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Emergent Percutaneous Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm Rupture With Acute Aortocaval Fistula
Journal of Vascular Surgery
Abstracts
880.e3
Volume 64, Number 3
A Case Report of Thoracic Endovascular Aortic Repair Under Local Anesthesia With Resolution of Acute-Onset Lower Extremity Paraplegia From an Acute Complicated Type B Aortic Dissection
Type IV Popliteal Arterial Entrapment Associated With an Osteochondroma
Selma El Hag, MD, Susan Shafii, MD, Elizabeth Hartman, MD, Michael Rosenberg, MD, Andrew Grande, MD, Gabriel Loor, MD, Rumi Faizer, MD. Vascular Surgery, University of Minnesota, Minneapolis, Minn
Case Report: A 27-year-old man complaining of a several-month history of right lower extremity coolness was seen by his primary care physician. He works as a farmer and tends his fields on the farm and commonly squats for milking cows. Ten days before presentation, he developed pain in his right foot with walking along with progressively increased coolness in his right leg. On physical examination, he was found to have a cool right lower extremity and no palpable dorsalis pedis or posterior tibial arterial pulses. Doppler examination produced a faint monophasic posterior tibial signal. No sensory deficits were noted. Computed tomography showed occlusion of the anterior tibial artery along with occlusion of the peroneal and posterior tibial arteries. Increased velocities were noted on the duplex ultrasound examination with provocative maneuvers in the tibial vessels. The patient underwent angiography, which demonstrated the occlusion of the anterior tibial, posterior tibial, and peroneal arteries. Catheters were then delivered to the anterior tibial and posterior tibial to allow infusion of tissue plasminogen activator. With repeated angiography, the posterior tibial artery remained occluded, and the anterior tibial artery opened with flow into the dorsalis pedis. The posterior tibial artery remaining occluded in spite of increased dose of tissue plasminogen activator. Further imaging was performed to look for a potential cause of thrombosis. The patient underwent magnetic resonance angiography with active dorsiflexion and plantar flexion to evaluate for potential popliteal entrapment as the patient’s pulse would diminish with plantar flexion. Magnetic resonance angiography demonstrated a pedunculated osteochondroma arising from the right proximal medial tibia. This lesion had significant mass effect on the adjacent medial gastrocnemius and popliteus muscles. With the active maneuvers performed, there was no evidence of compression; however, with the patient’s history, it was suspected that certain activities would cause compartment compression secondary to the osteochondroma. With this pedunculated osteochondroma, the patient was referred to orthopedics for resection. The patient underwent operative exploration with resection of the osteochondroma and release of his popliteus muscle to open the popliteal compartment. Postoperative duplex ultrasound examination demonstrated return of normal ankle-brachial index.
Spinal cord ischemia is rarely a presenting symptom of an acute complicated type B aortic dissection, occurring in approximately 3% of patients. The mechanisms leading to spinal cord ischemia in aortic surgery are multifaceted and not completely understood; however, theories involve a compromised collateral vascular network and malperfusion as well as microembolism. We describe the case of a 75year-old man with a prior history of aortobi-iliac bypass graft presenting with a 3-hour history of acute-onset paraplegia secondary to acute complicated type B aortic dissection. The patient was treated emergently with placement of a thoracic endograft under local anesthesia with significant improvement of true lumen flow and subsequently increasing flow through the infrarenal aortic graft. This resulted in recovery of paraplegia and coordinated lower limb motor function on the operating table within 10 minutes. Assessment of recovery was facilitated by our anesthesia mode, which allowed us to have the patient respond to verbal commands. This case report supports the concept of improvement of spinal cord blood flow through restoration of spinal cord arterial pathways and suggests that the time frame for attempting interventions may extend beyond 3 hours for malperfusion to the spinal cord from acute aortic dissection. The direct association between true lumen flow restoration using thoracic endovascular aortic repair under local anesthesia and paraplegia resolution intraoperatively is a novel finding that has not been described in the literature. We think that this case report may provide support for recognized cord perfusion theory as well as contribute to the understanding of the time frame associated with spinal cord ischemia and reversibility of paraplegia. Author Disclosures: S. El Hag: None; S. Shafii: None; E. Hartman: None; M. Rosenberg: None; A. Grande: None; G. Loor: None; R. Faizer: Honoraria; Medtronic Inc.
Development of Angiosarcoma in a Previous Femoral to Below-Knee Popliteal Artery In Situ Saphenous Vein Graft Rachel A. Morris, MD, Brian Keyashian, MD, Cheong J. Lee, MD. Medical College of Wisconsin, Milwaukee, Wisc
Dustin D. Lucarelli, MD, Aswath Subram, MD. Marshfield Clinic, Marshfield, Wisc
Author Disclosures: D. D. Lucarelli: None; A. Subram: None.
