Ortner syndrome secondary to saccular thoracic aneurysm.

Mechanical stretching of the left laryngeal nerve secondary to an enlarged left atrium was first described by Dr Norbert Ortner in 1987. An extensive literature search revealed only 76 reported cases of Ortner syndrome, with the more recent reports describing other causes of the syndrome such as pulmonary hypertension, aortic dissection, and a thoracic aneurysm. We recently encountered this rare pathologic entity in an elderly man who had presented with severe hoarseness, presumed to be due to one of the aforementioned vascular anomalies. In the present report, we have highlighted the pathology and hybrid repair of this challenging entity.

Acute aortoiliac and infrainguinal arterial thrombotic events in four patients diagnosed with the novel coronavirus 2019.

The novel coronavirus disease 2019 (COVID-19) pandemic is seriously challenging the healthcare system globally. Endothelial damage and increased coagulation activity have been reported in some patients with COVID-19, resulting in a variety of thrombotic events. We report the cases of four patients with various severities of COVID-19 who had presented with acute arterial thrombosis. Although these are rare events, they carry high morbidity and mortality and require prompt diagnosis and treatment. These cases highlight the major life- and limb-threatening clinical sequelae of COVID-19 that frontline medical providers must be aware can occur even in the absence of previous cardiovascular disease.

Brescia-Cimino AV Fistula Complicated by Steal Syndrome.

The Brescia-Cimino AV fistula is most commonly performed and rarely associated with steal syndrome. A case is presented with details regarding its correction.

Iatrogenic Interval Gangrene of the Thigh.

Interval gangrene of the thigh is an extremely rare complication in vascular surgery. Most cases have reported interval gangrene of the calf as a consequence of a distal bypass procedure, with little documentation of interval thigh gangrene occurring after endovascular intervention. The present case suggests that in the process of placing multiple-level covered and bare metal stents in the iliac, superficial femoral, and popliteal arteries, interval gangrene of the thigh must be considered as a potential, albeit rare, complication. Preservation of pelvic and profunda femoris flow to the thigh is imperative to prevent the development of interval tissue loss. This case demonstrates the importance of maintaining profunda femoris circulation, especially in patients with significant vascular comorbidities. Patient consent was obtained for details of the case to be used for publication.

Hybrid Repair of an Intrathoracic Bilobed Subclavian Artery Aneurysm.

Intrathoracic subclavian artery aneurysms are extremely rare, <1% of all aneurysms. The formation of these aneurysms is often multifactorial, with the most common contributing factor being atherosclerosis. This case report describes a right subclavian artery aneurysm that required a surgical hybrid approach. These operations can be a safe and effective treatment option, particularly in patients with high-risk factors.

Genesis of Crural Revascularization.

BACKGROUND: The purpose of this study is to recognize those investigators responsible for initiating progress in limb salvage where runoff beyond the arterial blockage was limited to the crural vasculature and to also describe how crural bypass has evolved into the contemporary setting where endovascular options have become increasingly prominent. METHODS: An extensive literature review of articles published from 1960 to 1979 was the basis for selecting and recognizing surgeons who pioneered infrageniculate revascularization. Documentation of patency and amputation rates were tabulated for these early series of distal limb bypass. Cases performed in the decade of interest, but not published until the 1980s, are also recognized and recorded separately. RESULTS: Subsequent to the first tibial bypass performed in 1961 by McCaughan, a total of 746 crural bypasses were defined in the decades of interest, where possible, with overall 6-, 12-, and 36-month patencies of 76%, 59%, and 48%, respectively. There was an overall amputation rate of 17%. Life table analysis and other statistical methods were also adopted during this time. CONCLUSIONS: Performance of crural bypass from 1960 to 1979 was analyzed in groups according to the distal anastomosis site. These results confirm the satisfactory early progress leading to further refinement in subsequent decades. It is essential that the current generation of vascular surgeons recognize the value of these early open procedures as a stable force for securing limb salvage in conjunction with evolving endovascular techniques.

Rapid Degradation and Subsequent Endovascular Salvage of Upper Extremity Cryogenic Allograft Bypass.

It has long been reported that cryogenic allografts have suboptimal mid- and long-term patencies and consequently are only used in the absence of autologous vein, predominantly in lower extremity limb salvage situations. As such, we felt that our recent experience with an upper extremity bypass for limb salvage using a cryogenic saphenous vein allograft, which aneurysmally degenerated after one month and required multiple endovascular rescues, serves to re-emphasize such concerns and the importance of continuous postoperative surveillance.

Dropped Bifurcation Technique for Femoral Endarterectomy.

Femoral endarterectomy is an established procedure with excellent outcomes. Variations in performing this operation generally reflect the extension of pathology into the superficial and deep femoral arteries. For these instances, we developed a technique not previously described that enables continued flow to the superficial and deep femoral arteries and facilitates patch placement.

