Ureteroarterial fistulas, although rare, appear to be increasing in frequency. Because open surgical repair may be difficult and associated with significant risk for complications, endovascular intervention may provide an attractive treatment alternative. We review the diagnosis and management of a ureteroarterial fistula and iliac pseudoaneurysm that presented with massive hematuria during ureteral stent removal. The patient was treated by means of the percutaneous embolization of the right hypogastric artery and placement of an expanded polytetrafluoroethylene stent-graft. Endovascular stent-graft placement may serve as a safe and practical alternative in the treatment of these patients, whose cases are challenging.

The authors present the case of a 17-year-old woman with ulcerative colitis who presented with phlegmasia cerulea dolens (PCD) of the right leg. On examination, the compartments of her right leg were tense, sensory and motor function were greatly diminished, and pedal pulses were absent. Venous duplex revealed extensive venous thrombosis from the tibial veins to the external iliac vein. Treatment consisted of anticoagulation with systemic heparinization, and she was brought to the operating room for intraoperative venography, inferior vena caval filter placement, and four-compartment fasciotomy. Arterial pulses did not return; therefore, venous thrombectomy was performed by extrusion of distal thrombus with an Esmarch bandage, and fluoroscopic guided balloon catheter thrombectomy of the distal inferior vena cava and iliac veins proximally. Completion venography revealed the absence of residual thrombus. Postoperatively, the patient developed a lower gastrointestinal hemorrhage and anticoagulation was terminated. The fasciotomy skin incisions underwent delayed closure on postoperative day 6, and the patient was subsequently discharged with compression stockings. Total abdominal colectomy with creation of a J-pouch was performed 1 month following discharge. After 1 year, the patient had no complaints related to her leg. On examination, no evidence of venous insufficiency was present. Venous duplex demonstrated a patent deep venous system with no evidence of reflux. Uncomplicated PCD responds to heparin therapy in 50-80% of patients, but the risk for developing the postphlebitic syndrome is high. Venous thrombectomy has been reported to provide better long-term functional outcome. Catheter-directed thrombolysis has the added theoretical benefit of preserving endothelial and valvular function, and high technical success rates have been reported. No long-term functional outcome results for thrombolysis are available. Thrombolysis is contraindicated if compartment syndrome or venous gangrene is present. The aggressive surgical management of PCD may result in improved outcome.

Leaflet escape from mechanical heart valves is a rare but potentially fatal complication of prosthetic valve replacement. Historically, the incompetent valve is replaced emergently and the escaped leaflet is subsequently retrieved from its settlement in a distal vessel. If it is not retrieved, the fragment can increase the risk of infection, thrombosis, and migration. We report a case of a mechanical aortic valve leaflet that embolized during valve reoperation and caused occlusive aortic disease found 2 years later. This case emphasizes the importance of locating leaflet fragments after they are noticed missing.

(TGA) as first described by Bender 1 is characterized by a sudden onset of the inability to acquire new information and the loss of memory for recent events while immediate recall is preserved.1 " 3The patient remains alert, maintains self identity, and usually demonstrates concern by asking the same questions repeatedly. There are usually no concomitant neurologic deficits, and the disorder resolves within 24 hours, with residual amnesia for the event.1 " 3 Many etiologies have been proposed for TGA, including cerebrovascular disease, 4 -3 seizure disorder, 67 stress, 8 focal cerebral mass lesions, 9 cardiac disorders, 10 and migraine. 1112 However, no definite association between cerebral ischemia 11314 or ictal events 67 has been documented. Since many of these patients are considered to have cerebrovascular disease equivalent to patients with focal cerebral transient ischemic attacks (TIAs), 56 patients with symptoms of TGA were evaluated with noninvasive carotid artery testing to determine if there was a relation between TGA and the presence of extracranial atherosclerotic cerebrovascular disease. Subjects and MethodsFifty-six consecutive patients with symptoms fulfilling the criteria for a diagnosis of TGA '" 3 were evaluated by a neurologist soon after the episode, usually within 1 day and always within 1 week. Most of the patients had been referred with the diagnosis of TGA by a neurologist. Their mean age was 67 years, with a 18 was performed on all 56 patients. This battery of tests has been shown to identify nearly all carotid lesions with a stenosis of > 5 0 % on angiography 19 and is also capable of identifying small atheromas in the carotid sinus not readily visualized on angiography.18 A hemodynamically obstructive lesion at the carotid artery bifurcation was identified when an atherosclerotic plaque was visualized at the carotid bifurcation associated with high-frequency turbulence on Doppler flow 19 or reduction in the ophthalmic artery pressure to 10% below the contralateral side or to < 6 5 % of the brachial artery pressure. 13 ' 20 Pneumooculoplethysmography was performed with a Life Sciences PVR (Boston, Mass.). Supraorbital directional Doppler and Doppler velocity wave form analysis of carotid flow was performed with a Parks 908 continuous-wave directional Doppler (Beaverton, Ore.) at 9.5 mHz. Real-time B-mode ultrasonography was performed with a High Stoy SP100B and duplex scanning with 4-and 8-mHz Sonomed continuouswave directional Dopplers (Lake Success, N.Y.). Statistical analysis was performed by Fisher's exact test with the Epistat program (Tracy Gustafson, Round Rock, Tex.) on an IBM PC XT computer. ResultsOnly 1 of the 56 patients with TGA in this series had a history of neurologic disturbance, an episode of cerebellar ataxia, which probably represented a TIA in the vertebrobasilar distribution. The remaining 55 patients had no other history suggestive of cerebrovascular disby guest on

Abdominal aortic aneurysms (AAA) have been reported in 5% of males between the ages 65 and 79. The most common malignancies have their highest incidence in the same age group. Coexistence of AAA and malignancy is estimated to be 1-4%. Because of the relative infrequency of the problem, no consensus opinion exists about its management. This article reviews the literature on the subject of AAA and concomitant abdominal malignancies. We describe the current indications and surgical management of AAA, review the population studies describing a link between cancer and AAA, and examine the proposed mechanisms and risk factors behind this association. We also discuss how to determine priority of resection and provide recommendations and guidelines regarding the surgical management of this complex problem.