Left Artery Research Articles

Construction and Validation of a Rat Model of Acute Necrotizing Pancreatitis-Associated Intestinal Injury.

Acute pancreatitis (AP) is an acute inflammatory reaction of the pancreatic tissue, which involves auto-digestion, oedema, haemorrhage, and necrosis. AP can be categorized into mild, moderately severe and severe AP, with severe pancreatitis also referred to as acute necrotizing pancreatitis (ANP). ANP is characterized by the accumulation of necrotic material in the peritoneal cavity. This can result in intestinal injury. However, the mechanism of ANP-associated intestinal injury remains unclear. We established an ANP-associated intestinal injury rat model (ANP-IR model) by injecting pancreatitis-associated ascites fluid (PAAF) and necrotic pancreatic tissue at various proportions into the triangular area formed by the left renal artery and ureter. The feasibility of the ANP-IR model was verified by comparing the similar changes in indicators of intestinal inflammation and barrier function between the two rat models. In addition, we detected changes in apoptosis levels and YAP protein expression in the ileal tissues of rats in each group and validated them in vitro in rat epithelial crypt cells (IEC-6) to further explore the potential injury mechanisms of ANP-associated intestinal injury. We also collected clinical data from patients with ANP to validate the effects of PAAF and pancreatic necrosis on intestinal injury. Our findings offer a theoretical basis for restricting the buildup of peritoneal necrosis in individuals with ANP, thus promoting the restoration of intestinal function and enhancing treatment efficacy. The use of the ANP-IR model in further studies can help us better understand the mechanism and treatment of ANP-associated intestinal injury.

A case of non-traumatic rectus sheath hematoma in a post-kidney transplant patient undergoing catheter embolization during anticoagulation treatment for atrial fibrillation.

A 65-year-old man, a post living donor kidney transplant patient, was admitted to the intensive care unit (ICU) with a severe bacterial infection. He also tested positive for coronavirus disease and had a cough. On admission, heparin was administered for atrial fibrillation. On the third day of hospitalization, his general condition had recovered, and he was discharged from the ICU to the general ward. On the fourth day of hospitalization, he experienced abdominal pain, and a hard mass was palpated in the left lower abdomen. On the fifth day of hospitalization, contrast-enhanced computed tomography showed an extensive rectus sheath hematoma (RSH) extending from the left lower abdominal wall to the left side of the bladder, with extravasation from a small branch of the left inferior epigastric artery. Heparin was discontinued, and transcatheter arterial embolization was performed to control the bleeding. RSH is a rare disease, and cases of extensive hematoma in post-kidney transplant patients occur even less frequently. Patients taking anticoagulants and those with chronic kidney disease are at high risk for RSH, so physicians should be cognizant of this disease when these patients develop abdominal pain.

Should the left internal mammary artery (LIMA) be imaged before radiotherapy in cases of unexpected early acute coronary syndrome?

Abstract Funding Acknowledgements None. Case A 41-year-old male patient presented to the cardiology outpatient clinic with a complaint of exertional chest pain persisting for the past 4 months, along with occasional palpitation attacks. In his medical history, aside from being diagnosed with lymphoma 15 years ago, there were no known additional comorbidities. The electrocardiogram (EKG) revealed sinus rhythm (84 beats/minute), and the blood tests showed creatinine: 0.81 mg/dL, WBC: 11.26 mm^3, LYM: 3.69 mm^3. Transthoracic echocardiography demonstrated an ejection fraction (EF) of 60%, with no additional pathologies except for grade 1 diastolic dysfunction. Considering the presence of typical chest pain, coronary imaging was performed to assess for stable angina. The coronary imaging revealed a lesion extending from the left main coronary artery (LMCA) to the proximal left circumflex artery (CX), with an 80% stenosis in the mid-segment of the LMCA, a 60% stenosis at the narrowest point of the CX proximal segment, and an 80% stenosis in the proximal right coronary artery (RCA). The left circumflex artery obtuse marginal branches (CX OM) appeared thin and extensively diseased (Figure-1) The patient was promptly scheduled for early coronary artery bypass grafting (CABG), transferred to the cardiac surgery intensive care unit, and underwent a successful coronary bypass procedure with LAD-LIMA, Ao-saphenous-IM-saphenous-CxOM1 (sequential) grafting. Throughout the postoperative follow-up period, the patient continued to experience exertional chest pain despite medical treatment. A repeat coronary angiography was performed, revealing that the bypass grafts were opened, but a diffuse 80% stenosis was detected at the mid-segment of the LIMA graft, prior to the anastomosis.(Figure-2) Successful stent placement was performed at the narrowest point of the LIMA mid-segment (Figure-3).The patient had no anginal complaints during post-procedure follow-up and has been stable under observation. Discussion Routine clinical practice does not involve LIMA imaging in patients who have undergone diagnostic coronary angiography with multi-vessel involvement and a CABG decision. However, the use of coronary artery bypass graft surgery (CABG) may entail a risk of rendering the graft unusable due to extensive mediastinal fibrosis and radiation-induced damage to the left or right mammary artery. Therefore, in patients with a history of radiation exposure in the thoracic region and a CABG decision, the visualization of the intermammary artery during coronary angiography and the consideration of alternative grafts, such as the radiation-free radial artery, or the necessity for high-risk percutaneous stent implantation, should be discussed.figure-1figure-2

