As the global population ages, the issue of abdominal aortic aneurysm continues to grow. With the evolution of new devices and refined operative technique, aneurysm treatment via endovascular aortic repair is becoming increasingly favourable. This, however, is not without drawbacks, where regular surveillance is paramount to long-term success and detection of post-procedure complications. Of these complications, endoleak is the most notable and poses the greatest risk of potential future aortic rupture. The purpose of this review paper is to discuss the armada of imaging modalities used in the detection and evaluation of endoleak and their varying usefulness. Plain abdominal X-ray is a cost-effective tool in detecting gross graft abnormalities such as stent migration or deformity (kinking or fracture). Though it may raise suspicion for endoleak, X-ray does not allow accurate classification of endoleak type when used alone. Duplex ultrasonography quantifies both aortic anatomy and real time flow dynamics. Most screening programmes are conducted using two-dimensional ultrasound. Unfortunately, observer and equipment variability may lead to surveillance discrepancies-but reduced when utilising a dedicated vascular sonography laboratory. Contrast enhanced ultrasonography is a promising alternative to computed tomography, though still is emerging. Computed tomography angiography certainly has disadvantages (ionising radiation, contrast-nephropathy, limited differentiation of endoleak type)-however, it provides near-real surgical dimensions and highlights graft complications and concomitant disease (such as neighbouring infection). With widespread availability and short scan time, it certainly remains valuable in surveillance. Magnetic resonance angiography has a similar sensitivity to computed tomography (minus the radiation), however is plagued by movement and metal artefact. Other novel modalities in endoleak surveillance include fourdimensional ultrasound, multiplanar intra-operative probes, nuclear medicine and wall stress analysis.
Post-traumatic high-flow priapism is a rare occurrence, with potentially debilitating long-term erectile dysfunction if left unaddressed. Even rarer, however, is for the priapism symptoms to be caused by a single cavernosal arterial pseudoaneurysm, with feeding vessels from the distal branched vessels of ‘both’ the left and right internal pudendal arteries. To the best of our knowledge, we present the first documented case of endovascular salvage utilizing superselective microcoil embolization in the treatment of high-flow priapism caused by a singular pseudoaneurysm with bilateral inflow. Timing of symptoms, interpretation of imaging, multidisciplinary discussions, procedural risk, arterial anatomy and choice of embolic agent were all careful considerations in this case. Following embolization, this young gentleman ultimately had a successful angiographic result, normalization of his cavernosal artery peak systolic velocity on ultrasound and a full return to normal erectile function by 6 months.
Popliteal artery entrapment syndrome (PAES) is a rare cause of limb-threatening vascular disease. Usually, it arises from aberrant embryological development or acquired dysfunctionality of the popliteal artery and its surrounding musculotendinous structures in the popliteal fossa. Here, we present a case report of a young woman with relatively sudden-onset short-distance claudication and paraesthesia affecting her right leg primarily. She had no recent traumatic history and no atherosclerotic risk factors and was otherwise previously very active. She had a feeble right popliteal artery pulse and no foot pulses. Nerve conduction studies demonstrated no electrophysiological abnormalities. Following computed tomography angiography and magnetic resonance imaging, it was determined she had type 2 PAES. Subsequently, the patient underwent surgical division of a lateralised head of her medial gastrocnemius, resection of her fibrosed popliteal artery, and repair with a reversed long saphenous vein interposition graft. Following surgery, her symptoms resolved, and she remains on aspirin and ultrasound surveillance.
The formation of a pulmonary arteriovenous malformation (PAVM) following penetrating chest trauma is a rare occurrence, often rapidly fatal or requiring emergency surgery. Even rarer still, is for the malformation to formed by an entangled and grossly tortuous network of multiple arteries and veins, with symptoms and eventual presentation to a medical facility taking place years after the initial injury. Without substantial literature available, and nil regarding instances of more than one involved artery and vein, we present the case of a complex left-sided PAVM, becoming symptomatic 15 years after a chest-wall stabbing. Clinical examination revealed hypoxia, tachycardia and an extracardiac bruit—prompting delineation with a computed tomography pulmonary angiogram and revealing the PAVM. Subsequent attempt at endovascular embolization was unsuccessful, though interrogation provided vital planning information for workup of urgent open-surgical ligation and resection. Surgery carries high morbidity and mortality, as does natural progression if left undealt.
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