There were no significant differences between AAA and controls at baseline, aside from higher rates peripheral vascular disease and younger age in the control group (P < .01). There was significantly greater inflammation found in AAA tissue compared with control (P < .00001). There was also significantly higher CD68þ macrophages counts in ILT-rich regions compared with control (P < .0001); however, there was no difference in MMP-12 or IL-6 levels between ILT and non-ILT regions, and no correlation between ILT thickness and MMP-12 levels. Conclusions: Although we demonstrated inflammation and increased CD68þ macrophage levels adjacent to ILT in AAA compared with control, contrary to our hypothesis there was no difference in macrophagerelated elastases and cytokines, suggesting that macrophages may have a limited role in AAA degeneration. We did, however, notice a trend toward higher levels of interleukin in thrombus containing regions compared with nonthrombus regions and control tissues, suggesting that perhaps macrophage activity may be elevated in the thrombus containing regions of the AAA that tends to rupture.

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Subclavian steal syndrome (SSS) has been well described in the setting of subclavian stenosis. We describe an unusual case of SSS caused by a high-flow arteriovenous dialysis fistula in the absence of subclavian stenosis, provide a review of the literature, and propose that arteriovenous fistula-induced SSS is an underdiagnosed cause of syncope in this population of patients.

Situs inversus totalis (SIT) is a rare condition characterized by the mirror image location of all of the thoracic and abdominal organs. There are only a handful of reports documenting the presence and repair of an abdominal aortic aneurysm in the setting of SIT. Here, we present a rare case of a juxtarenal abdominal aortic aneurysm repaired through a retroperitoneal approach in a patient with SIT. We demonstrate that the retroperitoneal approach is a safe and effective method to manage complex aortic aneurysm disease in a patient with SIT.

Background: Worldwide, the majority of kidney failure patients are treated by hemodialysis. The demand for vascular access surgery is increasing rapidly because of the continuing expansion of this population. A reliable access to the circulation for hemodialysis is essential. A proportion of hemodialysis patients exhaust all options for permanent arteriovenous (AV) access (fistula or graft) in both upper extremities. AV thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper limb sites. This paper reports our experience with vascular access in the thigh.Methods: We performed a retrospective review of the University Health Network's Division of Nephrology dialysis access database to identify all thigh AV access grafts placed between November 1995 and November 2015. Electronic medical records were then reviewed to determine demographic and clinical information. The charts were examined for subsequent surgical or endovascular procedures performed on the accesses. The patency of each thigh AV access was determined from the time of surgical creation placement, and the reason for failure was documented.Results: A total of 41 hemodialysis patients received 47 thigh AV accesses for hemodialysis vascular access during the study period. The average age of the cohort was 46 years (range, 13-79 years). The majority of the patients (53.6%; n ¼ 22) were female, and the majority of AV accesses (55.3%; n ¼ 26) were placed in the left leg. Three patients were lost to follow-up; but of the remaining 38 patients, the average patency for the grafts (n ¼ 44) was 1130.6 days (range, 0-4745 days). Thirty-six percent (n ¼ 17) of the grafts required surgical revision to eradicate infection or to maintain patency. Seventeen of 44 grafts (38.6%) served as definitive hemodialysis AV access during the patient's lifetime of dialysis. The majority failed because of infection 43.1% (n ¼ 19) or thrombosis 13.6% (n ¼ 6).Conclusions: AV thigh grafts are used infrequently, but they have a good patency. However, they require frequent revisions and have a high infection rate resulting in the ultimate loss of the access in 43.1% of cases. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.