Left Renal Artery Chronic Occlusion in the Setting of Extensive Intraprosthetic Mural Thrombus in an Abdominal Aortic Endograft

Left Renal Artery Chronic Occlusion in the Setting of Extensive Intraprosthetic Mural Thrombus in an Abdominal Aortic Endograft

Decreasing the blood flow of non-compressible intra-abdominal organs with non-invasive transcutaneous electrical stimulation

Non-invasive neuromodulation of non-compressible internal organs has significant potential for internal organ bleeding and blood-shift in aero/space medicine. The present study aims to investigate the potential influences of the non-invasive transcutaneous electrical nerve stimulation (TENS) on multiple non-compressible internal organs’ blood flow. Porcine animal model (n = 8) was randomized for a total of 48 neuromodulation sessions with two different TENS stimulation frequencies (80 Hz, 10 Hz) and a placebo stimulation. A combination of two different electrode configurations (Abdominal-only or Abdominal and hind limb) were also performed. Intraarterial blood flow measurements were taken during pre and post-stimulation periods at the left renal artery, common hepatic artery, and left coronary artery. Intracranial, and extracranial arterial blood flows were also assessed with digital subtraction angiography. TENS with abdominal-only electrode configurations at 10 Hz demonstrated significant reductions in average peak blood flow velocity (APV) of the common hepatic artery (p = 0.0233) and renal arteries (p = 0.0493). Arterial pressures (p = 0.0221) were also significantly lower when renal APV was reduced. The outcome of the present study emphasises the potential use of TENS in decreasing the blood flow of non-compressible internal organs when the correct combination of electrodes configuration and frequency is used.

Multicentre Experience with Novel Bidirectional Double Cuffed Inner Branches for Complex Endovascular Aortic Repair

This study aimed to report the initial experience with a novel bidirectional double cuff inner branch design for incorporation of renal and mesenteric arteries in patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR). A retrospective review was undertaken of the experience of F/BEVAR with grafts integrating at least one bidirectional double cuffed inner branch implanted at three tertiary aortic centres between March 2022 and June 2023. All consecutive patients were included. Baseline characteristics, operative and follow up data were collected. Results were presented as number or median (interquartile) unless otherwise stated. Thirteen patients (10 male; median age 72 [68, 77] years) had F/BEVAR using a total of 15 bidirectional double cuffed inner branches (30 cuffs). Indications for bidirectional doubled cuffed inner branches included cranial vessel orientation or double renal arteries in four patients each, common coeliomesenteric trunk in three patients, and early renal artery bifurcation, renal artery origin from a false lumen requiring a flexible route for catheterisation, and surplus configuration in one patient each. Twenty three of the 30 cuffs were used, whereas the remaining seven cuffs were intentionally occluded with vascular plugs. Target vessel incorporation was successful in all bidirectional branches. There was one technical failure related to unsuccessful catheterisation of a left renal artery targeted through a unidirectional caudal inner branch. During a median follow up of seven months there were no instances of target vessel instability or re-interventions and two patients died of causes unrelated to the bidirectional branches. The results of the use of bidirectional double cuff inner branches are promising, with high technical success and no short term branch related complications in this preliminary experience. This could potentially expand the applicability of branch endografting of complex endovascular aortic repairs, but long term results are still missing.

