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.
Our 23-year-old female patient with no significant past medical history presented to the hospital complaining of acute shortness of breath, abdominal pain, and severe left lower extremity pain. The patient was in her usual state of health until the evening of her symptoms, when she suddenly turned in her bed and began to experience numbness, tingling, and purplish discoloration of her left lower extremity. On arrival to the emergency department, the patient was in respiratory distress and had bilateral swelling of her lower extremities, the left side larger than the right. A bilateral lower extremity duplex ultrasound revealed a deep vein thrombosis (DVT) in the left lower extremity, the popliteal, and the femoral veins. In addition a CT of the chest utilizing our pulmonary embolism protocol delineated two pulmonary emboli in the first order pulmonary arteries and multiple segmental emboli located in the right upper and right lower lobes. She was subsequently started on a heparin drip.\nThe patient denied any tobacco use, recent immobilization, or travel. She reported the use of an estrogen vaginal delivery device (ethinyl estradiol vaginal ring) for the previous 6 months. Her hypercoagulable workup was revealing for heterozygosity at C677T for factor V Leiden. It should be noted that heterozygous carriers of FVL have been shown to have an overall 3- to 7-fold increased risk of venous thrombosis, while homozygotes to C677T have a 50- to 100-fold increased risk. []\nDue to the acute presentation of her venous thromboembolism, a left pelvic and lower extremity venous thrombectomy was performed. This was followed by stenting of a popliteal venous occlusion, and subsequent thrombolysis with tissue plasminogen activator. Surprisingly, a left lower extremity venogram revealed bilateral inferior vena cavas.\nIn our patient, the left-sided duplicated IVC and iliac veins were found to be thrombosed. This was marked by the stippled appearance of the duplicated left IVC vessel seen in Figure . The decision was made to stent the duplicated IVC given the anatomic irregularity and increased risk of repeat thrombosis. Two wall stents (Figure ) were deployed at the proximal end at the level of the left sided (duplicated) IVC. Next a balloon was used to angioplasty the entire length of the stented segment of the duplicated IVC (Figure ). Figure depicts the duplicated left IVC with wall-stent draining into the left renal vein with a non-occlusive thrombus within it. The orthotopic IVC remained patent. The patient was kept on heparin for 24-hours and then started on Coumadin.