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Vascular access for large endovascular devices has evolved as patients have become more complicated and device indications have expanded. As the benefits of catheter-based treatments for aortic aneurysm repair and aortic valve replacement become mainstream, there is a need to address difficult vascular access by developing not only smaller-diameter devices but also creative options for vascular access. We describe direct descending thoracic aortic access during endovascular aneurysm repair, transcatheter aortic valve replacement, and redo mesenteric revascularization in three patients who did not have traditional access options.

Our objective was to determine the impact of abdominal ultrasound (US) on 1) the use of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (ACT) for diagnosing blunt abdominal trauma (BAT) and on 2) surgical resident training. The study design was a retrospective chart review. Patients sustaining BAT who had ACT or DPL done during the 1-year period before the introduction of US (pre-US) were compared with those from a 1-year period beginning 6 months after US (post-US). Data collected included diagnostic modality, demographic data, mortality, associated injuries, length of stay, mechanism of injury, and number of exploratory laparotomies. Of 128 patients in the pre-US group, 35 patients (27%; P < 0.001) underwent DPL, 0 patients (0%; P < 0.001) received US, and 92 patients (72%) received ACT, with positive results for 31 patients (34%). Exploratory laparotomy was performed on 35 patients (27%) in the pre-US group. Of 140 patients in the post-US group, 8 patients (6%; P < 0.001) underwent DPL, 120 patients (85%; P < 0.001) received US, and 108 patients (77%) received ACT, with positive results for 44 patients (42%). Exploratory laparotomy was performed on 22 patients (15%; P < 0.001) in the post-US group. Resident experience with DPL before and after the introduction of US and availability of US for graduated residents was documented. Chi-square and Fisher's exact test were used for statistical analysis. Resident experience changed from 22 to 3 DPLs per year in the pre- and post-US groups, respectively. Ten per cent of graduating residents had US available for use after leaving this institution. US replaced DPL and resulted in slightly more positive ACT scans in assessing BAT at our institution. Paradoxically, only 10 per cent of graduating residents had US available after leaving this institution. Until the use of US for diagnosing BAT has widespread use in the community, we must question our adequacy of resident preparation for diagnosing BAT.

A 30-year-old female with Ehlers–Danlos syndrome and prior right iliac dissection treated with covered stent placement in 2005 presented with acute severe left leg pain. It began with arising from bed and was exacerbated by left hip flexion. Initial evaluation with arterial Duplex imaging revealed evidence of dissection extending from the proximal left common iliac artery to the proximal left superficial femoral artery. Computed tomographic (CT) angiography was performed and confirmed dissection with aneurysmal dilatation of the left common iliac artery to 2.0 × 1.7 cm (Panel A). The patient required intravenous narcotics and was admitted for pain control. A repeat CT angiogram four days later revealed further dilation of the left common iliac artery to 2.4 × 2.0 cm and new aneurysmal dilatation of the proximal left superficial femoral artery (Panel B). Owing to the growth of the aneurysm a third CT angiogram was obtained two days later. This revealed rapid expansion of the common iliac artery aneurysm to 3.3 × 2.7 cm as well as expansion of the proximal superficial femoral artery aneurysm (Panel C).