Retrograde embolization of anterior tibial artery for an iatrogenic arterio-venous fistula causing left lower extremity claudication.

Lower extremity angiogram is generally a safe and effective procedure with a low rate of vascular complications. We report here a unique case of a 33-year-old female with anterior tibial artery (ATA) to anterior tibial vein fistula formation after lower extremity endovascular intervention. This was initially treated with open repair of the fistula and ligation of ATA. However, patient continued to complain of claudication like symptoms. Patient subsequently had an endovascular embolization of ATA in a retrograde fashion. Recovery was unremarkable; patient was discharged home same day. Three months postoperatively patient denies leg pain, a follow-up arterial duplex failed to show presence of arterio-venous fistula. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after lower extremity endovascular intervention.

Repair of giant inguinoscrotal hernia with loss of domain.

A massive inguinoscrotal hernia extending below the midpoint of the inner thigh, in a standing position, constitute a 'giant' inguinoscrotal hernia. A 74-year-old male presented with giant left sided inguinal hernia for the last 30 years. Patient underwent open repair under general anesthesia after perioperative respiratory exercise. Standard hernia repair identified a sliding hernia containing entire omentum, small and large bowel, and the appendix. Giant hernias pose a challenging problem because reduction of the hernia contents inside the abdominal cavity may increase intra-abdominal and thoracic pressures. Recurrence remains an issue for these patients after successful meshoplasty and debulking of abdominal contents. We describe a simple reduction with biological mesh repair, omentectomy, small bowel resection and sigmoidopexy as a viable technique for patients with greater than 50% of abdominal contents in the inguinoscrotal region with complete loss of domain.

Arterial thoracic outlet syndrome secondary to hypertrophy of the anterior scalene muscle.

Thoracic outlet syndrome (TOS) was first introduced in literature by Peet et al. in 1956. Since then is has been studied extensively and subcategorized into at least four closely related syndrome. Neurogenic TOS due to the compression of brachial plexus, arterial TOS in cases of compression of the subclavian artery, venous TOS in cases of compression of the subclavian vein, and non-specific type of TOS. Neurogenic TOS is by far the most common consisting of 95% of the cases, followed by venous and lastly arterial. Arterial TOS comprises ~1% of all TOS cases, they are caused largely by presence of cervical rib and/or anomalies of first rib. Here we describe arterial TOS caused by hypertrophy of the anterior scalene muscle in a 65-year-old male. Patient underwent successful open surgical repair with Dacron interposition graft. Postoperative course was unremarkable. Patient was discharged home on POD 2.

An unusual case of massive hematemesis caused by aorto-esophageal fistula due to mycotic aneurysm of mid-thoracic aorta in a patient without prior aortic instrumentation.

In the words of Sir William Osler: "There is no disease more conducive to clinical humility than aneurysms of the aorta". Here, we describe a case of a primary fistulous tract between a pseudoaneurysm sac and a portion of the mid thoracic esophagus leading to massive extravasation of blood causing hemorrhagic shock in a 71-year-old female.