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We present a patient with multiple injuries sustained in a road traffic accident. At initial presentation, an intracranial bleed was present, which required neurosurgical intervention. After surgery, he improved and was discharged from the hospital. Two months later, he returned with progressive weakness in the right upper limb. Imaging studies revealed a large pseudoaneurysm of the subclavian artery secondary to a fractured clavicle that had been treated conservatively during the initial visit. During endovascular treatment of the pseudoaneurysm, thrombosis occured in the distal subclavian artery. The thrombus was treated using a multidisciplinary approach with thrombolysis and surgical embolectomy.

The field of cardiothoracic surgery is facing many challenges. Cardiologists and vascular surgeons have developed catheter-based skills to offer minimally invasive therapy, while cardiothoracic surgeons have been slow to embrace new technologies. The future of cardiothoracic surgery will be determined by five unique forces: (1) a decrease in referrals for coronary revascularization; (2) an aging population; (3) a decline in interest in the field of cardiothoracic surgery; (4) a predicted shortage of cardiac surgeons; and (5) the development of new minimally invasive techniques. In this review, each of these influences will be further investigated.

Chronic mesenteric ischemia (CMI), or abdominal angina, is a rare disorder accounting for less than 5% of all intestinal ischemic events, and in more than 90% of instances is caused by atherosclerosis.^1–4 CMI has the potential to worsen and develop into acute intestinal ischemia with bowel infarction.1 Therefore, treatment of symptomatic CMI is necessary to prevent acute mesenteric ischemia, which may cause bowel infarction and death.5 Until recently, open revascularization has been the method of choice for therapy of patients with CMI. However, the rate of major complications is relatively high.5,3 As an alternative to open surgical revascularization, PTA was introduced by Furrer et al in 1980. Since then, several studies have presented the results of angioplasty and/or stenting in the treatment of CMI, with a periprocedural mortality rate of 0 to 13%, and complication rate of 0–25%. The technical success rate of PTA is 90–100%.^2–6

Successful recanalization and percutaneous revascularization of coronary arteries with chronic total occlusion (CTO) is one of the “last frontiers” in coronary interventions. Conquering this objective will enable complete percutaneous revascularization in an increasing number of patients. Learning and mastering the skills to recanalize CTO is an advanced-stage procedure that is best suited to the experienced operator. The variety of CTO cases is wide, and special expertise is needed to differentiate between different anatomic situations to select the appropriate devices, to change strategies as the cases progress, and to keep it safe — avoiding and treating potential complications. The appropriate selection is the key to success. The clinical history, symptoms, and myocardial viability are important for deciding on the need for recanalization of a CTO and the clinical and prognostic advantage the patients will get. The interventional cardiologist has to have an understanding of anato