Homolateral Embolic Stroke After Emergency Ligation of the Common Carotid Artery to Stop Heavy Bleeding Caused by Carotid Blowout Syndrome.

Emergency common carotid artery (CCA) ligation for bleeding control during carotid blowout syndrome with consecutive embolic stroke has been reported rarely. The patient is a 70-year-old man, who was suffering from acute profuse bleeding from the left superior thyroid artery into the piriformis sinus, which was not controlled other than by ligation of the left CCA. The cause of the bleeding remained unclear but was suspected to be related to his history of being positive for squamous cell carcinoma of the left hypopharynx with ari and postcricoid infiltration, diagnosed at age 58. Squamous cell carcinoma was treated with local resection, chemotherapy (docetaxel, carboplatin, and cetuximab), and radiotherapy. Neurological examination 4 days after CCA ligation revealed multiple subacute embolic strokes in the territory of the left middle cerebral artery, macroangiopathy of the extra and intracranial cerebral arteries, and hypoplasia of the left vertebral artery. This case demonstrates that carotid blowout syndrome may require CCA ligation when external carotid artery ligation is not possible, and that ligation can be complicated by an asymptomatic embolic stroke.

Emerging Hypertension in Young Adults: A Detailed Case Report on Takayasu Arteritis in a 29-Year-Old Female from South India

Abstract Introduction: Takayasu arteritis is a rare vasculitic disorder predominantly affecting young women, characterized by inflammation of the aorta and its major branches usually seen in the East Asian population. Due to its varied clinical presentation, early diagnosis remains challenging, necessitating a high index of suspicion. Case Report: A 29-year-old South Indian female presented with exertional dyspnea to the emergency department and was initially diagnosed and treated as middle lobe pneumonia. Further physical and laboratory evaluations done at that time were unremarkable. Following successful treatment, she remained largely asymptomatic and sought evaluation at the local clinic due to elevated blood pressure detected during home monitoring. On work up of hypertension Echocardiography was done which showed unusual wall thickening of the ascending aorta and mild aortic regurgitation .CT aortogram was then done which revealed aortic thickening and left renal artery stenosis. Confirmation of takayasu arteritis was achieved through PET-CT imaging at a higher tertiary care centre, leading to initiation of immunosuppressive therapy and subsequent percutaneous transluminal angioplasty stenting of the left renal artery. Conclusions: A high index of suspicion is crucial in young females with unusual presentations especially in the South Indian population where the disease is not prevalent. Due to financial constraints it is very likely that appropriate imaging is not done in cases where takayasu arteritis is not suspected by the treating physician. Lack of appropriate work up of hypertension can result in missed diagnoses which can lead to potentially disastrous side effects to the disease Keywords: Takayasu arteritis, young female, vasculitis, immunosuppressive therapy, angioplasty.

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

BackgroundDuring laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel.MethodsThis is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our“five-step process”(n = 34) between January 2021 and July 2023 were included.ResultsThe vessels can be effectively exposed using the aforementioned “five-step process.” It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein.ConclusionWe have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer

The "Bundle Wire" Technique: A Novel Approach to Cannulating Challenging Target Vessels Using Multiple Fine Atraumatic Guidewires That Together Serve as a Stiff Guidewire.

To present a novel technique that enables safe and effective cannulation of target vessels with challenging anatomy during fenestrated/branched endovascular aortic repair (F/B-EVAR). Following deployment of the F/B-EVAR endograft, the target vessels (TVs) are cannulated. The bundle wire technique provides a solution to challenging TVs and uses multiple fine atraumatic guidewires that together serve as a stiff guidewire. The technique can be executed in 2 ways using: (1) one 0.018 inch and one 0.014 inch guidewire or (2) three 0.014 inch guidewires. We demonstrate the technique in a case of a complex abdominal aortic aneurysm treated using branched EVAR in which the left renal artery with severe ostial stenosis was catheterized using the bundle wire technique. The bundle wire technique offers a technically feasible and economically viable solution for facilitating catheter and bridging stent delivery in anatomically challenging TVs during F/B-EVAR. It is a useful addition to the therapeutic armamentarium available to physicians for accessing demanding TVs.

Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms.

Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma. A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery. Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.

Far Lateral Approach and Occipital Artery to Posterior Inferior Cerebellar Artery Bypass With Staged Flow Diversion for Treatment of De Novo Vertebrobasilar Junction Aneurysm: 2-Dimensional Operative Video

Intracranial aneurysms refractory to endovascular treatment often require complex cerebral revascularization strategies, including combined open-endovascular techniques. 1-3 An adolescent girl presented with headache, and a fusiform right V4 vertebral artery aneurysm was diagnosed. Initial treatment was attempted with coil embolization. Surveillance imaging at 3 years after embolization demonstrated a de novo vertebrobasilar junction (VBJ) aneurysm with involvement of the right anterior inferior cerebellar artery-posterior inferior cerebellar artery (PICA) origin. The VBJ aneurysm was initially observed. Enlargement was noted at 1 year, and secondary treatment was attempted with left V3 segment coil occlusion to induce flow reversal. Follow-up demonstrated progressive VBJ aneurysm enlargement, prompting attempted left occipital artery (OA)-PICA bypass at an outside facility, which was unsuccessful. The patient was referred to our institution. After her parents gave informed consent, she underwent right OA-PICA bypass on the contralateral side through far lateral craniotomy with inside-out harvest of the donor vessel. 4 After trapping and arteriotomy of the recipient PICA, an OA-PICA end-to-side anastomosis was performed using a running continuous technique. 5 Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the bypass. The patient tolerated the procedure well and remained neurologically intact. On postoperative day 3, a staged transcirculation flow diversion device was placed to facilitate progressive thrombosis of the aneurysm. 6,7 Follow-up angiography at 1 year demonstrated complete occlusion of the aneurysm. This video demonstrates successful multimodal management of a complex de novo VBJ aneurysm after a series of refractory endovascular treatments and unsuccessful cerebral revascularization techniques.

Polyarteritis Nodosa Confined to the Kidneys in a Patient with Proteinuria and Mild Renal Impairment

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis predominantly involving medium- or small-sized arteries, typically of the kidneys and other internal organs. Given the rarity of PAN and the variable clinical presentation, diagnosis is challenging and, to date, no definitive diagnostic marker has been identified. A patient diagnosed with immunoglobulin A nephropathy was observed to exhibit deterioration in renal function. To determine whether new structural abnormalities had developed, computed tomography scans of the kidneys, ureters, and bladder were obtained. Both kidneys exhibited multiple cortical defects, and a renal angiogram was performed to determine the cause. Angiography revealed partial obliteration of the left distal renal artery branches and multifocal extensive infarctions in both kidneys, and the patient was diagnosed with renal-limited PAN. Following steroid monotherapy, an improvement in renal function was observed. We believe that this case report may be helpful to physicians who assess and treat patients with suspected renal-limited PAN.

Thrombosed Persistent Median Artery with Coexisting Bifid Median Nerve in a Robotic Arthroplasty Surgeon: A Case Report.

A 47-year-old orthopaedic surgeon presented with acute volar left wrist pain. He performed over 250 robot-assisted knee arthroplasties each year. Color Doppler evaluation revealed bilateral persistent median arteries and bifid median nerves, with focal occlusive thrombosis of the left median artery. He was advised rest and oral aspirin. He could return to his professional activities after 1 month. He had no recurrence of symptoms at 1 year of follow-up. Orthopaedic surgeons use vibrating hand tools on a daily basis. The possibility of hand-arm vibration syndrome must be considered in the differential diagnosis of wrist pain among orthopaedic surgeons.

SOX4 silencing alleviates renal injury in rats with acute renal failure by inhibiting the NF-κB signaling pathway and reducing apoptosis and oxidative stress.

