Endovascular treatment of large and wide aortic neck: case report and literature review

Large (24\u201334 mm) and wide ( 6535 mm) aortic necks are a contraindication to endovascular aneurysm repair (EVAR). A 63-year-old man, unfit for conventional surgery, presented a 79 mm abdominal aortic aneurysm with 36.5 mm aortic neck and a 62 mm right common iliac artery aneurysm. He was treated endovascularly with standard commercially available stent-graft using the so-called \u2018funnel technique\u2019; by placing a thoracic stent-graft inside a bifurcated device to achieve proximal sealing. The completion angiography and the 6 months follow-up with computed tomography showed no stent-graft migration, limb occlusion or endoleak. The literature review reported 179 cases of large aortic neck managed with EVAR, all cases treated with standard devices. Conversely a wide aortic neck was reported in 9; in 2 cases were employed custom-made devices and in 7 standard stent-graft. The use of EVAR with commercially available stent-grafts is feasible and it represents an option especially in non-elective setting

History and Analysis of the Fayetteville, Arkansas Human Civil Rights Ordinance

This study is a thorough documentation of the introduction and development of civil rights legislation in the City of Fayetteville, Arkansas. Specifically, the study details local and state-wide civil rights legislation that offers civil right protections to the Lesbian, Gay, Bisexual and Transsexual (LGBT) community and the discrimination that they face. The state’s progression towards a more LGBT inclusive society began with local municipalities drafting ordinances protecting citizens from discrimination based on sexual orientation and gender identity; this study focuses on Fayetteville’s and the legislative process that followed. The discussion of LGBT civil rights is a sensitive and controversial matter, and this study concludes with community and statewide feedback on the matter, and the question for federal reform

Endograft connector technique to treat popliteal artery aneurysm in a morbid obese patient.

Surgical repair of popliteal artery aneurysm in morbid obese patients poses additional challenges. We report a morbid obese patient who had a 59mm right popliteal artery aneurysm which was successfully treated with the endograft connector technique. This technique was used to perform the distal anastomosis of the below-knee femoro-popliteal bypass. A 10mm Dacron graft was used as a main graft bypass and an 11 mm/10 cm stentgraft as endograft connector. Following the respective tunnel of the Dacron graft, an end-to-side proximal anastomosis was performed at distal femoral artery. The aneurysm exclusion was obtained through a proximal and a distal ligation. Postoperative duplex showed adequate bypass patency. Knee x-rays demonstrated no signs of stent kinking/fractures. The postoperative course was uneventful and the patient was discharged home on fourth day post operative. The six-month computed tomography scan and the 12-month duplex control showed a patent bypass with no signs of stenosis

Clinical outcomes of endurant II stent-graft for infrarenal aortic aneurysm repair: Comparison of on-label versus off-label use

PURPOSE We aimed to compare the outcomes of the Endurant II (Medtronic) stent-graft used under instructions for use versus off-label in high-risk patients considered unfit for conventional surgery. METHODS Data from patients treated with the Endurant II stent-graft between December 2012 and March 2015 were retrospectively analyzed. Sixty-four patients were included. Patients were assigned to group A if treated under instructions for use (n=34, 53%) and to group B if treated off-label (n=30, 47%). Outcome measures included perioperative mortality and morbidity, survival, freedom from reintervention, endoleak incidence, in-hospital length of stay, and mean stent-graft component used. Mean follow-up was 22.61±12 months (median, 21.06 months; range, 0–43 months). RESULTS One perioperative mortality (1.6%) and one perioperative complication (1.6%) occurred in group B. At two months follow-up, one iliac limb occlusion (1.6%) occurred in group A. No type I/III endoleaks were recorded. A type II endoleak was identified in three cases (4.7%). Overall survival at three years was 89% (97% for group A, 82% for group B; P = 0.428). Reintervention-free survival at three years was 97% for both groups (P = 0.991). A longer in-hospital stay was observed in group B (P = 0.012). CONCLUSION The Endurant II (Medtronic) new generation device was safe in off-label setting at mid-term follow-up. The off-label use of the Endurant II (Medtronic) is justified in patients considered unfit for conventional surgery. Larger studies are required in this subgroup of patients

