Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms

PubMed Central

Xue, Zhe; Wang, Fuyu; Sun, Zhenghui; Zhang, Hui; Wu, Chen; Kong, Dongsheng; Xu, Bainan

2017-01-01

Background Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm. Material/Methods A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3–6 months, 1 year, and 2 years after surgery. Results A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery. Conclusions Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion. PMID:28640793

Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.

PubMed

Meshaal, Marwa Sayed; Kassem, Hussein Heshmat; Samir, Ahmad; Zakaria, Ayman; Baghdady, Yasser; Rizk, Hussein Hassan

2015-01-01

Infective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE. From July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke's criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥ 5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention. The mean age was 30.43 ± 8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture. Routine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.

Reconstructive surgery of true aneurysm of the radial artery: A case report.

PubMed

Erdogan, Sevinc Bayer; Akansel, Serdar; Selcuk, Nehir Tandogar; Aka, Serap Aykut

2018-01-01

True radial artery aneurysms are uncommon pathologies and have an organic cause, unlike trauma-induced false aneurysms. A 52-year-old man presented with a pulsatile mass at the anatomical snuff box area of his left hand. The aneurysm was repaired with reconstructive procedure. Although many posttraumatic and iatrogenic cases of false aneurysm of the radial artery have been reported; there are a few reported cases of a true idiopathic aneurysm. A case of reconstructive surgery for true idiopathic radial artery aneurysm is reported in this paper.

Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm: a case report and literature review.

PubMed

Zhang, Shi-Huai; Zhang, Fu-Xian

2017-09-06

Aneurysm or pseudoaneurysm is the main vascular complication of Behcet's disease. Most hospitals adopt endovascular treatment. We report a case of Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm. The patient underwent two rounds of endovascular surgery, but developed new aneurysms immediately after surgery. Eventually, the patient died due to rupture of recurrent aneurysm. For vasculo-Behcet's disease, we suggest performing the operation during the stable period. At the same time, glucocorticoids could be used with immunosuppressants preoperatively and postoperatively.

Endovascular Treatments in Combination with Extracranial-Intracranial Bypass for Complex Intracranial Aneurysms.

PubMed

Sato, Kenichi; Endo, Hidenori; Fujimura, Miki; Endo, Toshiki; Matsumoto, Yasushi; Shimizu, Hiroaki; Tominaga, Teiji

2018-05-01

Although most intracranial aneurysms can be treated with microsurgery or endovascular procedure alone, a subset of aneurysms may require a combined approach. The purpose of this study was to assess the efficacy of endovascular interventions combined with bypass surgery for the treatment of complex intracranial aneurysms. We retrospectively reviewed medical records from a prospectively maintained patient database to identify patients who underwent endovascular treatment of an intracranial aneurysm at our institutes between 2007 and 2017. We recruited patients who received a preplanned combination of endovascular treatment and extracranial-intracranial bypass surgery. Forty-four patients (44 aneurysms) were treated with a combined approach. Twenty-four patients presented with subarachnoid hemorrhage. Treatment strategies included endovascular parent artery occlusion with the bypass surgery to restore cerebral blood flow (n = 12), endovascular trapping with bypass surgery to isolate incorporated branches (n = 12), and intra-aneurysmal coil embolization with bypass surgery to isolate incorporated branches (n = 20). During a mean period of 35.6 months, follow-up catheter angiography was performed in 35 of 44 patients (79.5%) and demonstrated complete aneurysm obliteration in 29 patients (82.9%) and bypass patency in 33 (94.3%). The postoperative aneurysm-related mortality and morbidity rates were 6.8% and 13.6%, respectively. Combined endovascular and surgical bypass procedures are useful for the treatment of complex intracranial aneurysms when conventional surgical or endovascular techniques are not feasible and show acceptable rates of morbidity and mortality. Copyright © 2018 Elsevier Inc. All rights reserved.

Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report.

