Left Internal Iliac Research Articles

Severe multiple injuries in a 15-year-old boy with pelvic fracture complete anterior dislocation of the sacroiliac joint and rupture of the internal and external iliac arteries: A case report of a rare injury.

Anterior dislocation of the sacroiliac joint combined with pelvic fractures is relatively rare in clinical practice. It is often associated with hemodynamic instability and severe injuries to other regions, resulting in a complex condition, prolonged treatment duration, and high rates of mortality and disability. However, there are few reports in the literature describing the diagnosis and treatment of anterior dislocation of the sacroiliac joint. In this case, the patient sustained a pelvic fracture with anterior sacroiliac joint dislocation and rupture of both the internal and external iliac arteries following a motor vehicle accident, making it an even rarer and more challenging case to treat. Reporting such cases can enhance the understanding of the diagnosis and treatment of anterior sacroiliac joint dislocation with rupture of the iliac arteries and provide valuable references for similar cases. The patient was riding an electric bicycle and was hit by a small truck, resulting in a pelvic fracture, anterior dislocation of the sacroiliac joint, and rupture of the internal and external iliac arteries. The patient was diagnosed with open pelvic fracture (type C1.2), left complete anterior dislocation of the sacroiliac joint, left acetabular fracture, left internal and external iliac arteriovenous rupture. emergency room resuscitation, intensive care unit resuscitation, 6 surgeries and perioperative management. He has been discharged from the hospital for more than 1 year and was rechecked every month after discharge, the fracture has healed, there is no obvious pain and discomfort in and around the wound, he has been fitted with a prosthesis, and he is doing the walking function exercise. Pelvic fracture with anterior sacroiliac dislocation is clinically rare and critical, and is associated with large vessel rupture, severe organ damage, and high mortality and disability rates. Rapid restoration of pelvic stability and hemodynamic stability is the key to treatment. Rapid transfer to a tertiary trauma center, rapid examination through the green channel to clarify the diagnosis, close intensive care, and reasonable multidisciplinary teamwork for surgical intervention are all valuable experiences that we have concluded.

Sciatica secondary to deep venous thrombosis of the persistent sciatic vein: the first case in the literature. Illustrative case.

Sciatica usually results from lumbar nerve compression due to factors like disc herniations or lumbar canal stenosis. Despite its common causes, sciatic pain in a 52-year-old man following a coronavirus disease 2019 infection highlighted the importance of considering less common factors. Initially, minor disc protrusions were suspected as the cause of the symptoms, leading to the offer of surgery at another facility. The patient sought a second opinion, and our evaluation revealed a unique finding. Pelvic magnetic resonance imaging uncovered varicose structures displacing the left sciatic nerve. Subsequent pelvic computed tomography angiography identified a remarkable finding-the lack of opacification in a left persistent sciatic vein ascending toward a left internal iliac vein, originating from a common internal iliac venous trunk-confirming a suspicion for deep venous thrombosis. These findings represented not 1, but 2, extremely rare and distinct variants in the venous anatomy. The authors promptly initiated anticoagulant therapy and tailored pain management strategies, observing progressive thrombosis resolution on follow-up imaging. This report highlights the need for comprehensive diagnostics when symptoms and imaging differ. Misdiagnosis could lead to unnecessary surgeries and potential risks for the patient. https://thejns.org/doi/10.3171/CASE23652.

Image-based assessment of aortoiliac aneurysm anatomical characteristics in patients from the global iliac branch study

ObjectiveEndovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes.MethodsPre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation.ResultsLeft total iliac artery length was shorter than right (6.7 mm, P = .0019); right common iliac artery less tortuous (P = .0145). Males exhibited greater tortuosity in the left total iliac artery (P = .0475) and larger diameter in left internal iliac artery's landing zone (P = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females.ConclusionThis study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.

Retrospective case-control study on radiation dose for uterine artery embolization procedures.