Acute renal failure (ARF) is a huge threat to the lives of most patients in intensive care units, and there is currently no satisfactory treatment strategy. SRY-box transcription factor 4 (SOX4) plays a key role in the development of various diseases, but its effect on ARF is unknown. Therefore, this study aimed to explore the relationship between SOX4 and ARF. Blood samples were collected from 20 ARF patients and 20 healthy volunteers. We also established an ARF rat model by excising the right kidney and ligating the left renal artery, and SOX4 knockdown in ARF rats was achieved down by means of lentiviral infection. Subsequently, we used quantitative polymerase chain reaction and western bolt assays to detect the expression levels of SOX4 and nuclear factor-κB (NF-κB) signaling pathway-related proteins in human blood or rat renal tissue and hematoxylin and eosin and terminal deoxynucleotidyl transferase (TdT) 2'-deoxyuridine 5'-triphosphate (dUTP) nick-end labeling staining to observe the pathological changes and apoptosis of renal tissue. Enzyme-linked immunosorbent assay and biochemical kits were used to measure the levels of renal function-related indicators (blood urea nitrogen, creatinine, and neutrophil gelatinase-associated lipocalin) and inflammatory factors (interleukin [IL]-1β, IL-6, and tumor necrosis factor-alpha), as well as changes in oxidative stress-related indicators (malondialdehyde [MDA], superoxide dismutase [SOD], and reactive oxygen species [ROS]) in rat serum. SOX4 expression levels in blood samples from ARF patients and renal tissue from ARF rats were significantly higher compared with those in healthy volunteers and control rats, respectively. ARF model rats displayed the typical ARF phenotype, while SOX4 silencing significantly improved pathological injury and apoptosis of renal tissue in ARF rats. Moreover, SOX4 silencing significantly inhibited increased levels of renal function-related indicators and inflammatory factors and reduced the level of excessive oxidative stress (MDA and ROS were upregulated, and SOD was downregulated) in ARF rats. SOX4 also reduced the activity of the NF-κB signaling pathway in ARF samples. Thus, SOX4 knockdown may reduce oxidative stress, the inflammatory response, and apoptosis by reducing the activity of the NF-κB signaling pathway, thereby improving renal injury in ARF rats.

ANGIOEMBOLISATION OF CREMASTERIC ARTERY FOR SCROTAL HAEMATOMA FOLLOWING HERNIAL REPAIR

Cremasteric artery is a branch of inferior epigastric artery supplying the cremaster muscle and coverings of the cord. The possible consequence of injury to this artery is scrotal haematoma. We present a case of haemorrhage from unexpected cresmastric artery injury post-hernioplasty treated with angioembolisation. To the best of our knowledge, this has not been reported in literature.
 A 66-year-old gentleman with left indirect inguinal hernia underwent a left inguinal hernioplasty in our institution with no immediate complications. However he presented to the emergency department the day after the procedure with complaints of rapidly worsening painful left scrotal swelling accompanied with symptoms of intestinal obstruction. Emergency laparotomy and re-do left hernioplasty was performed, revealing a strangulated inguinoscrotal hernia. Post-operatively, there was non-resolving scrotal swelling with a drop in the haemoglobin level; from 11.9g/dl to 8.5g/dl requiring packed cell transfusion. CT angiogram revealed active contrast extravasation from the left cremasteric artery. Angiographic run confirmed the finding and the left cresmatric artery was superselectively cannulated with a 1.9Fr microcatheter and embolization done with 0.5mm microcoil. Ultrasound scan 24-hour post-procedure showed patent proximal vessel. Clinically there was a reduction of the left scrotal swelling and the haemoglobin remained stable. 
 Cremasteric artery courses laterally deep into the fascia transversalis entering the cord deep to the internal spermatic fascia to supply the cremaster muscle and coverings of the cord. This course renders the artery to be prone for injury during procedure such as hernioplasty; one of the possible consequences is scrotal haematoma. This artery is usually small in caliber and its identification is important for efficient and effective treatment.
 Angioembolisation is able to treat this injury with superior precision owing to its ability for localization and selective cannulation of the offending vessel.