PubMed

Nagai, Yasunori; Goto, Masanori; Toda, Hiroki; Nishida, Namiko; Yoshimoto, Naoya; Iwasaki, Koichi

2017-08-01

Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery. A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma. Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms. Copyright © 2017 by the Congress of Neurological Surgeons

Clipping in Awake Surgery as End-Stage in a Complex Internal Carotid Artery Aneurysm After Failure of Multimodal Endovascular and Extracranial-Intracranial Bypass Treatment.

PubMed

Cannizzaro, Delia; Peschillo, Simone; Mancarella, Cristina; La Pira, Biagia; Rastelli, Emanuela; Passacantilli, Emiliano; Santoro, Antonio

2017-06-01

Intracranial carotid artery aneurysm can be treated via microsurgical or endovascular techniques. The optimal planning is the result of the careful patient selection through clinical, anatomic, and angiographic analysis. We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment. We describe complete trapping in awake craniotomy after failure of coiling, stenting, and bypassing. ICA aneurysms could become complex aneurysms following multi-treatment failure. Endovascular approaches to treat ICA aneurysms include coiling, stenting, flow diverter stenting, and stenting-assisted coiling technique. The role of surgery remains relevant. To avoid severe neurologic deficits, recurrence, and the need of retreatment, a multidisciplinary discussion with experienced endovascular and vascular neurosurgeons is mandatory in such complex cases. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery.

PubMed

Lai, Leon T; O'Neill, Anthea H

2017-06-01

Evolution in the surgical treatment of intracranial aneurysms is driven by the need to refine and innovate. From an early application of the Hunterian carotid ligation to modern-day sophisticated aneurysm clip designs, progress has been made through dedication and technical maturation of cerebrovascular neurosurgeons to overcome challenges in their practices. The global expansion of endovascular services has challenged the existence of aneurysm surgery, changing the complexity of the aneurysm case mix and volume that are referred for surgical repair. Concepts of how to best treat intracranial aneurysms have evolved over generations and will continue to do so with further technological innovations. As with the evolution of any type of surgery, innovations frequently arise from the criticism of current techniques. Copyright © 2017 Elsevier Inc. All rights reserved.

The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature.

PubMed

Joo, Sung-Pil; Kim, Tae-Sun

2017-01-01

Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.

Surgical internal iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms to avoid buttock claudication and distal type I endoleaks.

PubMed

Gaudric, Julien; Tresson, Philippe; Derycke, Lucie; Tezenas Du Montcel, Sophie; Couture, Thibault; Davaine, Jean-Michel; Kashi, Mahine; Lawton, James; Chiche, Laurent; Koskas, Fabien

2018-06-21

The objective of this study was to assess outcomes of a hybrid technique for treatment of abdominal aortic aneurysm (AAA) associated with iliac aneurysm without distal neck by combining an AAA endovascular repair approach with open surgery for preservation of the internal iliac artery (IIA). The files of 51 patients operated on between 1998 and 2017 in a single vascular surgery department were retrospectively analyzed. Inclusion criteria were patients with AAA associated with uni-iliac or bi-iliac aneurysm without suitable distal sealing zone. Surgery consisted of deployment of an aortouni-iliac stent graft combined with an extra-anatomic crossover prosthetic bypass. With use of a limited retroperitoneal approach, the contralateral proximal common iliac aneurysm was surgically excluded and the IIA revascularized by direct ilioiliac anastomosis or terminal common iliac suture, preserving the iliac bifurcation. The patients' mean age was 74 years (58-88 years), and 92% were men. The mean follow-up was 5.8 years (0.1-18 years). Twenty-nine patients (57%) had one or more high-risk criteria for open surgery. Nineteen patients (37.3%) had aortouni-iliac aneurysms, 19 (37.3%) aortobi-iliac aneurysms, 5 (10%) isolated iliac aneurysms, and 8 (15.7%) bi-iliac aneurysms without aortic location. Four patients (7.8%) also had IIA aneurysms. Surgery was successful in all cases. Two patients (4%) died during the 30 days after surgery. One surgically preserved IIA occluded within the first month, resulting in buttock claudication. The 5-year IIA primary patency rate was 96%. Type I proximal endoleaks occurred in two patients, requiring additional surgery 3 years and 13 years after the initial surgery, respectively. This hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Successful use of Gamma Knife surgery in a distal lenticulostriate artery aneurysm intervention.