Uterine artery embolization is performed in pre-menopausal women. Understanding the contribution of radiation dose at each stage of the procedure is important for potential dose reduction. The aim was to retrospectively analyse radiation dose on a per-procedural-stage basis, comparing digital subtraction angiography (DSA) and conventional roadmap (CRM). Group A consisted of 50 patients where DSA was used for road mapping at all stages: (I) Aortogram, (II) Left internal iliac artery (IIA) DSA, (III) Left uterine artery (UA) DSA, (IV) Right IIA DSA and (V) Right UA DSA. Group B included 50 patients, where CRM was used for road mapping at stages (II) and (IV). For Group A, mean total dose-area product (DAP) was 39.7 Gy·cm2; mean DAP for each stage were (I) Aortogram = 3.4 Gy·cm2, (II) Left IIA DSA = 5.9 Gy·cm2, (III) Left UA DSA = 3.2 Gy·cm2, (IV) Right IIA DSA = 5.5 Gy·cm2 and (V) Right UA DSA = 3.0 Gy·cm2. For Group B, mean total DAP was 33.6 Gy·cm2, mean DAP for each stage were (I) Aortogram = 3.3 Gy·cm2, (II) Left IIA CRM = 1.5 Gy·cm2, (III) Left UA DSA = 3.3 Gy·cm2, (IV) Right IIA CRM = 1.5 Gy·cm2 and (V) Right UA DSA = 3.3 Gy·cm2. Fluoroscopy time was 10 and 9.4 min for Groups A and B, respectively. The highest road-mapping radiation dose contribution was from bilateral IIA DSA. The use of CRM, intermittent fluoroscopy and elimination of the aortogram is recommended to further reduce procedural radiation dose.

Internal iliac debranching in combination with abdominal aortic stent graft to treat bilateral common iliac aneurysms

Introduction
 Common iliac artery aneurysms are often diagnosed during routine screening for infrarenal abdominal aortic aneurysms. Preserving the internal iliac artery helps avoid colonic ischemia and buttocks claudication. Hybrid surgery combining internal iliac artery transposition and endovascular treatment is a method with good early and long-term results.
 Methods
 We report of a case of bilateral common iliac artery aneurysm treated by hybrid surgery and endovascular intervention at Dong Nai General Hospital
 Results
 A 69 year-old male, diagnosed with bilateral common iliac artery aneurysm and left internal iliac artery occlusion. Surgical transposition was performed to repimplant the right internal iliac artery into the right external iliac artery, folowed by endovascular treatment, the right branch of the graft was placed at the external iliac artery, the left branch of the graft was placed at the common iliac artery. Postoperative condition was stable, no early complications recorded
 Conclusion
 Hybrid surgery to treat iliac aortic aneurysms and common iliac artery aneurysms has quite good mid- and long-term results. The initial successful implementation of this technique at Dong Nai General Hospital contributes to team development, reduces the load on central hospitals and brings practical benefits to patients.

THU153 Deep Vein Thrombosis As The Presenting Symptom In An Adolescent With New-Onset Type 2 Diabetes

