventricular to left ventricular ratio on echocardiography during thrombolysis therapy was 1.01 (p < 0.00001). Patients were tachycardic on admission (mean heart rate 102.2 beats per minute) with improvement by completion of thrombolysis (mean heart rate 72.9 beats per minute) (p < 0.00001). There was a 0% incidence of periprocedural complications. Overall 30-day complication rate was 7.1% (n = 1 arrhythmia, n = 1 delayed intracranial hemorrhage). At 6-week follow-up, 91% of the patients who received echocardiography had normal right ventricular function. Conclusion: This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients.

We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.

Despite the promising initial results regarding the creation of percutaneous arteriovenous fistulas (pAVFs), a paucity of data exists providing a direct comparison between percutaneously created AVFs and open surgically created AVFs (sAVFs). The present study compared the clinical outcomes of pAVFs and sAVFs, with an emphasis on clinical maturation and the frequency of postoperative interventions. A single-center retrospective review was performed of all consecutive patients who had undergone treatment with a surgically created brachiocephalic AVF (BC-AVF; sAVF group) during 2018 (Fig 1) and Ellipsys (Avenu Medical, San Juan Capistrano, Calif) percutaneously created AVFs (pAVF group) during 2019 (Fig 2). A comparative analysis between the two groups was performed. A total of 24 patients had undergone pAVF creation and 62 patients had undergone surgically created BC-AVF (Table). Both the pAVF and sAVF groups had comparable mean operating times (60 ± 40 vs 56 ± 25 minutes; P = .67) and rates of technical success (n = 23 [96%] vs n = 62 [100%]; P = .28), respectively. The pAVF group had a lower clinical maturation rate (n = 12 [52%] vs n = 54 [87%]; P = .003) and greater primary failure rate (n = 9 [39%] vs n = 6 [10%]; P = .003) compared with the sAVF group. The pAVF group had an increased overall rate of requiring a postoperative intervention (n = 18 [78%] vs n = 13 [21%]; P < .001) and an increased number of postoperative interventions (1.1 ± 0.9 vs 0.3 ± 0.6 interventions; P < .001) compared with the sAVF group. Percutaneous transluminal angioplasty of the juxta-anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency compared with the rate for the sAVF group (n = 13 [57%] vs n = 5 [8%]; P < .001). Patients undergoing Ellipsys-created pAVF had inferior rates of clinical maturation and underwent more postoperative interventions than did patients undergoing surgically created BC-AVF in our single-center retrospective review. These outcome discrepancies compared with previously reported Ellipsys data demonstrate the need for further studies examining the real-world translatability of the pAVF device.TableComparison of pAVF and sAVF groupsVariablepAVF group (n = 24)sAVF group (n = 62)P valueAge, years56.7 ± 22.662.5 ± 13.2.15Preoperative hemodialysis14 (58)41 (66).62Operating time, minutes60 ± 4056 ± 25.67Technical success23 (96)62 (100).28Clinical maturation12 (52)54 (87).003Postoperative intervention (any)18 (78)13 (21)<.001No. of postoperative interventions1.1 ± 0.90.3 ± 0.6<.001Complication (any)3 (13)7 (11)>.99Follow-up duration, months6.1 ± 4.02.7 ± 2.6<.001Categorical data presented as number (%) and continuous variables as mean ± standard deviation. Boldface P values represent statistical significance. Open table in a new tab Fig 2Percutaneous arteriovenous fistulas (AVFs).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) fistulas or malformations are extremely rare, with only 36 cases reported. Low incidence and nonspecific clinical signs and symptoms make mesenteric arteriovenous fistulas difficult to diagnose. We describe a case of a primary IMA-IMV fistula. Our patient presented with severe portal hypertension and cardiomyopathy along with robust arteriovenous connections between the IMA and IMV. Arterial embolization in this patient had to be followed by venous embolization for successful resolution of portal hypertension and cardiomyopathy. This case also highlights that close outpatient monitoring for treatment failure and recurrence is necessary for this disease process.

A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.

