A 13-year-old male presented to our hospital after sustaining injuries from a motor vehicle accident (MVA). The patient had bee sitting unrestrained in the front passenger seat of a car when he met with the accident. He had been found unconscious inside the car. Upon arrival in the emergency room, he regained consciousness. As part of the trauma protocol, the patient underwent a full-body CT, which revealed moderate subgaleal hematoma, small hemorrhagic brain contusion, multiple lung contusion, and moderate-size pseudoaneurysm in the descending aorta just distal to the left subclavian artery (LSCA) with associated mediastinal hematoma (Figure ).\nThe CT scan also revealed hepatic, right renal, and splenic lacerations without any evidence of active bleeding. Multiple fractures in the ribs, sternum, right femur, and tibia were also observed. The patient was subsequently admitted to the pediatric intensive care unit (ICU). After a combined surgical and cardiac team discussion, and in the view of other stable lesions, the decision was made to proceed with treating the aortic pseudoaneurysm with impending rupture first. Because of the presence of intracerebral haemorrhage and visceral organ lacerations, the patient was deemed at high risk for systemic anticoagulation required for an operative aortic repair. Available percutaneous endograft sizes were deemed too large for his descending aortic diameter, and the associated potential risk of vessel injury from the large sheath required to implant the endograft removed this option from consideration. The decision was made to attempt percutaneous implantation of a balloon-expandable covered stent across the pseudoaneurysm in the cardiac catheterization laboratory. Under general anesthesia, the right femoral artery access was obtained, and an 11 French (Fr) sheath was inserted. A pigtail catheter was advanced to the transverse aorta, and an angiogram was performed (Figure ).\nThe angiogram revealed a diameter of 14 mm at the mid-aortic arch, descending aorta immediately after the pseudoaneurysm, and aorta at the level of the diaphragm. The length of the disrupted aortic segment was 22 mm, and it was 10 mm away from the origin of the LSCA. Based on the angiogram measurements, a 16x38 mm BeGraft aortic stent, which is a balloon-expandable covered stent, was used successfully. This was followed by post-stenting dilation with short non-compliant 17 x 30 mm Z-Med balloon (B. Braun, Melsungen, Germany). There was no residual aneurysmal filling, and comparison pressures demonstrated no significant gradient from ascending to descending aorta (Figure ).\nThe patient was transferred in stable condition to the pediatric ICU for further management. His post-catheterization course was uneventful. Subsequently, he underwent several orthopaedic procedures until he was discharged home in good condition.
We present a case of a 54 years old male who initially presented with one month history of worsening epigastric pain and vomiting. He was referred to our care after an ultrasound and CT abdomen showing dilated common bile duct up to 13mm with no obvious intraductal obstruction. An incidental type 1 duplicated IVC was demonstrated on the CT abdomen (Figure and 2).\nNo intra-abdominal mass or lymphadenopathy were detected. Notably, he is a known BRCA2 mutation carrier. Both, his mother and sister had BRCA2-positive breast cancer. One of his great uncles also had male breast cancer. The patient was clinically jaundiced on presentation, with a bilirubin of 106. His other liver function tests were ALT at 465, GGT at 1032 and at ALP 271. His tumour markers CA-125 and CA-199 were 12 and 94 respectively.\nThe patient was subsequently found to be hypotensive and tachycardic with a new drop in haemoglobin from 100 to 72 during his stay. An urgent gastroscopy then revealed a 10mm punched-out ulcer with adherent clot at the ampulla. The lesion was partially obstructed and no active bleeding was seen. Histology on biopsy showed moderately differentiated adenocarcinoma. CT angiography was then performed. No active extravasation was seen and the gastroduodenal artery was empirically embolised with microcoils. An apparent cavitation at the medial aspect of the second part of duodenum was now identified on the CT imaging (Figure ). No metastasis was seen on staging CT imaging.\nA whipple procedure was performed. The duplicated right IVC was visualised intraoperatively with mobilisation of the uncinate process but appeared relatively normal. The left sided IVC was not encountered. No major complications were reported during his inpatient stay. Patient was discharged home and subsequently commenced on adjuvant therapy.