One-Stage Endovascular Treatment of a Symptomatic Penetrating Ulcer in the Lusorian Artery and an AAA: A Challenging Case in a Rare Entity.

INTRODUCTION: We report a case of a 57-year-old man with a successful total endovascular treatment of a symptomatic penetrating arterial ulcer (PAU) of a lusorian artery (LA) together with a standard endovascular abdominal aortic aneurysm (AAA) repair. The LA is an aberrant subclavian artery and a congenital aortic arch anomaly with a reported prevalence of 0.4-2.6%. Typical for the base of the LA is a Kommerell diverticulum making an endovascular approach even more difficult. METHODS: The patient was admitted to our hospital due to an unspecific retrosternal and hypopharyngeal pulsation feeling. The contrast computed tomography scan revealed a PAU in the middle of the aberrant right subclavian artery, apart from the size progression of an asymptomatic and followed-up AAA. Beside a standard abdominal endovascular aortic repair (EVAR), a total endovascular PAU exclusion was achieved using an Endurant tapered leg extension. The system was released in a back-table procedure and then remounted reversed on the system which now could be introduced via a transverse arteriotomy of the right axillary artery. RESULTS: The technical result was excellent, no endoleak was observed, and the symptoms disappeared immediately. The patient was discharged symptom free after 5 days. SUMMARY: This is so far the first reported total endovascular therapy of a symptomatic PAU of an LA. There are no tapered leg extensions or main bodies with a necessary working length for a femoral approach and correct sizing at the same time available on the market. The technical success was, therefore, based on the possibility of releasing and remounting parts of the Endurant Stent Graft System in emergency cases in a back-table setting. Although this is off-label use in experienced hands, it is easy to handle and can surely help the endovascular surgeon in some challenging situation where no standard stent-graft system is available.

[Thoracic Outlet Syndrome]. / Thoracic-Outlet-Syndrom.

Introduction Thoracic outlet syndrome (TOS) is one of the most extensively discussed diagnoses. There is neither a clear and homogenous clinical presentation nor an accepted definition. The term describes a complex of symptoms and complaints caused by the compression of nerves and vascular structures at one of the three defined constrictions of the upper thoracic aperture. Methods Based on a comprehensive literature review, this article presents the etiology, epidemiology and clinical diagnostics as well as the possibilities and outcomes of surgical treatment. Results The thoracic outlet syndrome is currently subdivided into three main forms: vascular TOS (vasTOS) including arterial TOS (aTOS) and venous TOS (vTOS), neurogenic TOS (nTOS), which is further subdivided into typical (nTOS) and atypical TOS (disTOS), and a mixed form of nTOS and vasTOS (nvasTOS). The diagnosis is complex and difficult since the disTOS group comprises over 90 % of all patients. In addition to conservative treatment attempts, nTOS may be treated by surgical procedures focusing on the decompression of neurovascular structures. A significant improvement after surgery was found in up to 92 % of cases. The most common access sites are supraclavicular and transaxillary. 50 to 80 % of patients benefit from surgery in the long run. The rates of vascular or neurological complications reported by specialised centres are 0 to 2 %; minor complications such as pneumothorax, bleeding and lymphatic fistula are reported in up to 25 % of cases. Summary Most patients suffering from any form of TOS benefit from surgical treatment. Duration of symptoms, socioeconomic factors and, most notably, stringent diagnostic workup and an adequate operative procedure performed by an experienced centre are crucial to success.

The seven-year' secondary patency of a fresh arterial allograft in the femorocrural position in a heart transplant recipient.

Critical limb ischemia in patients with diabetes at the organ complication stage represents a considerable challenge in vascular medicine. Because of the complexity of the disease and the often symmetric involvement of both lower limbs, a discrepancy between suitable vascular conduit availability and the actual requirement can occur: notably, the prevalence of multilevel and diffuse arterial disease often limits the possibilities of endovascular treatment, and, in surgical cases, frequently prohibits the effective use of prosthetic material. In our patient with bilateral critical limb ischemia and previous coronary artery bypass graft followed by cardiac transplantation, only one great saphenous vein remained available. That was used in its entirety to salvage one limb as a sequential femorocrural bypass. A similar surgical procedure with a fresh arterial allograft retrieved from a deceased donor was performed on the other extremity . ABO compatibility as well as the chronic immunosuppressive therapy in a heart transplant recipient may have contributed to the favorable long-term clinical outcome of the allogeneic arterial reconstruction.

Unusual groin resistance--a case study.

Extraskeletal osteochondroma is a benign, cartilaginous, slow-growing tumor with typical location near the joints of hands, feet, and knees. The authors present the case of a 44-year-old patient who experienced increasing pain in the right groin. Two isolated calcium deposits formed an encapsulated mass in the iliopsoas muscle, and the extraskeletal osteochondroma was diagnosed. An unusual location required that the operation be performed by a vascular surgeon. The authors present a wide range of groin-resistance differential diagnoses.

Sleep apnea in carotid stenosis.