PubMed

Lan, ZhiGang; Li, Jin; You, Chao; Chen, Jing

2012-02-01

We report a case of a 21-year-old woman who underwent radiosurgical treatment of a distal lenticulostriate artery (LSA) aneurysm. Twenty-two months after treatment, repeat angiography demonstrated patency of the parent vessel and complete obliteration of the aneurysm. Our case implies that Gamma Knife surgery (GKS) might serve as an alternative microinvasive technique in the treatment of LSA aneurysms, making this procedure a potential addition to present methods.

Abdominal aortic aneurysm

MedlinePlus

... this problem include: Smoking High blood pressure Male gender Genetic factors An abdominal aortic aneurysm is most ... body from an aortic aneurysm, you will need surgery right away. If the aneurysm is small and ...

Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal-type posterior communicating artery--two case reports and review of the literature.

PubMed

Nakano, Yoshiteru; Saito, Takeshi; Yamamoto, Junkoh; Takahashi, Mayu; Akiba, Daisuke; Kitagawa, Takehiro; Miyaoka, Ryo; Ueta, Kunihiro; Kurokawa, Toru; Nishizawa, Shigeru

2011-12-01

Only a small number of aneurysms arising on the posterior communicating artery itself (true Pcom aneurysm) have been reported. We report two cases of ruptured true Pcom aneurysms with some characteristic features of true Pcom aneurysm. A 43 year old man suffering from subarachnoid hemorrhage (SAH) had an aneurysm arising on the fetal-type Pcom artery itself, and underwent surgery for clipping. Most of the aneurysm was buried in the temporal lobe, so retraction of the temporal lobe was mandatory. During the retraction, premature rupture was encountered. After tentative dome clipping and the control of bleeding, complete clipping was achieved. Another patient, a 71 year old woman presenting with consciousness disturbance due to SAH, had an aneurysm on the fetal-type Pcom artery itself, and underwent surgery for clipping. It has been generally considered that hemodynamic factor plays an important role in the formation, the growth, and the rupture of the cerebral aneurysm. This factor is especially significant in true Pcom aneurysm formation and rupture. According to the literature, a combination of fetal type Pcom and formation of the true Pcom aneurysm has been reported in most cases (81.8%). Most of the aneurysm can be buried in the temporal lobe, and the retraction of the temporal lobe during the dissection of the neck would be necessary, which causes premature rupture of the true Pcom aneurysm. In the surgery for a true Pcom aneurysm, we should be aware of possible premature rupture when temporal lobe retraction is necessary.

Total Endovascular Aortic Repair in a Patient with Marfan Syndrome.

PubMed

Amako, Mau; Spear, Rafaëlle; Clough, Rachel E; Hertault, Adrien; Azzaoui, Richard; Martin-Gonzalez, Teresa; Sobocinski, Jonathan; Haulon, Stéphan

2017-02-01

The aim of this study is to describe a total endovascular aortic repair with branched and fenestrated endografts in a young patient with Marfan syndrome and a chronic aortic dissection. Open surgery is the gold standard to treat aortic dissections in patients with aortic disease and Marfan syndrome. In 2000, a 38-year-old man with Marfan syndrome underwent open ascending aorta repair for an acute type A aortic dissection. One year later, a redo sternotomy was performed for aortic valve replacement. In 2013, the patient presented with endocarditis and pulmonary infection, which necessitated tracheostomy and temporary dialysis. In 2014, the first stage of the endovascular repair was performed using an inner branched endograft to exclude a 77-mm distal arch and descending thoracic aortic aneurysm. In 2015, a 63-mm thoracoabdominal aortic aneurysm was excluded by implantation of a 4-fenestrated endograft. Follow-up after both endovascular repairs was uneventful. Total aortic endovascular repair was successfully performed to treat a patient with arch and thoraco-abdominal aortic aneurysm associated with chronic aortic dissection and Marfan syndrome. The postoperative images confirmed patency of the endograft and its branches, and complete exclusion of the aortic false lumen. Endovascular repair is a treatment option in patients with connective tissue disease who are not candidates for open surgery. Long-term follow-up is required to confirm these favorable early outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Textbook Outcome: A Composite Measure for Quality of Elective Aneurysm Surgery.