Liquid embolic agents can be used as a primary embolic agent or adjunct to coil embolization for treatment of type 2 endoleaks. Ethylene-vinyl-alcohol copolymer (EVOH) or Onyx (ev3 Inc, Irvine, California) is a popular nonadhesive liquid embolic agent due to the slow and controlled manner the glue is delivered ( 1 Khaja M.S. Park A.W. Swee W. et al. Treatment of type II endoleak using Onyx with long-term imaging follow-up. Cardiovasc Intervent Radiol. 2014; 37: 612-633 Google Scholar ). This report, which met the institutional review board’s criteria for exemption approval, discusses a patient who underwent extensive nonselective Onyx embolization for a type 2 endoleak and developed ischemic peripheral lumbosacral plexopathy.

Background: Leiomyosarcoma of the inferior vena cava (IVC) is an exceedingly rare smooth muscle sarcoma. Approximately 300 cases have been described in the literature, and further research is needed to understand the disease and guide its management. Surgery remains the only potential curative measure.Methods: A retrospective chart review of patients who underwent surgical resection of IVC leiomyosarcoma at our institution over the past 3 years was performed. The patients were identified using a prospectively maintained database.Results: Three patients with leiomyosarcoma of the infrahepatic IVC underwent radical resection carried out by a team of surgical oncologists and vascular surgeons. There were 2 males (66.7%) and 1 female (33.3%). Mean age at diagnosis was 60.3 years (range 43-78). Mean tumor size was 12.2 cm (range 5.6-22). The mean operative time was 320 min (range 180-421), mean estimated blood loss was 1,300 mL (100-2,000) mL, and average length of stay 8.67 days (6-12). All patients achieved grossly negative margins (R1 or R0 resections) and are alive with a mean overall survival of 21 months (range 12-30). Patient 1 was a 60-year old man who presented with metachronous skin leiomyosarcomas at 2 different sites. He underwent PET/CT scan that revealed an IVC mass.,Resection of the middle segment of the IVC and right kidney was performed with reconstruction with polytetrafluorethylene (PTFE) graft. Patient 2 was a 78-year-old man with an incidentally found a 9-cm IVC tumor. Resection of the tumor was performed, and no reconstruction was needed since the tumor had a completely extraluminal growth pattern. Patient 3 was a 43-year-old woman who presented with abdominal pain. Her work-up showed a 15-cm IVC mass. She underwent resection of the middle segment of the IVC, right nephrectomy, and cholecystectomy with reconstruction of the IVC with PTFE graft.Conclusions: Surgical resection is the mainstay of treatment in patients with leiomyosarcoma of the IVC. A collaborative approach involving surgical oncologists and vascular surgeons ensures adequate resection with functional reconstruction to achieve the best patient outcomes.