Abstract Disclosure: F.I. Cooper: None. S. Gurnurkar: None. M. Carakushansky: None. Introduction The prothrombin G20210A mutation occurs in a small portion of the population, but usually does not become apparent unless the individual exhibits another risk factor for clotting (such as diabetes in adulthood). In this case report, we discuss a 15-year-old male with extensive deep vein thrombosis (DVT) in the setting of hyperglycemia and a newly-discovered prothrombin G20210A mutation. Case Presentation A previously healthy, obese 15-year-old male presented to the emergency department with two days of left hip pain radiating down to the left calf, and one day of left calf swelling. The patient denied prolonged immobility, recent infections, or recent vaccinations. There was strong maternal family history of diabetes but no history of thrombosis. D-dimer was 2013 ng/mL (0-500 ng/mL). A Computed Tomography of the abdomen and pelvis with contrast revealed thrombi in the inferior vena cava, left common iliac, left external iliac, left internal iliac and left common femoral veins. Initial labs were remarkable for unexpected significant hyperglycemia-- random serum glucose 317 mg/dl (<140 mg/dl).He was started on unfractionated heparin infusion as well as Lantus and Humalog insulins. An echocardiogram did not reveal pulmonary embolism or right heart strain. Hemoglobin A1C was 11.8% (3.4-5.6%) and C-peptide was detectable at 1.2 ng/mL (1.1-4.4 ng/mL), suggesting type 2 diabetes (in addition to negative anti-GAD 65 and islet cell antibody titers, in this child with a BMI of 34 kg/m2). The patient underwent image-guided thrombolysis and thrombectomy from the popliteal vein to the left iliac vessels and received continuous infusion of heparin and tissue plasminogen activator (TPA). As the clot improved over the subsequent days, he underwent image-guided angioplasty and removal of the popliteal sheath. He was then transitioned to enoxaparin and discharged on day 10 of hospitalization. His blood sugars responded well to insulin therapy (85-308 mg/dl). The patient received a staged thrombophilia workup. A heterozygous mutation was found in factor II (prothrombin G20210A) gene which is associated with a 2-4 fold increased risk of venous thromboembolism. The patient was discharged on enoxaparin, as well as Lantus and Humalog. He is followed by the Hematology and Endocrinology departments. Conclusion In this case, we presented the first written occurrence of DVT in a pediatric patient with type 2 diabetes. Our patient’s hyperglycemia caused by his new onset type 2 diabetes may have led to onset of an extensive DVT thrombosis at an usually young age, since he had an underlying prothrombin G20210A mutation. Our case also illustrates the need for a multidisciplinary approach (involving endocrinology, hematology, pediatric intensive care, and interventional radiology) for successful outcomes in these patients. Presentation: Thursday, June 15, 2023

A novel approach to the treatment of type B aortic dissection and common iliac artery aneurysms in a patient necessitating redo renal transplantation

In patients with end-stage renal disease (ESRD), treatment of common iliac artery (CIA) aneurysm disease necessitates safe operative repair while simultaneously maintaining candidacy for future renal transplant. We present the case of a patient with a type B aortic dissection and aorto-biiliac aneurysmal degeneration who has a previously failed right kidney transplant. Initial operative planning was approached with three goals: 1) endovascular repair as possible; 2) minimize paraplegia risk; 3) maintain renal transplant candidacy. As such, a three-stage operation was planned. Endovascular repair of the R CIA aneurysm was followed by thoracic endovascular aortic repair (TEVAR). The third stage, repair of AAA and left CIA aneurysm, was performed open using an aorto-biiliac graft with a surgically modified prosthetic bypass to preserve the left internal iliac artery to reduce paraplegia risk and the left external iliac artery (EIA) for future kidney transplantation. This novel technique successfully allowed for surgical repair of the Type B aortic dissection and the CIA aneurysms, while maintaining the patient’s future redo transplant candidacy with minimal paraplegia risk.

Balloon Trocar Is a Suitable Instrument for Retroperitoneal Para-aortic Lymphadenectomy in Gynecologic Malignant Diseases

To demonstrate the surgical technique of retroperitoneal para-aortic lymphadenectomy to prevent peritoneal rupture in gynecologic malignant disease. In this video, the authors describe how to use a balloon trocar to create a safe and efficient working space without peritoneal rupture. A step-by-step video demonstration of a surgical technique. Department of Gynecology and Obstetrics, Mie University, Tsu, Japan. Para-aortic lymphadenectomy is a part of most gynecologic oncology procedures for primary and recurrent gynecologic malignancies. There are 2 approaches to para-aortic lymphadenectomy: transperitoneal and retroperitoneal approaches. Although there are no significant differences between these approaches (such as in terms of the number of isolated lymph nodes or related complications), they are performed based on the operator's preference. The retroperitoneal approach is an unfamiliar surgical technique compared with usual laparotomy and laparoscopic surgery, and its disadvantages include a steeper learning curve for attaining proficiency. It is also difficult to develop the retroperitoneal space without a peritoneal rupture. In this video, we demonstrate the use of balloon trocars to create a retroperitoneal compartment. The patient was placed in the lithotomy position with the pelvis elevated at 5° to 10°. The left internal iliac approach, which is considered the standard approach, was used in this case (Fig 1). After identifying the left psoas muscles and the ureter crossing the common iliac artery, dissection of the left para-aortic lymph node was initiated (Supplemental Video 1, 2). Herein, we demonstrated a successful surgical technique for retroperitoneal para-aortic lymphadenectomy to prevent peritoneal ruptures.

