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A 28-year-old male was referred to our emergency department with a swollen left arm after intensive exercise. Physical examination revealed distension of the superficial veins of his left arm and chest. Duplex ultrasound confirmed the diagnosis of Paget-Schroetter syndrome. He was successfully treated with thrombolysis and first rib resection.

Background: Loeys-Dietz syndrome is a connective tissue disorder accompanied by life-threatening vascular abnormalities such as aneurysms and dissections. Recognising the acute clinical picture is essential for rapid diagnosis and treatment., Case Description: We describe three members of a family with a typical acute presentation of Loeys-Dietz syndrome, but without the characteristic physical abnormalities. A 40-year-old man presented with a type B aortic dissection and was treated with medication. Shortly afterwards he required emergency surgery for a ruptured aneurysm of the left common iliac artery. He subsequently developed a type A aortic dissection and progressive dilatation of his thoraco-abdominal aorta, for which surgical repair was performed. His sister and brother also presented with type B aortic dissections and both underwent surgery for thoraco-abdominal aortic aneurysms. They died at the age of 50 and 53 respectively. Clinical genetic investigation revealed a mutation of the type 2 receptor of the transforming growth factor beta (TGFβ) gene., Conclusion: Loeys-Dietz syndrome is a rare hereditary condition accompanied by acute clinical symptoms. Physical characteristics of the syndrome may be absent. Timely recognition is essential for appropriate treatment and a good prognosis.

Background: Infection is the most obvious cause of fever following implantation of an endovascular prosthesis; however, fever and inflammation around the arterial wall can also be caused by a sterile inflammatory reaction: periaortitis., Case Study: An 81-year-old man was referred because of fever and back pain. He had undergone an endovascular aortic repair (EVAR) 1 year earlier; an endovascular prosthesis had been placed during this procedure, to repair an abdominal aortic aneurysm. A positive emission tomography (PET)-CT scan revealed uptake of 18F-fluorodeoxyglucose around the endovascular prosthesis, consistent with infection; however, intensive microbiological investigation, including biopsy from the site of the endovascular prosthesis, revealed no micro-organisms. Empirical administration of antibiotics had no effect. Decreased renal function occurred approximately 4 weeks later, and a CT scan revealed spread of the inflammatory process accompanied by hydronephrosis, consistent with periaortitis. Following treatment with glucocorticoids, renal function returned to normal and the symptoms disappeared., Conclusion: Periaortitis is a rare, late complication of an EVAR. Clinical presentation can closely resemble an infection, while distinguishing infection from (sterile) periaortitis is important for the choice of treatment.

A 55-year-old female experienced palpitations and thoracic pain. Coronary angiography showed a right sided aorta. The patient was diagnosed with a Kommerell's diverticulum that compressed the esophagus and trachea. During follow-up she developed dysphagia and she underwent a transposition of the left subclavian artery to the left common carotid artery followed by endovascular treatment of the distal aortic arch and thereby excluding the diverticulum.

Carotid artery stenosis is an important cause of transient ischaemic attacks (TIAs) and ischaemic strokes, and is associated with a particularly high risk of recurrent stroke both in the acute phase and the long-term. Early secondary preventive measures would therefore seem warranted. Carotid endarterectomy (CEA) is an effectively therapy in patients with a severe symptomatic stenosis. Hypertension is an important risk factor for recurrent stroke both in the acute phase and the long-term. Moreover, hypertension is an important risk factor for complications of CEA. In patients on the waiting list for CEA, following a TIA or a non-disabling ischaemic stroke, it would seem worthwhile to attempt to start antihypertensive treatment after approximately 24 h, and to at least strive after a preoperative systolic blood pressure of < 180 mmHg and a diastolic blood pressure of < 90 mmHg. In patients who cannot undergo surgery in the desirable short run, hypotensive treatment must be considered in the context of secondary prevention. The blood pressure target level depends on the presence or absence of a severe unilateral or bilateral stenosis (> 70% lumen diameter). In postoperative hypertension one must strive after a blood pressure < 140/90 mmHg, thereby avoiding an excessively rapid hypotensive response (> 25% daily). Patients with a TIA or an ischaemic stroke and a carotid artery stenosis must also be treated with antiplatelet agents and a statin, while other vascular risk factors must be controlled.

Patient A, 46-year-old woman, underwent lumbar disc surgery in connection with a radicular syndrome and patient B, a 34-year-old man, underwent laparoscopic cholecystectomy. Both patients suffered postoperatively from dyspnoea, high central venous pressure and an abdominal bruit. Both patients had an initially unrecognised, peroperatively caused, arteriovenous fistula between the common iliac artery and the inferior vena cava. Endovascular therapy was successful. Iatrogenic arteriovenous fistulae are rare and often diagnosed late, partly because in some patients the symptoms may only develop after some delay, partly due to unfamiliarity with this complication on the part of the physician. Doppler ultrasound, CT-scanning and angiography may be used for imaging. Endovascular placement of a covered stent to close the arteriovenous fistula is the treatment of choice.

A 78-year-old female had chest pain, radiating to the back, caused by a thoracic aneurysm of the aorta. A vascular prosthesis was sutured into place through a left-sided thoracotomy. Six days after the operation she developed chylothorax on the right side. Following 14 days of conservative management, chyle leakage persisted at a rate of 1500 ml per 24 hours. By thoracoscopy the thoracic duct was dissected and clipped, which stopped the chyle leakage. The patient recovered moderately well. Conservative measures, such as adjusted nutrition, are successful in 50% of patients. Clipping of the thoracic duct by thoracoscopy is a definitive and minimally invasive procedure to treat persistent chyle leakage.

Arterial occlusive disease developed after radiation therapy in three patients: a woman aged 56 had a sensation of heaviness in her right arm and bluish-black discolorations of fingers 3 years after radiation therapy for breast carcinoma, and two men aged 46 and 45 years had intermittent claudication 23 and 14 years, respectively, after radiation therapy for testicle malignancy. After creation of a bypass, the symptoms subsided. Radiation-induced arterial disease is a rare complication after radiotherapy and usually presents after a latent period of several years. Arterial lesions induced by radiotherapy may be distinguished from atherosclerotic lesions by their atypical localization, limited to the irradiated sites, and occurrence at an earlier age. Symptoms may be masked by pain, limitation of motion, nerve root damage and lymphoedema and may therefore not always be recognized. Indications for treatment are identical to those for atherosclerotic occlusive disease, but due to increased risk of restenosis, rethrombosis and graft infection, percutaneous transluminal angioplasty (with or without stent), endarterectomy or venous bypass surgery should be preferred to prosthetic bypass material.

The use of the preperitoneal approach in the treatment of recurrent inguinal hernias is gradually increasing in the Netherlands. This may be concluded from an inquiry conducted among the General Surgery teaching hospitals. The technique, indications and early results are described. Fifty-six recurrent inguinal hernias in 48 patients were treated by this approach. When indicated prosthetic material was used. The follow-up after an average of 19.5 (4-36) months revealed 5 (8.9%) unilateral recurrences.