A wide variety of clinical presentations of complicated iliac arterial aneurysms is documented; however, iliorectal fistula in this setting has not been reported previously. We present a case of an 88-year-old gentleman who presented with massive lower gastrointestinal hemorrhage secondary to rupture of a left common iliac aneurysm with iliorectal fistula. Given the severe shock, patient was treated with endovascular exclusion of the aneurysm achieved with a percutaneous left common to external iliac artery stent-graft and embolization of internal iliac artery. Definitive repair was performed after resuscitation for 72 hours. This included a cross-femoral bypass followed by laparotomy, explantation of stent graft, endoaneurysmorrhaphy, and rectosigmoidectomy with end colostomy. Patient recovered well and over 18 month follow-up has had no complications. In conclusion, primary iliac aneurysms can rarely present with enteric and urological erosions or fistulas resulting in life threatening hemorrhage. Temporizing endovascular therapy despite the contaminated field can be life-saving. Zoe Jones MD, Muhammad Ali A Rana MD*, Mark Langsfeld MD and John Marek MD Division of Vascular Surgery, University of New Mexico School of Medicine, USA Muhammad Ali A Rana Clinics in Surgery Vascular Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2016 | Volume 1 | Article 1156 2 up to 27% mortality in contemporary literature [4]. Iliorectal fistulas have been reported secondary to internal iliac aneurysmal erosion [3], however, common iliac aneurysm with iliorectal fistula has not been described in the literature. Our patient proved to be a diagnostic challenge. Lower gastrointestinal endoscopy was inconclusive and non-enhanced CT guided drainage of suspected abscess revealed arterial blood. A subsequent CT arteriogram confirmed the diagnosis [5]. Figure 1: Oblique coronal reconstruction from CT scan showing CIAA and iliorectal fistula. Figure 2,3: Pre EVAR and post-EVAR arteriograms demonstrating aneurysm and its subsequent exclusion via common to externai iliac stent-graft and embolization of left internal iliac artery. Although in a contaminated field endovascular treatment using a prosthetic stent-graft is traditionally contraindicated, it proved to be life-saving in the setting of life threatening hemorrhage. This was later converted to an aseptic extra-anatomical vascular reconstruction along with required fecal diversion once the patient was stabilized. Conclusion Primary iliac aneurysms can rarely present with enteric and urological erosions or fistulas resulting in life threatening hemorrhage. Temporizing endovascular therapy despite the contaminated field can be life-saving. References 1. Brunkwall J, Hauksson H, Bengtsson H, Bergqvist D, Takolander R, Bergentz SE. et al. Solitary aneurysms of the iliac arterial system: an estimate of their frequency of occurrence. J Vasc Surg. 1989; 10: 381-384. 2. Chaer RA, Barbato JE, Lin SC, Zenati M, Kent KC, McKinsey JF. Isolated iliac artery aneurysms: A contemporary comparison of endovascular and open repair. J Vasc Surg. 2008; 47: 708-713. 3. Goto A, Yu I, Naito T, Yabana T, Adachi T, Kondo Y. et al. Fistula from the internal iliac artery aneurysm to the sigmoid colon after endovascular arterial repair. Endoscopy. 2014; 46: E367-E368. 4. Huang Y, Gloviczki P, Duncan AA, Kalra M, Hoskin TL, Oderich GS, et al. Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair. J Vasc Surg. 2008; 47: 1203-1210. 5. Sandhu RS, Pipinos II. Isolated iliac artery aneurysms. SeminVasc Surg. 2005; 18: 209-215. Figure 4: Follow-up CTA showing final reconstruction (endoanuerysmorrhaphy, exclusion of left iliac system and right-to-left cross femoral bypass).

Blunt subclavian artery injuries are rare and are associated with high morbidity and mortality. Several case reports have suggested that endovascular repair is safe with short operative times and minimal blood loss. We report a case of a 20-year-old male patient involved in a high-speed motor vehicle collision that resulted in partial transection of left subclavian artery with complete luminal thrombosis. Patient also had a left main-stem bronchus avulsion along with major intra-abdominal injuries and multiple spine and long bone fractures. He underwent emergent abdominal exploration due to multisystem trauma and hemodynamic instability. Following laparotomy and resuscitation, the subclavian artery injury was repaired using a hybrid technique geared at protecting the patent vertebral and axillary arteries from embolization. We used supraclavicular dissection and arterial control with endovascular stent-graft placement in retrograde fashion to repair the left subclavian artery injury. At 6-month follow-up, computed tomography scan confirmed patency of the left subclavian artery stent and there was no evidence of vertebrobasilar insufficiency or left upper extremity ischemia. In conclusion, stent-graft repair of blunt subclavian artery injuries is expedient and safe. Supraclavicular vascular dissection and control are effective in preventing distal embolization in rare cases complicated with luminal thrombosis.

INTRODUCTION: Inferior vena cava (IVC) agenesis is one of rare entities of IVC anomalies which presents in young patients with unprovoked deep venous thrombosis (DVT) or unexplained bilateral lower venous insufficiency. We are presenting a case of IVC agenesis which was treated with IVC reconstruction.CASE: We describe a case of 28 years old male with painful bilateral lower extremity varicose veins and a history of right lower extremity DVT and was on anticoagulation with warfarin. He was found to have extensive bilateral greater saphenous veins (GSVs) and right femoral vein reflux with patent bilateral deep veins. He was treated with bilateral GSV ablation and microphlebectomies. Six weeks later he presented with acute bilateral iliofemoral DVTs treated with tissue plasminogen activator thrombolysis tPA via bilateral popliteal vein access which helped relieve his leg swelling but he continued to have debilitating venous claudication. A computed tomography (CT scan) demonstrated resolution of DVT but revealed IVC agenesis. He underwent IVC reconstruction with prosthetic graft which helped complete resolution of his chronically debilitating bilateral lower extremity claudication.CONCLUSION: In young patients with severe manifestations of lower extremity venous hypertension i.e. edema, varicosity and DVT, central venous anomaly should be considered. Severely symptomatic cases of IVC agenesis can be treated with IVC reconstruction. (C) 2015 The Authors. Published by Elsevier Ltd.