Long-Term Treatment Outcome of a Patient with Extensive Circular Soft Tissue Defect of the Distal Third of the Lower Extremity: A Case Report

Background. Open fractures of the lower leg bones associated with extensive soft tissue defects are among the most challenging in trauma surgery.
 Aim of the study is to demonstrate the possibilities of modern reconstructive surgery in the treatment of severe polystructural trauma of the lower limb using a unique clinical example.
 Case description. An 18-year-old patient sustained a polytrauma which included head and extremities injuries as a result of a fall under a moving train. Due to the signs of uncompensated ischemia of the left lower limb at the first stage of treatment the patient underwent emergency left tibial artery thrombectomy, repeated debridement of the left lower leg wound, remounting of the external fixator, and lumbar sympathectomy. The second stage of surgical treatment included free transplantation of a vascularized anterolateral flap of the right thigh. The third stage included staged necrectomies; replacement of the soft tissue defect of the posteromedial surface of the distal lower leg with a sural fasciocutaneous vascularized flap on the distal vascular pedicle from the contralateral tibia; the fourth stage included cutting off the fasciocutaneous cross flap. At the follow-up, 2 years after the end of the treatment the patient complained of persisting swelling of the foot, which occurred during prolonged standing in the upright position and required elastic compression of the ankle joint. The cause of the swelling was impaired lymphatic outflow due to the damage to all venous collaterals in the injury area. She walks with full load on the injured limb without additional support. There is no pain syndrome, foot sensitivity is fully preserved.
 Conclusion. Presented clinical case demonstrates the possibility of successful replacement of an extensive circular defect of the distal lower leg using sequentially free and non-free vascularized tissue complexes.

AUTOTRANSPLANTATION WITH EXTRACORPORAL RECONSTRUCTION OF RENAL VESSELS: A CLINICAL CASE OF “THE NUTCRACKER SYNDROME” AND LEFT RENAL ARTERIES HYPOPLASIA COMBINATION

Ex vivo kidney autotransplantation with renal artery reconstruction is an effective method of surgical correction of vascular abnormalities (fibromuscular dysplasia, hypoplasia, and renal artery aneurysms) showing good long-term results. The combination of renal artery abnormalities with aorto-mesenteric compression syndrome (“the nutcracker” syndrome) is extremely rare and complicates the diagnosis making greatly. Renal artery hypoplasia is an abnormality that is rarely diagnosed and may not manifest clinically in the absence of contralateral kidney pathology as well as its vascular structures. Renal hypoplasia may be caused by mutations in the kidney development genes (HNF1B, PAX2, PBX1) and/or several environmental factors such as intrauterine growth retardation, maternal diseases (diabetes, hypertension), medication taken by the mother (renin-angiotensin system inhibitors or nonsteroidal anti-inflammatory drugs) and intoxication (smoking and alcohol). Premature delivery (before the 36th week) is also a risk factor due to incomplete nephrogenesis. Renal arteries hypoplasia is associated with fibromuscular dysplasia in most cases. The disease is characterized by non-inflammatory non-uniform focal hyperplasia of the renal artery wall with damage to small and medium arteries. Simultaneous damage to two or more vascular segments is detected in 25% of patients.
 A clinical case of successful treatment of “the nutcracker” syndrome (annular renal vein) combined with hypoplasia of the left main and accessory renal arteries associated with fibromuscular dysplasia is described. A 27-year-old female was admitted to the Department of Vascular Surgery of Municipal Noncommercial Enterprise of the Lviv Regional Council “Lviv Regional Clinical Hospital” on October 4, 2021, with complaints of pain in the left lumbar region and the left half of the abdomen, hematuria, proteinuria, a persistent increase in blood pressure. Ultrasound of the renal veins: the left renal vein in the aorto-mesenteric segment was not visualized, the posterior portion of the left renal vein was determined. Peak systolic velocity was up to 230 cm/s at the point of confluence with the inferior vena cava and 28 cm/s more distally. The vein was up to 12.0 mm in the renal hilum and up to 11.0 mm in the middle third. MSCT of the abdominal cavity, retroperitoneal space and pelvic organs: CT signs of pyelonephritis of the left kidney. Hypoplasia of the left kidney. Reactive para-aortic lymphadenopathy on the left. Hypoplastic left renal artery (3,8 mm) and presense of accessory ones, annular left renal vein. Angiomyolipoma of the right kidney (2,6 cm). Varicose veins of the small pelvis on the left. The patient underwent surgical treatment, namely ex vivo autovenous prosthetic repair of the left renal artery with autotransplantation of the left kidney. The course of the postoperative period was without complications, the reconstruction was functioning. Ultrasound of the renal vessels (1 week after the surgery): the blood flow was located in the renal hilum in the course of Doppler sonography of intrarenal branches. Venous outflow was unobstructed. Corticomedullary differentiation was marked satisfactorily.
 The study presented by us demonstrates the effectiveness of kidney autotransplantation for the correction of renal vascular abnormalities.
 Though of a solitary nature, the combination of renal vessels abnormalities complicates significantly the course of the disease and the possibilities of this pathology diagnostics.

[Staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection: a series of 10 cases].

Objective: To examine the efficacy and experience of staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection (TIAD). Methods: This study was a retrospective case series. The clinic data of 10 patients with acute TIAD who were admitted to the Department of Cardiac Surgery, Second Hospital of Lanzhou University or the First People's Hospital of Lanzhou, between January 2016 and August 2022, were retrospectively studied. Ten patients underwent hybrid surgeries in two hospitalizations (stages), including 7 males and 3 females with an age of (60±7) years (range: 49 to 71 years). In stage 1, the first type Ⅱ hybrid arch repair was performed to treat the ascending, total arch, and descending thoracic aorta for acute TIAD without circulatory arrest. In stage 2, the second hybrid surgery including infrarenal abdominal aorta replacement, visceral arteries bypass and endovascular thoracoabdominal aortic repair was performed to treat residual thoracoabdominal aortic dissection after the first hybrid operation (segmented). Basic data, preoperative concomitant diseases, high-risk factors, surgical approaches and postoperative complications of all important organs, as well as CT imaging were analyzed. Results: There was no death in the 20 hybrid surgical procedures. In stage 1 type Ⅱ hybrid surgery, 4 cases underwent reconstruction of the aortic sinutubular junction, while Bentall and David surgery was performed for 3 cases, respectively. A patient received coronary artery bypass grafting. Then all patients were sequentially treated with arch debranching and thoracic aortic endovascular repair. Postoperative complications included renal insufficiency (4/10), hemofiltration (1/10), hypoxemia (4/10), neurologic event (1/10) and type Ⅱ endoleak (1/10). Complete false lumen thrombosis occurred in 9/10 of the patients. All complications recovered successfully at discharge and the average hospital stay was (21±4) days (range: 16 to 28 days) in the first hospitalization. At stage 2, the second hybrid surgery was successfully performed in all patients. No paraplegia, hepatic or renal insufficiency, or endoleak occurred. However, branch graft embolism of the left renal artery was found in one patient 3 days after laparotomy, as well as of superior mesenteric artery in another. Superior mesenteric artery occlusion was successfully treated by endovascular recanalization. Complete false lumen thrombosis occurred in all patients. Although all patients had different degrees of intestinal dysfunction, they were gradually relieved at discharge, and the average hospital stay was (19±2)days (range:16 to 21 days) in the second hospitalization. During follow-up, CT angiography showed aortic remodeling in all patients. Conclusion: Staged and segmented two hybrid surgeries are safe and feasible for total repair of Debakey type Ⅰ aortic dissection and are associated with acceptable early and midterm outcomes.

Medulla and cervical cord contrast-induced encephalopathy detected by neuromonitoring during coil embolization of posterior circulation aneurysms.

Understanding the risks of contrast-induced encephalopathy (CIE), a serious complication of contrast agents, is crucial in endovascular treatment. We present the case of a 73-year-old woman who developed CIE in the medulla and cervical cord during coil embolization for unruptured left basilar-superior cerebellar artery and basilar artery tip aneurysms. The CIE was identified via neuromonitoring. In this case, spinal cord ischemia might have occurred due to reduced perfusion pressure after inserting the distal access catheter (DAC) in the vertebral artery. Multiple injections of contrast medium via the DAC during coil embolization likely contributed to an unusual form of CIE. Extreme caution is warranted during endovascular treatments involving the posterior circulation, due to the relatively high incidence of contrast-mediated encephalopathy, which can lead to severe consequences such as perforator infarction. Neuromonitoring is very useful for the early detection of neurological changes, particularly because intraoperative angiography may not reveal all irregularities.