Aberrant splenic artery complicated by aneurysm during pregnancy.

The aberrant splenic artery is an uncommon anomaly. It may become a challenging problem when it is associated with an aneurysm diagnosed during pregnancy. Our experience with a patient who underwent two interventions, each performed in the postpartum period without incident, highlights the need to employ techniques that ensure aneurysm closure and thus avoid recurrence and need for repetitive procedures.

Endovascular rescue of long-term vascular graft implants and need for continuous surveillance.

We present two cases of vascular graft degradation after long-term implantation. In both patients, endovascular techniques were employed to effect continued graft patency and function. Furthermore, these cases lend further credence to the doctrine of lifelong surveillance of all vascular interventions regardless of graft material. Postoperative surveillance of vascular interventions is generally recommended to avoid failures by identifying "the failing graft"1 at the earliest possible time to facilitate corrective procedures. There is a tendency that with continued function, over time, surveillance methods are spread farther apart and in fact often discontinued. Recent experiences with two cases illustrate the vital importance of lifelong continuous surveillance regardless of the site, graft material, or absence of symptoms. Clearly, the patient's compliance is essential. Both patients consented to the publication of their cases.

True Aneurysm of the Anterior Tibial Artery.

Most anterior tibial aneurysm cases described in the literature are pseudoaneurysms resulting from trauma. Since 1967, only 8 cases published on true anterior tibial artery aneurysms were atraumatic. Recent experience with an atraumatic aneurysm of the anterior tibial artery prompted a literature review regarding their incidence, and accordingly, we feel the need exists for greater recognition and understanding of this entity.

Endovascular stent graft repair of thoracic aortic mural thrombus in a patient with polycythemia vera: a word of caution.

Thoracic aortic mural thrombus (TAMT) is a rare pathology and potential source of cerebral, visceral, and peripheral emboli. We present a 62-year-old male in a hypercoagulable state due to primary polycythemia vera (PV) developed TAMT and catastrophic thromboembolisms despite aggressive medical and surgical management. The outcomes and adverse events of endovascular exclusion of TAMT in the presence of PV are unknown. We would recommend proceeding with extreme caution when performing endovascular exclusion of TAMT, as PV may be a prohibitive risk.

Bilateral giant extracranial carotid artery aneurysms.

Extracranial carotid artery aneurysms (ECAAs) are rare and extremely challenging disease entities. Untreated ECAAs can lead to serious neurologic sequelae, primarily from thromboembolism. Because of the high incidence of major neurologic complications, surgical intervention is warranted in most cases. We report a 63-year-old woman with voice fatigue and difficulty swallowing. Upon work-up, we discovered bilateral giant ECAAs and treated them with a combination of aneurysmectomy, primary anastomosis, and an interposition polytetrafluoroethylene graft. Unique features of the aneurysms include their unprecedented size and bilaterality, which is exceedingly rare.

Early recognition of acute thoracic aortic dissection and aneurysm.

BACKGROUND: Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary. METHODS: A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant. RESULTS: In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS. CONCLUSIONS: Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.

A novel method for the treatment of dysphagia lusoria due to aberrant right subclavian artery.

Dysphagia lusoria occurs secondary to an aberrant right subclavian artery coursing posterior to the oesophagus. Open ligation and transposition to the right carotid artery via a right supraclavicular approach has been described as a minimally invasive method. However, approaching the origin of the aberrant right subclavian artery through this incision can be extremely challenging. A persistent aberrant right subclavian artery stump may account for postoperative residual dysphagia. This article describes a safe, effective and reproducible surgical approach to dysphagia lusoria due to a non-aneurysmal aberrant right subclavian artery.

Endovascular repair of thoracic aortic aneurysms.

A thoracic aortic aneurysm is a potentially life-threatening condition that involves a structural weakness of the aortic wall, which can lead to aneurysm, rupture, or dissection. Optimal treatment strategies for lesions of the thoracic aorta are still controversial. Open surgery is complex and is associated with significant morbidity and mortality. Endovascular stenting has emerged as an alternative to open repair in patients requiring surgery for thoracic aortic pathology. Endovascular treatment of vascular disease involving the descending thoracic aorta can be performed safely. It is an alternative option to open repair, less invasive, and carries a relatively low risk. Due to the low morbidity and mortality of endovascular repair, this option has become attractive to many surgeons lately. Stent grafting has become the first-line approach to traumatic thoracic aortic transections in some trauma centers. However, the challenges of accurate placement within an angulated arch, size of the delivery system, and uncertainty regarding long-term durability have been cited as reasons for caution. Major challenges are the technical aspects of the procedure and the learning curve to handle the delivery system and the variability in the anatomy of the aorta. The goal of this article is to review endovascular repair of the thoracic aorta in the current literature outlining some recent patents.