Objectives: This study evaluated early and long-term results of endovascular treatment of iliac artery occlusions and compared these outcomes with those in patients treated for stenotic lesions.Methods: During a 10-year period ending in January 2010, 223 endovascular procedures to treat aortoiliac occlusive disease (PAD) were performed. All patients were prospectively enrolled in a dedicated database. The intervention was performed for iliac occlusion in 109 patients (group 1) and for iliac stenosis in 114 (group 2). Early results were analyzed and compared by chi(2) and Fisher exact tests. Follow-up consisted of clinical examination and duplex scanning at discharge, <= 3 months, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed with Kaplan-Meier curves and compared with the log-rank test.Results: The two groups had similar risk factors for atherosclerosis and comorbidities. Critical limb ischemia was more common in group 1 (20.5%) than in group 2 (8.5%; P = .01). Intraoperative technical details were similar, except for a higher percentage of brachial and contralateral femoral access and more frequent use of nitinol stents in group 1. Two immediate technical failures occurred, one in both groups, requiring immediate conversion to surgical bypass. Four intraoperative iliac ruptures occurred, two in each group; all were successfully treated with covered stents. An additional 10 immediate complications occurred (8 in group 1; 2 in group 2), one of which required conversion to open surgical bypass. The cumulative rate of perioperative complications was 9% in group 1 and 3.5% in group 2 (P = .08). Primary patency at 30 days was 97.3% and 98.7%, respectively. Mean duration of follow-up was 28.4 months; 203 patients (91%) had a regular postoperative follow-up visit. At 60 months, primary patency in group 1 vs group 2 was 82.4% vs 77.7% (P = .9), assisted primary patency was 90.6% vs 85.5% (P = .4), and estimated secondary patency was 93.1% vs 92.8% (P = .3). The cumulative rate of reintervention during follow-up (excluding reinterventions performed in the perioperative period) was 2.5% in group 1 and 12.5% in group 2 at 60 months (P = .09). Univariate analysis in group 1 failed to find any of the examined risk factors significantly affected long-term primary patency rates.Conclusions: In our experience, endovascular treatment of iliac occlusions provides excellent early and long-term results, similar to those obtained in the treatment of stenotic lesions. (J Vasc Surg 2011;53:92-8.)

BACKGROUND:To determine whether patient adherence to follow-up and patient outcomes after endovascular aneurysm repair (EVAR) are affected by the distance between a patient's residence and a tertiary care treatment center. METHODS:A retrospective review of 136 consecutive patients undergoing EVAR at the New Mexico Veterans Affairs Medical Center over a 7-year period was conducted. Patients were stratified as living within a 100-mi radius of the treatment center (group 1) and those living outside this radius (group 2). Follow-up included clinic visits and computed tomography scans at 1 month after discharge, every 6 months for 2 years, and then yearly. Incomplete follow-up was defined if two or more consecutive appointments were missed. Survival and graft-related complication rates were analyzed for both the patient groups. RESULTS:Of the 136 patients, 10 patients died from nonaneurysm-related causes less than 1 year after their EVAR procedures, and hence were not a part of the study. Of the surviving patients, 44% lived within a 100-mi radius of the treatment center (group 1), and 56% outside this 100-mi radius (group 2). The mean patient follow-up time was 52.1 ± 25.9 months. Of the surviving patients, 15% had inadequate follow-up, yet there was no significant difference in the adequacy of follow-up for patients in group 1 compared with group 2. The incidence of major complications, defined as aneurysm rupture, conversion to open repair, myocardial infarction, and stroke, was not statistically different in group 1 versus group 2 (5.0% vs. 11.8%, p = 0.23). Of the five patients (3.7%) who died as a result of abdominal aortic aneurysms related causes, three were in group 1 and two in group 2. CONCLUSIONS:Distance from a tertiary care center is not a limiting factor in patient adherence to follow-up, patient graft-related morbidity, or patient survival, likely because of the Albuquerque VA Medical Center's electronic tracking of patients and provision of travel vouchers.