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Middle aortic syndrome (MAS) is rare entity described as a progressive narrowing of the aorta between the aortic arch and terminal bifurcation of the aorta. Surgical treatment is with the use of grafts for bypassing the narrow aortic segment. Rarely, graft complications may occur over long periods of time due to the axial growth of the patient and loss of tensile strength of the graft material. This is a case of MAS, presenting 34 years after initial surgery due to aneurysmal dilation of the graft, treated with redo surgery and complete recovery of the patient.

Primitive neuroectodermal tumors (PNETs) are rare type of small cell, aggressive tumors, commonly seen in the central nervous system, and PNET of the kidney with inferior vena cava thrombus is an extremely uncommon presentation of this entity. There are no established distinctive signs or radiological characteristics for diagnosis, but a majority of cases report positivity for CD99 marker. The patients usually present in the advanced stages of the disease and require progressive techniques of immunohistochemical analysis and expertise of multidisciplinary team of physicians to arrive at a correct diagnosis and have a proper management. Although rare, these tumors should be considered in the differential diagnosis of all patients with large renal masses, especially in the younger population. We present a case of a 23-years-old female, with PNET of the left kidney, treated with radical nephrectomy and adjuvant chemotherapy. Key words: Inferior vena cava thrombus, Kidney tumor, Primitive neuroectodermal tumor Key words: Inferior vena cava thrombus, Kidney tumor, Primitive neuroectodermal tumor

Patients of valvular heart disease treated with mechanical valve replacement are required to be on lifelong medication with anticoagulants. Complications may arise when adequate International Normalized Ratio (INR) control is not maintained, leading to thromboembolic events, but very few cases have been reported where these complications arise despite therapeutic INR control. We, here, highlight a case of rare fatal complication of Acute Coronary Syndrome in a one month postoperative patient of Dual Mechanical Valve Replacement with therapeutic INR, which evaded correct diagnosis due to unawareness on the part of the treating team of physicians. Keywords: Acute Coronary Syndrome; Arrhythmias; International Normalized Ratio; Valvular Heart Disease