PD18-09 THE INCIDENCE OF LEFT COMMON ILIAC VEIN COMPRESSION IN MEN WITH A VARICOCELE. IMPLICATIONS FOR ETIOLOGY AND MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD18-09 THE INCIDENCE OF LEFT COMMON ILIAC VEIN COMPRESSION IN MEN WITH A VARICOCELE. IMPLICATIONS FOR ETIOLOGY AND MANAGEMENT Peter Chin and Laurencia Villalba Peter ChinPeter Chin More articles by this author and Laurencia VillalbaLaurencia Villalba More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003273.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The etiology of varicocele is thought to be related to incompetence of the gonadal vein. Epidemiological studies have shown that Left Common Iliac Vein Compression (LCIVC) ≥25% occurs in 22-35% of the general population. The objective of this study was to compare the incidence and severity of LCIVC in men with a varicocele with the published incidence in asymptomatic men, document the incidence of left gonadal incompetence and provide a possible explanation for varicocele treatment failure. METHODS: Men presenting at our practice with a varicocele were enrolled into this study. Ethics approval was obtained. All participants underwent a Duplex Ultrasound of the pelvic veins. The degree of LCIVC was grouped into ≥25% (significant compression) and ≥50% (severe compression). The results were compared to a vascular epidemiological study of 272 asymptomatic men (Cheng et al 2017), by Chi-squared analyses. Degree of compression was analyzed for association with Grade of varicocele by Kruskal-Wallis ANOVA test. RESULTS: 80 men with varicoceles completed the investigations. Mean age of the cohort was 39.5 years. In our study group, 91.2% men had a LCIVC ≥25% (73/80) compared to the expected incidence in asymptomatic men of 29.4% (80/272) [χ2=96.2; p<0.001]. The study also showed that 67.5%% (54/80) had LCIVC ≥50% (severe) compared to the expected incidence in asymptomatic men of 6.9% (19/272) [χ2=137; p<0.0001]. Only 23% of men had incompetent gonadal veins (19/80). 16% of men with varicoceles had retrograde flow through the left internal iliac vein. 8.8% (7/80) men presented with recurrent varicocele and all had severe LCIV compression ≥50%. There was no significant correlation between WHO varicocele grade and degree of compression (Kruskal-Wallis one-way ANOVA H=3.26, p=0.196). CONCLUSIONS: This is the largest study to show that men with varicoceles have a significantly higher incidence of LCIVC ≥25% (significant) and LCIVC ≥50% (severe) than asymptomatic men. Increased pelvic venous pressure from LCIVC can lead to retrograde flow through the left internal iliac vein (16%). The high incidence of LCIVC in men with a varicocele suggests that a varicocele is an “escape” vessel for increased pelvic venous pressure. The majority of men in our cohort did not have a demonstrable incompetent gonadal vein (23%). This would make embolization difficult, and ligation unlikely to provide long term benefit if there was a separate pelvic feeding vessel. Severe LCIV compression (≥50%) is associated with DVT and pelvic venous congestion. Men with varicoceles should be further investigated with a pelvic duplex ultrasound. All of the men presenting with recurrent varicocele after embolization had severe LCIV compression. Although these results are significant, larger studies are needed to confirm these findings. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e506 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Chin More articles by this author Laurencia Villalba More articles by this author Expand All Advertisement PDF downloadLoading ...

Triple Threat: Spinal Dural Arteriovenous Fistula in Spinal Dysraphism and Tethered Cord Syndrome, a Case Report with Literature Review