Blood cyanide determination in two cases of fatal imtoxication: comparison between headspace gas chromatography and a spectrophotometric method

Blood samples of two cases were analyzed preliminarily by a classical spectrophotometric method (VIS) and by an automated headspace gas chromatographic method with nitrogen-phosphorus detector (HS-GC \u2044 NPD). In the former, hydrogen cyanide (HCN) was quantitatively determined by measuring the absorbance of chromophores forming as a result of interaction with chloramine T. In the automated HS-GC \u2044NPD method, blood was placed in a headspace vial, internal standard (acetonitrile) and acetic acid were then added. This resulted in cyanide being liberated as HCN. The spectrophotometric (VIS) and HS-GC\u2044NPD methods were validated on postmortem blood samples fortified with potassium cyanide in the ranges 0.5\u201310 and 0.05\u20135 lg \u2044 mL, respectively. Detection limits were 0.2 lg \u2044mL for VIS and 0.05 lg \u2044mL for HS-GC\u2044NPD. This work shows that results obtained by means of the two procedures were insignificantly different and that they compared favorably. They are suitable for rapid diagnosis of cyanide in postmortem cases

Type 1A endoleak detachable coil embolization after endovascular aneurysm sealing: Case report

Introduction: Endovascular aneurysm sealing (EVAS) with the Nellix system was introduced to reduce endovascular aneurysm repair (EVAR) perioperative complications, especially endoleaks. Herein we report a case of successful type 1A endoleak managed with detachable coils embolization after EVAS. Presentation of case: A 77-year-old male was referred for abdominal pain. The angio-CT scan confirmed the previous EVAS procedure and showed a type Is2 endoleak below the right renal artery resulting in a 2.5 cm aortic blister with contrast medium filling the space between the aortic wall and the endobags. The patient was considered unfit for conventional open surgery and an endovascular approach with coil embolization Concerto Helix Detachable Coil System was chosen under local anesthesia. After intervention, a complete abdominal pain regression was registered. The 12- month CT follow-up showed endoleak sealing and Nellix system stability. Discussion: EVAS has been associated to a high endoleaks and complications incidence when compared to EVAR. The EVAS different device concept led to a different endoleak classification and management. Endoleak management main options include the Nellix system explantation or the Nellix in Nellix application, however these are nearly always not applicable, respectively, due to the high surgical risk condition and the Nellix system availability, especially in emergent setting. Despite the use of coil embolization is controversial, this tool is off-the-shelf and leads to a disease resolution in most of patients without other surgical options. Conclusion: Proximal type Is2 embolization after EVAS is feasible with limited invasiveness

Mechanical rotational thrombectomy in long femoropopliteal artery and stent occlusion in COVID-19 patient: Case report

Introduction: Coronavirus disease-19 (COVID-19) has been increasingly associated with thromboembolic complications. COVID-19 infection has a thrombogenic potential for stents. Herein, we report a case of stent thrombosis in diabetic obese patient COVID-19 positive where was previously released a Multilayer Flow Modulator stent (MFM) for large popliteal aneurysm. Case report: A 78-year-old male was referred to our hospital for fever and acute pain in the left leg. At history, the same patient had endovascular procedure for a large symptomatic popliteal aneurysm, treated through release of three MFM. The pulmonary CT scan showed COVID-19 infection with confirm of rhino-laryngeal swab. Duplex ultrasound and CT-angiography showed complete thrombosis of stents. The treatment consisted of mechanical thrombectomy using an 8Fr catheter Rotarex plus release of Vibahn stent-graft. Discussion: COVID-19 patients can present arterial occlusion. In literature are not reported cases about thrombosis peripheral stent. Minimally invasive approaches in redo-procedure reduce risk of infection. Rotarex device was used in revascularization of acute and subacute iliac and femoropopliteal arteries. The goal is to have a debulking, to avoid an incomplete deployment of stent-graft. In our precedent experience, MFM and stent-graft to treatment of popliteal aneurism were safe. It is important to monitor these patients for early identification of failure and rapprochement. In this case, the COVID-19 infection was determinant in promoting thrombosis. Conclusions: COVID-19 increases risk of thrombosis stent. In our experience debulking through Rotarex and stenting, were decisive factors for revascularization and limb salvage

