Presentation and management of rare saccular superior mesenteric artery trunk and branch aneurysms.

Superior mesenteric artery (SMA) aneurysm is caused by degeneration of the visceral arteries. Although a rarely encountered entity, it requires timely management owing to the high mortality rate associated with rupture, particularly when the aneurysm is saccular in nature. As such, urgent treatment is generally indicated. We present five cases of SMA aneurysm arising from the main trunk or branches of the SMA.

Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era.

BACKGROUND: Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. METHODS/RESULTS: Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1 centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. CONCLUSIONS: SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Delayed stroke after hospitalization for coronavirus disease 2019 pneumonia from common and internal carotid artery thrombosis.

Large vessel arterial thrombosis has been reported to complicate a subset of cases of coronavirus disease 2019 (COVID-19). Thrombosis of the extracranial carotid arterial system can lead to devastating stroke in some patients with COVID-19. We have presented the case of a patient previously hospitalized with COVID-19 for oxygen supplementation who had presented after discharge with delayed stroke from a right common carotid artery and internal carotid artery thrombosis. The thrombotic occlusion resolved with antithrombotic medications and no invasive intervention. The present report highlights the complicated and heterogeneous nature of COVID-19 and provides one approach to managing the devastating complication of stroke from carotid arterial thrombosis.

Successful repair of an arteriovesical fistula as a complication after coil embolization for right hypogastric artery aneurysm.

An 84-year-old man has a history of a right hypogastric artery aneurysm that was excluded with endograft several years ago. His course was complicated by a type II endoleak with an enlarging aneurysm that required multiple attempts of coil embolization. Several years later, he presented with gross hematuria and was found to have embolization coils extruding into his bladder and an arteriovesical fistula. As seen in this case, endovascular intervention for a type II endoleak is not benign. We describe a novel complication of an arteriovesical fistula that necessitated a difficult repair and ultimate revascularization.

Transcarotid Endovascular Repair of Extracranial Internal Carotid Artery Aneurysms Using Flow Reversal for Distal Embolic Protection.

Extracranial carotid artery aneurysms (ECAAs) have a low incidence between 0.4% and 4% of all peripheral artery aneurysms and involving 0.1-2% of all carotid artery procedures. Some form of repair is generally warranted as nonoperative management has shown mortality as high as 71%. However, to date a standard method for ECAA repair has not been suggested. Generally, open surgical repair is the preferred technique; however, it has its own limitations and risks. Recently, endovascular approach is increasingly being used not only for the elective repair of unruptured ECAA but also for the management of ruptured ECAA. Herein we present 3 cases of distal extracranial internal carotid artery aneurysms treated with placement of stent grafts.

Transcervical Carotid Artery Stenting Using a Prosthetic Arterial Conduit: Case Series of a Novel Surgical Technique.

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.