Nutcracker syndrome is a rare anomaly resulting from compression of the left renal vein between the aorta and the superior mesenteric artery. Open and endovascular interventions have both been performed to relieve the compression. Each of these interventions has strengths and weaknesses. We report two patients in whom a hybrid approach was adopted in the process combining the strengths of each intervention while reducing potential complications.

Although not currently available in the United States, multilayer stents have been used successfully to treat a variety of aneurysms. These stents promote laminar flow and depressurize the aneurysmal portion of the vessel, while preserving side branch vessel flow. A conceivable benefit of the multilayer stent is in the treatment of infected pseudoaneurysms, given the absence of a fabric covering, a potential nidus for colonization. Here we present the case of a 64-year-old woman with symptomatic, enlarging infrarenal mycotic pseudoaneurysms who was successfully treated with an in vivo multilayer stent created by the layering of three concentric bare-metal Wallstents (Boston Scientific, Natick, Mass).

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Acute mesenteric ischemia is a life-threatening vascular emergency associated with a very high mortality rate. In the setting of necrotic bowel, the current standard of care requires a laparotomy with bowel resection and surgical or endovascular revascularization of the superior mesenteric artery. Unfortunately, mesenteric bypass confers high perioperative mortality, in some reports up to 45%. A hybrid technique that employs an exploratory laparotomy, catheterization of the distal superior mesenteric artery, and stent deployment across the atherosclerotic lesion was first described in 2004 for the treatment of acute-on-chronic mesenteric ischemia. This chapter describes the appropriate clinical indications, the technical aspects of performing this hybrid procedure, as well as the challenges and common pitfalls encountered.

factor beta receptors (TGFBR) 1 and 2. The syndrome, characterized by vascular, skeletal, craniofacial and cutaneous manifestations, predisposes patients to aggressive and widespread vascular disease including aortic root dilation and arterial dissection. Women with LDS are prone to aortic dissection and uterine rupture during pregnancy and the postpartum period. Additionally, aortic disease is believed more aggressive during pregnancy as a result of estrogen-induced changes in the aortic media. We describe the case of a 29 year-old G2P1 woman at 28 weeks gestation presenting with abdominal pain. Workup revealed a 7cm ascending aortic aneurysm and a DeBakey type 1 aortic dissection extending to the aortic bifurcation. Surgical management included concomitant Cesarean-section delivery of a live born premature infant, tubal ligation, ascending aortic replacement with reconstruction of the arch vessels and aortic valve replacement. This is the first reported case of aortic dissection with visceral involvement occurring in a patient with both LDS and pregnancy. This case highlights key concepts regarding etiology and management of acute aortic pathology in the setting of pregnancy and/or LDS including: the effects of pregnancy on aortic pathology, management of aortic pathology during pregnancy, diagnostic criteria for LDS and management of aortic pathology in patients with LDS and CTD.http://dx.