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An aorto-gastric fistula is a catastrophic and rare cause of an upper gastrointestinal bleed. The diagnosis requires a high index of suspicion and expedient management as any delay in each of these component, will be to the detriment of the patient. We report a case of a patient with two episodes of this rare event, with haemodynamic compromise, 15 years after having had a trans-hiatal oesophagectomy for an adenocarcinoma of the oesophagus who presented on both occasions. He had thoracic endo-vascular aortic repair (TEVAR) on both presentations and survived. This case exemplifies the fact that while TEVAR is a good bridging therapy for the management of an aorto-enteric fistula. It however should not be considered as the definitive management for patients who are operable or patients who do not have prohibitive surgical risk.

Background:The ability to safely achieve hemostasis is a key aspect of percutaneous vascular access. Vascular closure devices (VCDs) were designed to improve the safety of vascular closure; however this has been difficult to prove in recent studies. We present our experience with achieving hemostasis including assessing the safety and efficacy of VCDs. The aim of this study is to assess the technical success, complications and associated risk factors for achieving hemostasis in antegrade femoral punctures for infrainguinal interventions. Method(s): A retrospective review of all patients who underwent antegrade common femoral puncture for infrainguinal endovascular procedures between January 2016 and November 2018. Access site hemostasis was achieved either using VCD or manual compression (MC). Patient demographics, body mass index (BMI), previous ipsilateral groin punctures and surgeries, skin to vessel distance, common femoral artery (CFA) diameter, sheath size and complications were recorded. Result(s): A total of 175 antegrade femoral punctures were performed in 159 patients. Mean patient age was 65 years (21-102). Male:female ratio was 120:39 patients and mean BMI was 27.2 (16.24-43.79). Mean CFA diameter was 7.5 mm (3.5-12.7 mm) and mean skin to vessel distance (SVD) was 33.7 mm (9.6-20 mm). Sheath sizes utilized were 5 Fr (n=93), 6 Fr (n=66), 4 Fr (n=13), and 7 Fr (n=3). MC was used to achieve hemostasis in 46% (n=81) of patients. Angioseal was the most commonly used VCD in 43.6% (n=41), Exoseal 36% (n=34) and Proglide in 20% (n=19). Technical success in the VCD group was 92.5% (n=87). Six patients experienced complications (VCD=4; MC=2) including groin hematoma, pseudoaneurysm, distal thromboembolism and arterial perforation. Conclusion(s): In our experience, vascular closure devices are effective and safe in antegrade arterial procedure with limited number of complications. A larger study is required to compare vascular closure devices in antegrade punctures.

Medicine and engineering are in collaboration to assist in the tackling of daunting surgical techniques which are associated with high rates of morbidity and mortality, in exchange for minimally invasive approaches with lower procedural risk. Endovascular procedures in general have already reduced the risk of surgery by limiting the extent of open surgery and often replacing it with purely percutaneous or hybrid procedures. Here, we describe a patient who had complex staged surgery with open repair of a proximal portion of a type A aortic dissection followed by a staged endovascular reconstruction of the arch and descending aorta by means of a fenestrated stent-graft to secure the left subclavian artery and the posterior cerebral circulation.