Introduction: The incidence of spinal dural arteriovenous fistula (SDAVF) in patients with spinal dysraphism is exceedingly rare with fewer than 30 cases reported. We report such a case and discuss the etiology, diagnostic, and treatment challenges of such patients. Case Presentation: This is a 37-year-old gentleman with a history of myelomeningocele (MMC) repair at the age of 2 years who presented to us with worsening bilateral lower limb weakness and numbness. Clinical examination demonstrated affected motor and sensory functions from the level of L2. An MRI Lumbosacral revealed S3/S4 dysraphism with a tethered low-lying conus. A CT angiogram of the spine followed by a spinal angiogram confirmed the diagnosis of a SDAVF with feeders from the median sacral artery and other branches of the left internal iliac artery. He underwent angioembolization, following which we noted a residual SDAVF and hence underwent a difficult second-stage angioembolization to the right lateral sacral artery branch. The patient remained status quo on follow-up. Conclusion: SDAVFs occurring in spinal dysraphism requires a high index of suspicion to ensure the diagnosis is not missed or masked by co-existing tethered cord and dysraphism. These lesions should be managed in a multidisciplinary multimodal individualized fashion.

Superior gluteal artery as a reliable back door to embolize mycotic pseudoaneurysm of an isolated Internal Iliac artery

BackgroundAntegrade access through the origin of the internal iliac and direct percutaneous access under cross-sectional imaging guidance are commonly used for embolization of internal iliac artery aneurysms, pseudoaneurysms, or endoleaks. Here, we report superior gluteal artery retrograde access to treat internal iliac artery mycotic pseudoaneurysm in a patient with failed direct percutaneous access.Case presentationWe present a 65-year-old female with a history of diverticulitis and sigmoidectomy. Post-sigmoidectomy course was complicated by left common iliac artery (CIA) iatrogenic injury which required surgical ligation of the left CIA and graft placement. However, the graft was subsequently resection due to infection. Follow up CT imaging showed a 6 cm mycotic pseudoaneurysm (PSA) of the left internal iliac artery. Initially, the PSA sac was directly accessed and embolized under direct CT-guidance using Onyx. However, enlargement of the PSA sac was noted on one week follow-up CT images. Then, superior gluteal artery was accessed under ultrasound guidance, and the PSA sac and feeding vessels were re-embolized with coil and Onyx under fluoroscopy.ConclusionRetrograde access through superior gluteal artery is a feasible and safe approach to embolize internal iliac aneurysms, pseudoaneurysms, or endoleaks, when the antegrade or direct percutaneous access is limited.

Vaginal varices in post-menopausal woman: A rare entity

Post-menopausal bleeding occurs in 4-11% of post-menopausal women with the most common cause being endometrial atrophy followed by malignancies of genital tract. Vaginal varices are a rare cause and are usually seen in pregnant women. They are less common than vulval varicosities which occur in 2-4%of pregnancies. Other causes of vaginal varices are portal hypertension, pelvic congestion syndrome and Klippel-Trenaunay syndrome. Here we report a post-menopausal woman with vaginal varices without any evidence of liver disease nor pelvic congestion syndrome. A 71-year-old multipara presented with complaints of post-menopausal bleeding for 2 years. She gave typical history of passage of gush of fresh blood followed by spontaneous resolution within minutes. She had these episodes at an interval of 2 to 3 weeks for which she underwent total abdominal hysterectomy. There was no evidence of malignancy in histopathology. However, 7 months following surgery the symptoms recurred. On examination she was not pale and a pelvic examination was unremarkable except a 3*3 cm bluish swelling seen in the anterior vaginal wall. Ultrasound with doppler revealed increased vascularity around vagina. CT angiography was performed which showed a vaginal varix draining into left internal iliac vein. The patient was planned for embolization by transfemoral catheterization and feeding vessel was selectively embolized. Post -embolization the varix resolved, patient was discharged and is currently asymptomatic. Vaginal varices should be kept as a differential in post-menopausal bleeding especially when the discharge consists of fresh blood. Early recognition and treatment can also avoid unwanted hysterectomies.