Emergent Percutaneous Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm Rupture With Acute Aortocaval Fistula
Case Report: We report a case of a 69-year-old man who developed an angiosarcoma after femoral to below-knee popliteal artery bypass with in situ saphenous vein graft. On his 6-month follow-up, the bypass graft was found to be occluded, and the patient denied further intervention as his claudication symptoms were not lifestyle limiting. The patient then presented 2 years after the initial operation with pain and swelling of the lower extremity and worsening claudication symptoms. Computed tomography angiography was performed, and he was thought to have a pseudoaneurysm of the superficial femoral artery on the basis of computed tomography imaging. The patient was taken to the operating room for exploration. Dissection toward the distal anastomosis revealed inflammatory tissue around the bypass graft and femoral artery, appearing aneurysmal. Isolation of the bypass graft was difficult as it was partially fused to the femoral vein and the genicular arteries. The graft and artery appeared to be pulsatile despite known occlusion. The anastomosis and proximal segments were intact despite the inflamed tissue. A biopsy of the tissue revealed high-grade soft tissue angiosarcoma. Conclusions: Angiosarcoma is a rare neoplasm representing 1% to 4% of soft tissue sarcomas. It is associated with radiation, chronic inflammation, chronic lymphedema, arteriovenous fistula, toxins, and the presence of foreign bodies. This case illustrates that angiosarcoma may be a rare, late complication of an autologous vascular bypass.
Aortocaval fistula as a result of ruptured abdominal aortic aneurysm is a relatively rare phenomenon. Because of the hemodynamic changes, patients can present in decompensated heart failure that can rapidly be fatal if it is not treated urgently. We describe the case of an 84-year-old woman who presented in cardiogenic shock with computed tomography evidence of an abdominal aortic aneurysm and an acute aortocaval fistula. She was taken directly to the operating room on arrival to the hospital and underwent a percutaneous endovascular abdominal aortic aneurysm repair with local anesthesia. On seal of the endograft, her hemodynamics rapidly improved, and pressors were weaned. The patient developed a femoral artery occlusion postoperatively that was repaired with an endarterectomy and patch angioplasty after her extremis resolved. She recovered quickly and was discharged on postoperative day 5. Percutaneous endovascular aneurysm repair with local anesthesia is an effective treatment modality for abdominal aortic aneurysm rupture with acute aortocaval fistula. The patient’s outcome is highly dependent on minimizing delay to operative intervention. Deployment of the endograft rapidly corrects hemodynamics.
Author Disclosures: R. A. Morris: None; B. Keyashian: None; C. J. Lee: None.
Author Disclosures: R. Denney: None. M. Murphy: None. A. Fajardo: None.
Richard Denney, MD, Michael Murphy, MD, Andres Fajardo, MD. Indiana University, Indianapolis, Ind
Abstracts
880.e3
Volume 64, Number 3
A Case Report of Thoracic Endovascular Aortic Repair Under Local Anesthesia With Resolution of Acute-Onset Lower Extremity Paraplegia From an Acute Complicated Type B Aortic Dissection
Type IV Popliteal Arterial Entrapment Associated With an Osteochondroma
Selma El Hag, MD, Susan Shafii, MD, Elizabeth Hartman, MD, Michael Rosenberg, MD, Andrew Grande, MD, Gabriel Loor, MD, Rumi Faizer, MD. Vascular Surgery, University of Minnesota, Minneapolis, Minn
Case Report: A 27-year-old man complaining of a several-month history of right lower extremity coolness was seen by his primary care physician. He works as a farmer and tends his fields on the farm and commonly squats for milking cows. Ten days before presentation, he developed pain in his right foot with walking along with progressively increased coolness in his right leg. On physical examination, he was found to have a cool right lower extremity and no palpable dorsalis pedis or posterior tibial arterial pulses. Doppler examination produced a faint monophasic posterior tibial signal. No sensory deficits were noted. Computed tomography showed occlusion of the anterior tibial artery along with occlusion of the peroneal and posterior tibial arteries. Increased velocities were noted on the duplex ultrasound examination with provocative maneuvers in the tibial vessels. The patient underwent angiography, which demonstrated the occlusion of the anterior tibial, posterior tibial, and peroneal arteries. Catheters were then delivered to the anterior tibial and posterior tibial to allow infusion of tissue plasminogen activator. With repeated angiography, the posterior tibial artery remained occluded, and the anterior tibial artery opened with flow into the dorsalis pedis. The posterior tibial artery remaining occluded in spite of increased dose of tissue plasminogen activator. Further imaging was performed to look for a potential cause of thrombosis. The patient underwent magnetic resonance angiography with active dorsiflexion and plantar flexion to evaluate for potential popliteal entrapment as the patient’s pulse would diminish with plantar flexion. Magnetic resonance angiography demonstrated a pedunculated osteochondroma arising from the right proximal medial tibia. This lesion had significant mass effect on the adjacent medial gastrocnemius and popliteus muscles. With the active maneuvers performed, there was no evidence of compression; however, with the patient’s history, it was suspected that certain activities would cause compartment compression secondary to the osteochondroma. With this pedunculated osteochondroma, the patient was referred to orthopedics for resection. The patient underwent operative exploration with resection of the osteochondroma and release of his popliteus muscle to open the popliteal compartment. Postoperative duplex ultrasound examination demonstrated return of normal ankle-brachial index.