Multilevel diabetic foot revascularization in COVID 19 patient: Case report

Introduction: Coronavirus 2019 (COVID-19) has been associated with endothelial dysfunction. This hypercoagulable state coming from the endothelial injury pones COVID-19 patients to a higher risk for thrombosis. COVID 19 diabetic patients are more exposed to peripheral vascular disease progression. Multilevel peripheral arterial disease is the main cause of critical limb ischemia. Vascular interventions are required to increase distal blood flow and reduce the risk of amputation. Presentation of case: We report a case of complex revascularization in a diabetic patient with aggressive right foot lesions evolution after COVID-19 infection. The patient presenting a Peripheral arterial ischemic involving the infrarenal aorta, iliac, femoral. The simultaneous intervention consisted of an endovascular aortic stent-graft placement and angioplasty of femoral artery. Discussion: Diabetes is a risk factor of severity and deaths in patients infected with pulmonary viruses. In our experience, COVID 19 virus can accelerate the ulcers generation and progression in diabetic patient. Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments. In the reported case, a complex simultaneous treatment in a patient presenting Multilevel peripheral arterial disease in association to COVID 19 infection was feasible in the same operation. Conclusion: Hybrid procedures are safe with high degree of efficacy in terms of revascularization, reduced morbidity and shorter intensive care. In our experience, the use of a hybrid procedure is technically feasible and allowed the treatment of complicated diabetic COVID-19 patient with a good outcome

Late Complication after Superficial Femoral Artery (SFA) Aneurysm: Stent-graft Expulsion Outside the Skin

A 78-year-old man presented with a 7-cm aneurysm in the left superficial femoral artery, which was considered unfit and anatomically unsuitable for conven- tional open surgery for multiple comorbidities. The patient was treated with stent-graft [Viabhan stent-graft (WL Gore and Associates, Flagstaff, AZ)]. Two years from stent-graft implantation, the patient presented a purulent secretion and a spontaneous external expulsion through a fistulous channel. No claudication symptoms or hemorrhagic signs were present. The pus and device cultures were positive for Staphylococcus aureus sensitive to piperacillin/tazobac- tam. Patient management consisted of fistula drainage, systemic antibiotic therapy, and daily wound dressing. At 1-month follow-up, the wound was closed. To our knowl- edge, this is the first case of this type of stent-graft com- plication presenting with external expulsion

When orofacial pain needs a heart repair

Objectives: The association of chronic orofacial pain (COFP) and congenital heart disease has never previously been reported. We report the first case of COFP secondary to a right-to-left shunt (RLS) due to asymptomatic patent foramen ovale (PFO) in a patient with prothrombotic states. Materials and methods: A 48-year-old female patient presented with a 10-month history of left-sided facial pain who was initially diagnosed with persistent idiopathic facial pain (PIFP) on account of its similar characteristics. Magnetic resonance imaging (MRI) of the brain revealed gliosis and carotid siphon tortuosity; in addition, hyperhomocysteinaemia due to the homozygosis mutation for 5,10 MethyleneTetraHydroFolate Reductase was identified. Transcranial doppler ultrasonography was requested from a neurology consultant which revealed a high degree of RLS. Subsequently, a cardiological evaluation was performed; the specialist requested a transesophageal echocardiography that detected an interatrial septum aneurysm with PFO. Results: Based on the analysis of the patient's high degree of RLS, prothrombotic state and gliosis in relation to age, the cardiological consultant chose to perform a percutaneous closure of the PFO to avoid the risk of a cryptogenic stroke. After PFO closure, a complete remission of the pain was obtained. Conclusions: The disappearance of the pain supports the possible association between RLS and COFP. PFO with RLS has been suggested as a risk factor for cryptogenic stroke, especially in association with other thromboembolic risk factors. Therefore, the early detection, in this case, could be considered a possible lifesaver. Communication between different care providers is essential when the patient presents symptoms of facial pain which are of an atypical nature