A 28-year-old man, with a history of CoA repair using Dacron patch aortoplasty at the age of 10 years, presented with shortness of breath and sudden, severe central chest pain that radiated across his chest and back. The patient had been lost to clinical follow-up over the last 15 years. He was conscious, hypotensive (90/60 mmHg on both arms), and in distress with tachycardia (120 BPM) and relatively weak pedal pulses with cold distal extremities. A chest X-ray (CXR) demonstrated the widening of the upper mediastinum (Figure ).\nHe underwent emergency CT angiography, which demonstrated extensive mediastinal hematoma and contrast leaking from a 4x12 cm complex pseudoaneurysm of the proximal thoracic descending aorta (Figure ).\nThe intimal disruption started about 2 cm distal to the origin of the left subclavian artery (LSCA), which was probably the site of the patch repair. The aortic diameter just prior to the disruption was 2.5 cm, and the normal distal thoracic aortic diameter was 2 cm. Of note, there was compression to the distal aorta by the pseudoaneurysm, leading to significant narrowing, which explained the weak distal pulses and cold extremities. After the heart-team discussion, the decision was made to proceed with transcatheter endograft implantation. The transcatheter approach was deemed more feasible and safer than a surgical one, especially in the presence of a good landing zone for endograft placement (away from the LSCA) (Figure ).\nThe patient was taken to cardiac catheterization laboratory and, under general anesthesia, we implanted a tapered (28 mm - 26 mm) x 150 mm Valiant Thoracic Stent Graft with the Captivia Delivery System (Medtronic Vascular, Santa Rosa, CA). The endograft was implanted successfully with complete exclusion of the pseudoaneurysm and excellent flow distally (Figure ).\nThe access site (right femoral artery) was secured successfully with two Perclose ProGlide™ devices (Abbott Laboratories, Abbott Park, IL). The patient did very well and was discharged home after three days. A follow-up CT angiography revealed a widely patent stent graft with no endoleaks.
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.