A Giant Left Common Iliac Artery Aneurysm with Endovascular Repair: A Case Report

Common iliac artery aneurysm (CIAA) is a very rare entity, but with potentially disastrous evolution, aneurysm rupture or distal embolization. A specific management, surgical or endovascular procedure, is required. We present a case with a huge distal left common iliac artery aneurysm, in which the diagnosis was made incidentally during a weekly ultrasound examination, in spite of impressive dimensions, 9 cm diameter. The patient was then examined by 128- Slices computed tomography and angio-coronarography. Despite the attractive anatomy for direct surgery with resection of the aneurysm and restoration of the iliac tract through the interposition of a tubular prosthesis, due to the previous pathology of the patient with necrotizing fasciitis in the left lower limb and abdominal wall, endovascular intervention was decided. Because, the big size of the left common iliac artery aneurysm, located distally, with tortuosity of the left common iliac artery as well external iliac artery (EIA), permeable left internal iliac artery (IIA), extensive intra-aneurysmal thrombosis, endovascular procedure was complex and particular. The peculiarities of the case and the complex endovascular technique, with the placement of a stent graft on the infrarenal abdominal aorta, extended on both common iliac arteries, embolization of the left internal iliac artery and extension of the left arm on the external iliac artery, are described in this presentation.

Congenital portosystemic shunts: surgical treatment experience

Congenital porto-caval shunts are rare and may have a different morphological structure (intra- and extrahepatic shunts, with or without portal blood flow). The main method of treating patients with this pathology is endovascular shunt occlusion. However, in some cases, this method is ineffective.&#x0D; The article contains a description of six clinical examples of surgical treatment of congenital porto-systemic shunts in children. In the diagnosis of congenital portosystemic shunts, the leading role belongs to Doppler ultrasound, multislice computed tomography, and angiography. The indication for surgical treatment was the anatomical features of the shunt, which makes endovascular occlusion technically impossible. In one observation a wide Arantian duct was diagnosed, its open ligation was performed. In another case, the portal vein emptied directly into an aneurysmal dilatation, performed reconstructive plastic surgery on the vessels of the portal vein. In the next observation, a pronounced retrograde blood flow was determined along the dilated inferior mesenteric vein, blood was discharged through the sacral plexus into the internal iliac vein. The left internal iliac vein was isolated and ligated, the dysplastic inferior mesenteric vein was ligated and partially removed. In 2 patients, the portal vein flowed directly into the inferior vena cava in the area of aneurysmal expansion; an operation was performed open ligation of the shunt. In one observation, a deep hypoplasia of the intrahepatic branches of the portal vein was diagnosed, and therefore the restoration of portal blood flow after the closure of the shunt is impossible. The child was sent to decide on a liver transplant.&#x0D; Each case of congenital porto-caval shunts is unique. The surgeon determines the tactics directly during the operation, depending on the morphological structure of the organs, since the preoperative examination does not always give an unambiguous idea.

Surgical Treatment of Small Intestinal Bleeding Caused by Arterial Gastrointestinal Fistula: A 2-Case Report

Background: This study aims to better understand diagnosing and treating arterial gastrointestinal fistulas. Methods: The diagnosis and treatment of two patients with arterial gastrointestinal fistulas were reported, and the experience with diagnosis and treatment was summarized. Results: In these two cases, both patients were admitted with bleeding as the primary complaint, both underwent emergency laparotomies, and both patients were diagnosed with small intestinal bleeding before surgery. the first patient died as a result of an abdominal aortic aneurysm rupture caused by chronic vascular repair and postoperative implant infection; the second patient underwent vascular repair on time, we treated him with third-generation cephalosporin, and after he was stabilized, we performed left total iliac stent placement and left internal iliac artery embolization; he had no fever after surgery, his incision was healed, and he was successfully discharged from the hospital. Conclusion: Aortic gastrointestinal fistula is rare and has a high mortality rate, attention should be paid to distinguishing it from small intestinal bleeding. Timely diagnosis and rapid surgical treatment are keys to improving survival.

410 “SHARK-FIN“ ECG: NOT ALWAYS A STEMI!

