Endovascular repair of a bacillus Calmette-Guérin mycotic aortic aneurysm.

Bacillus Calmette-Guérin (BCG) is an attenuated form of Mycobacterium bovis used for intravesical treatment of bladder carcinoma. Aortic infection has been rare. In the present report, we have described the case of a patient with an infrarenal mycotic aortic pseudoaneurysm and para-aortic abscess after intravesical bacillus Calmette-Guérin and cystectomy. Sampling of the abscess demonstrated acid-fast bacilli. Given the hostile anatomy of the abdomen, he was offered endovascular aortic repair. A thoracic endograft was used to cover the lesion. The patient was discharged on postoperative day 2 without incident. He was seen at 1 and 6 months with resolution of his pseudoaneurysm found on the imaging studies. The technique shows promise for stabilizing such lesions with close surveillance.

Effect of Stent-Graft Active Fixation and Oversizing on Aortic Neck Dilation After Endovascular Aneurysm Exclusion For Infrarenal Aortic Aneurysm.

INTRODUCTION: Aortic neck dilation post endovascular aneurysm repair (EVAR) has been implicated in the long-term development of endoleak and the subsequent re-intervention. Optimal endograft sizing is a vital aspect to successful repair. This study looked at percentage of graft oversizing as well as type of fixation on aortic neck dilation. METHODS: We retrospectively evaluated all EVARs completed at Loyola's University from 2006 to 2015 after IRB approval. Patients without follow-up scans within a year were excluded. We collected demographics, comorbidities, graft type, size, aortic neck diameter, maximum sac size diameters from the pre-operative and follow-up scans. We reviewed and collected data on 432 patients but analyzed 154. We measured the largest aortic diameter on axial images 1 cm above and 1 cm below the lowest renal artery. Change in supra and infrarenal aortic measurements were evaluated by calculating the mm difference from each scan compared to the pre-operative scan. Linear mixed effects models were used to estimate patients' mean differences over time. RESULTS: We compared three groups of neck fixation grafts. Those with active suprarenal fixation had a significant change in suprarenal aortic diameter at four-year follow-up (1.86 mm, CI:0.65-3.06), compared to those with active infrarenal (0.22 mm, CI: -0.67 to -1.11) or passive suprarenal fixation (1.52 mm, CI: -0.11 to -3.15) (Fig. 1). Those with active suprarenal fixation were the only ones to have significant increase in suprarenal aortic diameter (P = 0.0026). Degree of oversizing was also divided into three groups. Oversizing by <10% had less impact on the suprarenal aorta than >15% oversizing at 4 years (0.41 mm, CI: -0.31 to -1.14 vs. 3.26 mm, CI: 1.63-4.88, P < 0.001) (Fig. 2). Oversizing had a more pronounced effect on the infrarenal aorta: 3.01 mm, CI: 2.18-3.83; 5.95 mm, CI: 3.26-8.64; and 5.05 mm, CI: 3.41-6.69 for <10%, 10-15%, and >15% oversizing at four years, respectively. CONCLUSION: Stent-grafts with active fixation below the renal arteries as well as oversizing by <10% seem to have the least effect on aortic neck dilation over time. These factors should be considered when performing EVARs, as aortic neck dilation could lead to endoleak and need for further intervention. Further research defining the optimal stent-graft type, self-expanding versus balloon expandable, type of fixation and degree of oversizing.

Extended Use of the Candy-Plug Technique with the Cook Dissection Stent.

Inducing false lumen (FL) thrombosis is crucial to achieve aortic remodeling when treating aortic dissection. One method to achieve FL thrombosis is modifying a graft and placing a plug inside it known as the candy-plug (CP) technique. CP stent graft is typically placed at the level of the celiac artery (CA) as noted by the original authors. Here, we present a case where the CP had to be placed distal to the CA but also require placing a bare metal dissection stent in the true lumen to oppose the radial force and expand the true lumen as well as to prevent re-entry tear in the visceral segment in the future.

A rare case of fibromuscular dysplasia involving multiple vascular beds.

OBJECTIVE: Fibromuscular dysplasia rarely involves vessels other than the renal and carotid arteries. We present a case of a rare fibromuscular dysplasia involving multiple vascular beds in a young female patient with history of spontaneous coronary artery (SCAD). METHODS: This is a case report with review of the literature using PubMed search for other cases of fibromuscular dysplasia that involves multiple vascular beds and its association with SCAD. The patient agreed to publish her case including her images. RESULTS: Fibromuscular dysplasia involving multiple vascular beds in a young female patient with prior coronary dissection is rarely reported in the literature. CONCLUSION: Fibromuscular dysplasia affecting multiple vascular beds is rare but should be suspected in patients with SCAD, particularly young female patients.

Non-operative management of water injection injury to the neck.

Although rarely reported in the pediatric population, high-pressure injection injuries are a common occurrence in adult industrial workers. These injuries commonly exhibit physiologic patterns consistent with direct kinetic trauma, localized substance toxicity, and in later stages infection. The majority of reported cases describe injection injuries caused by caustic substances at high pressures frequently necessitating debridement. In this case, we present a 12-year old boy who sustained a Zone III penetrating neck injury after running in front of a commercial pressure washer. In our case presentation there was concern for vascular and aero-digestive injuries; however, following physical examination and advanced imaging, expectant management was successfully adopted.

Effects of folic acid plus levothyroxine on serum homocysteine level in hypothyroidism.

BACKGROUND: Rise in serum homocysteine level may be associated with higher prevalence of cardiovascular diseases in hypothyroidism. Levothyroxine can partly diminish serum homocysteine level. Folic acid participates in homocysteine metabolic cycle in the human body. The effect of concomitant administration of folic acid and levothyroxine on serum homocysteine level was evaluated in the present study. METHODS: Sixty patients with hypothyroidism participated in this double-blinded clinical trial study. They were divided into two equal groups; Group A received oral levothyroxine 50-100 µg daily. Group B took oral folic acid 1 mg on a daily basis in addition to levothyroxine with similar schedule to group A. The patients were followed up for two months. The serum homocysteine levels of these two groups were measured before and after the study. This study was registered in Iranian Registry of clinical trial (IRCT number: 201112077723N1). RESULTS: Mean serum homocysteine level fell from 11.5±4.2 to 9.9±3.5 µmol/lit and from 11.2±3.1 to 6.9±1.9 µmol/lit in group A and B, respectively (p<0.001). The mean reduction in serum homocysteine levels were 1.6±1.2 µmol/lit and 4.3±1.4 µmol/lit in group A and B, respectively (p<0.001). CONCLUSION: Levothyroxine can decrease serum homocysteine level partly; still its combination with folic acid empowers the effect. Combination therapy declines serum homocysteine level more successfully.