OBJECTIVES: Sleep apnea is associated with advanced atherosclerosis. This study was focused on sleep breathing in patients with hemodynamically significant carotid stenosis, currently free from clinical symptoms. DESIGN AND SETTINGS: 17 patients with carotid artery stenosis of 70% and more in the absence of actual neurological symptoms indicated for non-acute endarterectomy, and 17 age- and sex-matched controls were examined using sleep polygraphy. 12 patients had a follow-up sleep polygraphy a month after the surgery. RESULTS: The criteria of obstructive sleep apnea (OSA) were met by 4 patients prior to operation, by 2 patients after the operation, and by 2 control subjects. The pre-surgery apnea/hypopnea index (AHI) was 14 (+/-SD=17.0), post-surgery 8.3 (+/-9.0) and in the controls 6.7(+/-6.7). The pre-surgery oxygen desaturation index was 20.1 (+/-17.7), post-surgery 15.0 (+/-12.0) and in the controls 11.6 (+/-6.1). A comparison between the pre-surgery results seen in the patients and in controls after adjustment for BMI revealed no significant difference. The only significant difference between the pre-surgery and post-surgery values was found in the AHI (P=0.045). CONCLUSION: According to this study there exists an association between carotid stenosis and OSA, however this association is explainable by a higher BMI. The study also found a tendency toward OSA alleviation in response to endarterectomy.

Roar of a Champion: Loudness and Voice Pitch Predict Perceived Fighting Ability but Not Success in MMA Fighters.

Historically, antagonistic interactions have been a crucial determinant of access to various fitness-affecting resources. In many vertebrate species, information about relative fighting ability is conveyed, among other things, by vocalization. Previous research found that men's upper-body strength can be assessed from voice. In the present study, we tested formidability perception of intimidating vocalization (roars) and a short utterance produced by amateur male MMA fighters attending the amateur European Championships in relation to their physical fitness indicators and fighting success. We also tested acoustic predictors of the perceived formidability. We found that body height, weight, and physical fitness failed to predict perceived formidability either from speech or from the roars. Similarly, there was no significant association between formidability of the roars and utterances and actual fighting success. Perceived formidability was predicted mainly by roars' and utterances' intensity and roars' harmonics-to-noise ratio and duration. Interestingly, fundamental frequency (F0) predicted formidability ratings in both roars and utterances but in an opposite manner, so that low F0 utterances but high F0 roars were rated as more formidable. Our results suggest that formidability perception is primarily driven by intensity and duration of the vocalizations.

Vocal Parameters of Speech and Singing Covary and Are Related to Vocal Attractiveness, Body Measures, and Sociosexuality: A Cross-Cultural Study.

Perceived vocal attractiveness and measured sex-dimorphic vocal parameters are both associated with underlying individual qualities. Research tends to focus on speech but singing is another highly evolved communication system that has distinct and universal features with analogs in other species, and it is relevant in mating. Both speaking and singing voice provides relevant information about its producer. We tested whether speech and singing function as "backup signals" that indicate similar underlying qualities. Using a sample of 81 men and 86 women from Brazil and the Czech Republic, we investigated vocal attractiveness rated from speech and singing and its association with fundamental frequency (F0), apparent vocal tract length (VTL), body characteristics, and sociosexuality. F0, VTL, and rated attractiveness of singing and speaking voice strongly correlated within the same individual. Lower-pitched speech in men, higher-pitched speech and singing in women, individuals who like to sing more, and singing of individuals with a higher pitch modulation were perceived as more attractive. In men, physical size positively predicted speech and singing attractiveness. Male speech but not singing attractiveness was associated with higher sociosexuality. Lower-pitched male speech was related to higher sociosexuality, while lower-pitched male singing was linked to lower sociosexuality. Similarly, shorter speech VTL and longer singing VTL predicted higher sociosexuality in women. Different vocal displays function as "backup signals" cueing to attractiveness and body size, but their relation to sexual strategies in men and women differs. Both singing and speech may indicate evolutionarily relevant individual qualities shaped by sexual selection.

Aortic insufficiency produced by stent-graft displacement.

The following case report describes an unusual example of aortic valve damage caused by iatrogenic stent-graft rupture (disconnection of the proximal uncovered part of a stent-graft) during delivery of a proximal extension, resulting in the displacement of a stent-graft wire to the aortic root. The wire was extracted under cardiopulmonary bypass, using circulatory arrest, and the damaged aortic valve replaced by a mechanical valve.

Emergency abdominal aortic aneurysm repair in a patient with failing heart: axillofemoral bypass using a centrifugal pump combined with levosimendan for inotropic support.

We describe the case of an 83-year-old patient requiring repair of a large symptomatic abdominal aortic aneurysm (AAA). The patient was known to have coronary artery disease (CAD) with symptoms and signs of significant myocardial dysfunction, left-heart failure, and severe aortic insufficiency. The procedure was performed with the help of both mechanical and pharmacological circulatory support. Distal perfusion was provided by an axillofemoral bypass with a centrifugal pump, with dobutamine and levosimendan administered as pharmacological inotropic support. The patient's hemodynamic status was monitored with continuous cardiac output monitoring and transesophageal echocardiography. No serious circulatory complications were recorded during the perioperative and postoperative periods. This paper suggests a potential novel approach to combined circulatory support in patients with heart failure, scheduled for open abdominal aortic aneurysm repair.