Abstract Background Coronary malperfusion due to type A aortic dissection is a life-threatening condition where timely recognition and treatment are mandatory. The International Registry of Acute Aortic Dissection (AAD) shows that only 5% of AAD patients present with ECG evidence of acute myocardial infarction, and prognosis is ominous due to the additional myocardial damage and missed or delayed diagnosis. The shark fin waveform is an uncommon but high-risk ECG pattern formed by fusion of QRS, ST-segment, and T waves. It is associated especially with the sub-occlusion of the left main coronary artery or proximal left anterior descending artery with a high risk of death due to cardiac arrest and cardiogenic shock. Case presentation A 61-year-old man was admitted to our cardiac cath-lab for typical chest pain and suspected acute ST segment elevation myocardial infarction (STEMI). A triangular pattern known as the ‘shark-fin’ sign in the precordial and inferior leads, and mirroring ST-segment depression in dI and aVL was detected. Unexpectedly coronary angiography revealed normal epicardial vessels, but a very-regular-shaped staining of the aortic sinus was observed. This finding was suspicious for acute aortic dissection. Bedside 2D-echocardiography within the cath-lab demonstrated an intimal flap in the aortic root and arch, with mild aortic regurgitation. Contrast-enhanced computerized tomography (CT) confirmed our diagnosis of Type A aortic dissection (AAD) highlighting the same dissection flap revealed by angiography arising from the left coronary cusp of the aortic root. The left main trunk was not directly involved, but the dissection extended from the ascending to the distal aorta involving both left and right external and internal iliac arteries with a thrombotic occlusion of the right femoral-iliac axis There was also a right inferior-pole renal infarction. Thus, the patient was immediately submitted to heart surgery. Conclusions Type A aortic dissection is a life-threatening disease in which early diagnosis and treatment are critical for survival. Occasionally it could mimic STEMI due to coronary involvement or dynamic obstruction of a coronary ostium. In our experience a bedside echocardiography performed before primary percutaneous coronary intervention (PCI) may confirm the clinical suspicious and avoid dangerous diagnostic delays.

DESMOID TUMOUR OF ANTERIOR ABDOMINAL WALL: A CASE REPORT

Desmoid tumours are broblastic neoplasms which show aggressive inltrative behaviour and can cause mass effect. They should be monitored for asymptomatic patient as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete pathologic resection is not achievable without signicant morbidity, more modest resection is recommended along with treatment with adjuvant therapies. A 36-year-old female presented to the surgery OPD with the complaint of lump in left iliac fossa for last 2 years, initially 3 x 2 cm in size but gradually increasing in size with stable vitals and examination nding of lump palpable in left iliac fossa of size 20 x 15cm, hard in consistency, not xed to skin, mobile, non-tender and becoming prominent on leg raising test. MRI pelvis was suggestive of 17.1 x 12.8 x 11.4cm, T2 hypointense lesion in left hemipelvis with extension into the hypogastrium and left iliac fossa, inltrating the left anterior abdominal wall in the left iliac fossa and hypogastrium and reaching to skin surface via large defect in the abdominal wall size, abutting and displacing the urinary bladder and left external and internal iliac vessels with the angle of contact less than 90 degrees with the vessels and left ovary not visualised separate from the lesion. FNAC was suggestive of spindle cell tumour. The patient successfully underwent wide local excision along with left oopherectomy, mesh repair and transverse rectus abdominis myocutaneous (tram) ap. Conclusion: Since, desmoid tumors are locally aggressive and invasive, timely surgical intervention with resection in this patient prevented further progression of the tumour and the high probability of invasion and involvement of major blood vessels thus signicantly reducing the fatality.

Abstract 12986: Internal Iliac Artery Occlusion With the Amplatzer Vascular Plug During Endovascular Repair of Large Abdominal Aortic Aneurysm

Background: Retrograde blood flow from the internal iliac artery resulting in a type II endoleak is a challenging complication of endovascular aorto-iliac aneurysm repair. Several methods have been developed to address this concern. We present a case where the Amplatzer vascular plug was used to embolize the internal iliac artery in a patient undergoing aorto-iliac stent-grafting with extension of the graft into the external iliac artery. Case: A 67-year-old male presented with abdominal pain. Abdominal contrast computed tomography confirmed a large infrarenal abdominal aortic aneurysm (AAA) measuring 100 mm across, extending into the common iliac artery on the right and the external iliac artery on the left, with perianeurysmal fat stranding indicating impending rupture. The patient was taken emergently to the operating room. Vascular access was obtained through bilateral common femoral arteries. The left internal iliac was occluded with an Amplatzer 16 mm by 12 mm vascular plug, with excellent angiographic apposition. A bifurcated aorto-iliac graft was then sequentially deployed to repair the aneurysm. Final angiography showed patent renal arteries with no endoleak. The patient was discharged home the following day. Discussion: Embolization of the internal iliac artery is indicated in endovascular aorto-iliac aneurysm repair to prevent endoleak formation. Traditionally performed with coils, the Amplatzer vascular plug has emerged as a safe and effective alternative, with the added advantage of recoverability prior to definitive release. Conclusion: Endovascular repair of an AAA must consider the complication of endoleak formation. In this case, the use of an Amplatzer vascular plug was successful in preventing a type II endoleak from the internal iliac artery. Panel A. 3D reconstruction of aneurysm anatomy; Panel B. Angiogram showing final result of endovascular repair with successful occlusion of the left internal iliac artery