Spinal cord ischemia is rarely a presenting symptom of an acute complicated type B aortic dissection, occurring in approximately 3% of patients. The mechanisms leading to spinal cord ischemia in aortic surgery are multifaceted and not completely understood; however, theories involve a compromised collateral vascular network and malperfusion as well as microembolism. We describe the case of a 75year-old man with a prior history of aortobi-iliac bypass graft presenting with a 3-hour history of acute-onset paraplegia secondary to acute complicated type B aortic dissection. The patient was treated emergently with placement of a thoracic endograft under local anesthesia with significant improvement of true lumen flow and subsequently increasing flow through the infrarenal aortic graft. This resulted in recovery of paraplegia and coordinated lower limb motor function on the operating table within 10 minutes. Assessment of recovery was facilitated by our anesthesia mode, which allowed us to have the patient respond to verbal commands. This case report supports the concept of improvement of spinal cord blood flow through restoration of spinal cord arterial pathways and suggests that the time frame for attempting interventions may extend beyond 3 hours for malperfusion to the spinal cord from acute aortic dissection. The direct association between true lumen flow restoration using thoracic endovascular aortic repair under local anesthesia and paraplegia resolution intraoperatively is a novel finding that has not been described in the literature. We think that this case report may provide support for recognized cord perfusion theory as well as contribute to the understanding of the time frame associated with spinal cord ischemia and reversibility of paraplegia. Author Disclosures: S. El Hag: None; S. Shafii: None; E. Hartman: None; M. Rosenberg: None; A. Grande: None; G. Loor: None; R. Faizer: Honoraria; Medtronic Inc.
Development of Angiosarcoma in a Previous Femoral to Below-Knee Popliteal Artery In Situ Saphenous Vein Graft Rachel A. Morris, MD, Brian Keyashian, MD, Cheong J. Lee, MD. Medical College of Wisconsin, Milwaukee, Wisc
Dustin D. Lucarelli, MD, Aswath Subram, MD. Marshfield Clinic, Marshfield, Wisc
Author Disclosures: D. D. Lucarelli: None; A. Subram: None.
Emergent Percutaneous Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm Rupture With Acute Aortocaval Fistula
Case Report: We report a case of a 69-year-old man who developed an angiosarcoma after femoral to below-knee popliteal artery bypass with in situ saphenous vein graft. On his 6-month follow-up, the bypass graft was found to be occluded, and the patient denied further intervention as his claudication symptoms were not lifestyle limiting. The patient then presented 2 years after the initial operation with pain and swelling of the lower extremity and worsening claudication symptoms. Computed tomography angiography was performed, and he was thought to have a pseudoaneurysm of the superficial femoral artery on the basis of computed tomography imaging. The patient was taken to the operating room for exploration. Dissection toward the distal anastomosis revealed inflammatory tissue around the bypass graft and femoral artery, appearing aneurysmal. Isolation of the bypass graft was difficult as it was partially fused to the femoral vein and the genicular arteries. The graft and artery appeared to be pulsatile despite known occlusion. The anastomosis and proximal segments were intact despite the inflamed tissue. A biopsy of the tissue revealed high-grade soft tissue angiosarcoma. Conclusions: Angiosarcoma is a rare neoplasm representing 1% to 4% of soft tissue sarcomas. It is associated with radiation, chronic inflammation, chronic lymphedema, arteriovenous fistula, toxins, and the presence of foreign bodies. This case illustrates that angiosarcoma may be a rare, late complication of an autologous vascular bypass.
Aortocaval fistula as a result of ruptured abdominal aortic aneurysm is a relatively rare phenomenon. Because of the hemodynamic changes, patients can present in decompensated heart failure that can rapidly be fatal if it is not treated urgently. We describe the case of an 84-year-old woman who presented in cardiogenic shock with computed tomography evidence of an abdominal aortic aneurysm and an acute aortocaval fistula. She was taken directly to the operating room on arrival to the hospital and underwent a percutaneous endovascular abdominal aortic aneurysm repair with local anesthesia. On seal of the endograft, her hemodynamics rapidly improved, and pressors were weaned. The patient developed a femoral artery occlusion postoperatively that was repaired with an endarterectomy and patch angioplasty after her extremis resolved. She recovered quickly and was discharged on postoperative day 5. Percutaneous endovascular aneurysm repair with local anesthesia is an effective treatment modality for abdominal aortic aneurysm rupture with acute aortocaval fistula. The patient’s outcome is highly dependent on minimizing delay to operative intervention. Deployment of the endograft rapidly corrects hemodynamics.
Author Disclosures: R. A. Morris: None; B. Keyashian: None; C. J. Lee: None.
Author Disclosures: R. Denney: None. M. Murphy: None. A. Fajardo: None.
Richard Denney, MD, Michael Murphy, MD, Andres Fajardo, MD. Indiana University, Indianapolis, Ind