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We report the rare anatomical variant of the middle colic artery arising from the coeliac axis in a patient with symptoms of chronic mesenteric ischaemia. The anatomy is illustrated by 2D and 3D reconstructed images from contrast-enhanced CT scanning. We discuss the importance of recognising this anatomical variant, which has major implications for endovascular surgical planning. There are also significant risks if this variant anatomy is not recognised and the middle colic artery is inadvertently sacrificed.

Purpose: To report the successful treatment of a type IIIb endoleak with an Amplatzer Septal Occluder. Case Report: A 76-year-old man was found to have a type IIIb endoleak in the proximal body component of a fenestrated graft at 4-year surveillance imaging; the leak was associated with rapid aneurysm growth. The anatomy of the graft and position of the fabric defect precluded treatment by relining with a secondary endograft. The defect was demonstrated with catheter angiography, sized with an angioplasty balloon, and repaired using an Amplatzer Septal Occluder. Follow-up imaging at 6 months showed no endoleak and marked reduction in the aneurysm size. Conclusion: The Amplatzer Septal Occluder may be considered as an option for managing type IIIb endoleaks.

IntroductionDiagnosis of endoleaks is imperative to prevent failure of endovascular aneurysm repairs (EVARs). The gold standard for diagnosis of endoleaks is catheter-directed subtraction angiography, which is not a practicable choice for surveillance. CT angiography (CTA) is the historical surveillance modality of choice. Concerns over cost, potential nephrotoxicity of contrast agents and repeated radiation exposure led to colour duplex ultrasound scan (CDUS) becoming an established alternative. CDUS has a lower sensitivity and specificity for endoleaks detection compared to CTA. Contrast-enhanced ultrasound scan (CEUS) represents an improvement of ultrasound imaging but comparisons against CTA report widely varying results, likely due to technical factors of CEUS and limitations of single-phase CTA.The development of time-resolved CTA (tCTA) offers timing information that much more closely mirrors the dynamic information available from CEUS. Theoretically, these two imaging modalities have the best potential for diagnostic accuracy. The aim of this study will be to compare CEUS to tCTA and investigate the utility of other measurements available from tCTA.Methods and analysisThis is a prospective, single UK centre, comparative study of paired binary diagnostic imaging modalities. Patients identified in routine post-EVAR surveillance as at risk of having a graft-related endoleak will undergo a CEUS and tCTA on the same day. This will allow the first comparison of CEUS to a semidynamic form of CTA. CEUS sensitivity and specificity to endoleak detection will be calculated.Ethics and disseminationThe study has achieved ethical approval. We hope the results will define the diagnostic accuracy of CEUS in comparison to a semidynamic form of CTA, representing a methodological improvement from previous studies. Results will be submitted for presentation at national and international vascular surgeryandradiology meetings. The full results are planned to be published in a medical journal.Trial registration numberNCT02688751

Chronic constipation and faecal impaction are common in the elderly, particularly in institutionalized patients and those with neurological impairment. Faecaloma formation is an extreme manifestation of coprostasis that can lead to stercoral ulcerations and perforation, a recognized severe complication. We present the case of an uncommon life-threatening complication resulting from a giant rectal faecaloma, which has rarely been reported in the literature. The patient presented with haemodynamic shock from profuse per-rectum haemorrhage. Clinical examination revealed a hard central abdominal mass and triple-phase CT of the abdomen demonstrated a tumour-like mass of hard stool in the rectum measuring up to 25 cm and stretching the adjacent vasculature, causing intraluminal active arterial haemorrhage. Emergency selective arterial embolization performed by the interventional radiologists successfully controlled the bleeding with a good outcome. This case highlights a rare but possibly fatal complication of chronic constipation and emphasizes the importance of having access to an acute interventional radiology service capable of promptly dealingwith life-threatening presentations.