Insight into Vietnamese women’s internal iliac artery anatomy

This study aims to assess the characteristics of the internal iliac artery and to examine correlations between the internal iliac artery and other anatomic structures in the pelvis. A cross-sectional study was conducted in the period between October 2019 and May 2020. Eighteen samples of the left and right internal iliac arteries were taken from formaldehyde-embalmed female cadavers at the Ho Chi Minh City University of Medicine and Pharmacy Department of Anatomy. The study showed that the origins of most internal iliac arteries were located by the lumbar vertebrae 4-5. The mean distance from the origin of the internal iliac artery origin to the sacral promontory was 33.95 ± 3.35 mm (on the left), and 31.70 ± 4.64 mm (on the right). The internal iliac artery always had two big branches – anterior and posterior. A third branch was an ilio-lumbar artery, often seen by 43.33%. The diameters of those internal iliac artery branches were comparable on both sides, and the branches of similar name had a little larger diameter on the left than on the right. The internal iliac artery always has two large anterior and posterior branches; in some cases, it has a third branch called ilio-lumbar artery. The internal iliac artery’s length from its origin to the initial branch division is comparable for both right and left sides. The distance from the internal iliac artery’s origin to the sacral promontory is suggestive for surgeons to find the internal iliac artery after determining the sacral promontory.

S2191 A Case Report of Syphilitic Proctitis Mimicking Rectal Cancer

Introduction: Syphilis rarely affects the gastrointestinal tract, and even more rarely manifests with lower gastrointestinal signs and symptoms. We report a rare case of syphilitic proctitis that presented with inguinal lymphadenopathy and pain with defecation mimicking anorectal malignancy. Case Description/Methods: A 31-year-old male with a history of multiple, recent male sexual partners, sexually transmitted infections (STIs), anxiety, depression, and migraines presented to the emergency department with a 2-month history of left inguinal pain, perianal pain, and pain with defecation. His initial exam was notable for a palpable rectal mass and tender left inguinal lymphadenopathy. CT abdomen/pelvis demonstrated a markedly enlarged left inguinal lymph node measuring 3.9 x 2.7 x 3.1 cm with multiple enlarged perirectal and left internal iliac lymph nodes, radiographically concerning for metastatic disease. Colonoscopy revealed congested mucosa in the rectum and a palpable external rectal mass on digital rectal exam. He was tested for sexually transmitted diseases and was found to have a reactive RPR with a titer of 1:128 and positive T. pallidum antibodies. His biopsy resulted with findings of syphilitic proctitis and spirochetosis confirmed by treponema pallidum immunostain, consistent with secondary syphilis. He was treated with a 14-day course of doxycycline (due to penicillin allergy) with initial improvement in symptoms. Discussion: Syphilis is an important public health issue with increasing cases in the United States over the last 20 years. Syphilis uncommonly affects the gastrointestinal tract, and even less commonly the lower GI tract. Syphilitic proctitis most often presents with pain on defecation, rectal bleeding, tenesmus, and diarrhea and is often difficult to distinguish from inflammatory bowel disease or malignancy. Given the rise in sexually transmitted infections, it is important for providers to be aware of this presentation, which requires a thorough sexual history and prompt testing if exposure is suspected, to prevent ongoing transmission and development of complications. Our case highlights the rare presentation of syphilis and the importance of screening for STIs in high-risk patients.