How to manage chronic mesenteric ischemia? A deliberated strategy.

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.

New Type A Aortic Dissection after a Chronic Type B Dissection, Compressing the Pulmonary Artery: A Case Report.

The authors report a case of a 69-year-old man with a 5-year history of medically treated type B aortic dissection, who presented a new retrograde type A aortic dissection (RTAD) of the aortic arch and the ascending aorta. Clinical presentation was suggestive of pulmonary embolism. Computed tomographic angiography revealed a contained rupture of the dissected aortic arch, confined to the connective tissue plane between the arch and the pulmonary arteries. Extrinsic compression of both pulmonary arteries caused right heart failure. The patient was successfully operated with replacement of the dissected aortic arch, decompressing the pulmonary arteries. The combination of a secondary new RTAD after a chronic type B aortic dissection and a compression of the pulmonary arteries by a contained rupture of the dissected aortic arch have not been reported previously in literature.

Penetrating atherosclerosis aortic ulcer: a re-appraisal.

BACKGROUND: Penetrating aortic ulcer is a rare pathology, often clinically silent, but potentially fatal when manifesting as an acute aortic syndrome. It is more often detected in recent years, due to ageing of the population and more widespread use of computed tomography. A literature review aims to define the distinct disease entity of penetrating aortic ulcer. METHODS: Five recent cases of penetrating aortic ulcer, treated in authors' department are reported. A review of English-language medical literature from 1980 to 2015 was undertaken using PubMed and EMBASE databases, to identify studies reporting surgical (open and endovascular) treatment of penetrating aortic ulcer. RESULTS: From September 2013 to September 2015, five cases of acute aortic syndrome caused by a penetrating atherosclerotic ulcer of the descending thoracic aorta were observed in authors' department. This represents 9% of all acute aortic syndromes admitted to our hospital in the same period. All five patients benefitted from thoracic endovascular stent grafting with a 100% success rate. Natural history and optimal management of penetrating aortic ulcer are outlined according to the most recent insights. CONCLUSION: Penetrating aortic ulcer represents 2-7% of all acute aortic syndromes. Symptomatic penetrating aortic ulcer requires coverage by thoracic endovascular stent grafting according to the recent guidelines.

Chronic False Aneurysm after a Healed Rupture of the Aortic Isthmus: TEVAR, Hybrid Surgery, or Open Arch Repair?

We report a case of post-traumatic chronic false aneurysm of the aortic isthmus in a 34-year-old man who had been involved in a car accident 10 years earlier. An initial chest X-ray demonstrated a calcified mass in the upper mediastinum and computed tomography scan revealed a false aneurysm of the aortic isthmus arising above the left subclavian artery. Partial covered rupture of the aorta is not always easy to diagnose and can remain clinically silent in a polytrauma patient. The duration from rupture to false aneurysm formation may extend over many years. This chronic lesion can be managed by surgery, by an endovascular procedure, or by a combined procedure. This case report highlights the current therapeutic approach. A debranching procedure was done in view of a secondary exclusion of the huge false aneurysm by a stent graft. Unfortunately, the false aneurysm ruptured during the procedure and a replacement of the aortic arch and the isthmus under total circulatory arrest was successfully done. The patient was doing well at 9-month follow-up.

Report of a case of Streptococcus agalactiae mycotic aneurysm and review of the literature.

A unique case of mycotic aneurysm of the abdominal aorta caused by Streptococcus agalactiae in an afebrile patient presenting with abdominal pain is described. Although this bacterium is associated with a variety of infections in human beings, aortitis is uncommon. Chronic alcoholism and diabetes mellitus are the 2 major predisposing conditions for group B Streptococci infection and both were present in this case. The abdominal pain and elevated inflammatory markers in the absence of fever were elusive in presentation; however, the diagnosis of mycotic aneurysm was established by abdominal computed tomography scan. The patient was treated successfully by resection of the diseased aorta and aortic allograft replacement. Culture of the excised tissue grew Streptococcus agalactiae sensitive to penicillin G and (other commonly tested antibiotics) fluoroquinolones. A prolonged course of moxifloxacin (for 6 months) was administered due to the persistence of elevated inflammatory markers and was remarkably well tolerated. Sixteen months after stopping the antibiotics, the patient is doing well, and the control imaging studies are satisfactory.

Association of abdominal aortic aneurysm, horseshoe kidneys, and left-sided inferior vena cava: report of two cases.

Surgery for abdominal aortic aneurysm may be challenging when rare renal or venous anomalies are present. This article reports two similar cases of aortic abdominal aneurysm associated with horseshoe kidney and left-sided inferior vena cava treated with a transperitoneal approach. Preoperative knowledge of the anatomic situation enabled appropriate aneurysm repair. Operative strategy is discussed. This report describes an uncommon venous vascular malformation complex and stresses the importance of computed tomography imaging not only in assessing the characteristics of the aneurysmal disease but also in detecting variations in pertinent vascular or parenchymal anatomy.

Infection of an abdominal aortic stent graft with suprarenal attachment.

Stent grafting for treatment of abdominal aortic aneurysm can lead to infectious complications. The purpose of this report is to describe a case involving a patient with an aortobiliac stent graft, a horseshoe kidney, and coronary artery disease who presented suprarenal aortic infection requiring removal of the stent graft and in situ reconstruction using an arterial homograft. The discussion deals with management of infected vascular material and reconstruction techniques.

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm.

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).

Endovascular stent-graft for thoracic aorta aneurysm caused by Salmonella.

We describe the placement of an endovascular stent-graft in a patient with mycotic aneurysm of the descending thoracic aorta caused by Salmonella. Endovascular grafting combined with antibiotic therapy in thoracic mycotic aneurysms might represent an alternative to conventional surgery in patients with high operative risk.