PubMed

Karthaus, Eleonora G; Lijftogt, Niki; Busweiler, Linde A D; Elsman, Bernard H P; Wouters, Michel W J M; Vahl, Anco C; Hamming, Jaap F

2017-11-01

To investigate a new composite quality measurement, which comprises a desirable outcome for elective aneurysm surgery, called "Textbook Outcome" (TO). Single-quality indicators in vascular surgery are often not distinctive and insufficiently reflect the quality of care. All patients undergoing elective abdominal aortic aneurysm repair, registered in the Dutch Surgical Aneurysm Audit between 2014 and 2015 were included. TO was defined as the percentage of patients who had abdominal aortic aneurysm-repair without intraoperative complications, postoperative surgical complications, reinterventions, prolonged hospital stay [endovascular aneurysm repair (EVAR) ≤4 d, open surgical repair (OSR) ≤10 d], readmissions, and postoperative mortality (≤30 d after surgery/at discharge). Case-mix adjusted TO rates were used to compare hospitals and to compare individual hospital results for different procedures. Five thousand one hundred seventy patients were included, of whom 4039 were treated with EVAR and 1131 with OSR. TO was achieved in 71% of EVAR and 53% of OSR. Important obstacles for achieving TO were a prolonged hospital stay, postoperative complications, and readmissions. Adjusted TO rates varied from 38% to 89% (EVAR) and from 0% to 97% (OSR) between individual hospitals. Hospitals with a high TO for OSR also had a high TO for EVAR; however, a high TO for EVAR did not implicate a high TO for OSR. TO generates additional information to evaluate the overall quality of the care of elective aneurysm surgery, which subsequently can be used by hospitals to improve the quality of their care.

Augmented reality in the surgery of cerebral aneurysms: a technical report.

PubMed

Cabrilo, Ivan; Bijlenga, Philippe; Schaller, Karl

2014-06-01

Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. To report our experience of cerebral aneurysm surgery aided by augmented reality. Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.

Long-term outcome of large artificial patch aortic repair for diffuse stenosis in Williams syndrome.

PubMed

Sughimoto, Koichi; Takahara, Yoshiharu; Mogi, Kenji; Sakurai, Manabu; Aoki, Chikashi

2010-10-01

There have been only a few reports concerning the long-term results of a surgical procedure using a large artificial patch for patients with Williams syndrome. Twelve years have passed since a patient with William's syndrome underwent a surgery with a patch angioplasty for the diffuse supravalvular aortic stenosis and deformities of the neck branch arteries. The patient had a well-balanced aortic growth without stenotic or aneurysmal changes, which was confirmed during the time of the second surgery when replacing the mitral valve. This technique of using a large patch has proven to be safe for Williams syndrome patients with diffuse supravalvular aortic stenosis in the long term.

The use of a stentless porcine bioprosthesis to repair an ascending aortic aneurysm in combination with aortic valve regurgitation.

PubMed Central

Akpinar, B; Sanisoğlu, I; Konuralp, C; Akay, H; Güden, M; Sönmez, B

1999-01-01

Over the years, many surgical methods have evolved for the treatment of ascending aortic aneurysm in combination with aortic valve regurgitation; however, precise guidelines for optimal surgical techniques for varying presentations have not been defined. We describe the use of a stentless porcine bioprosthesis (Medtronic Freestyle) in a patient with an ascending aortic aneurysm and aortic regurgitation. We used the complete root replacement method, and anastomosed a Dacron graft (Hemashield) between the bioprosthetic valve and the native aorta to replace the distal part of the aneurysm. Images PMID:10524742

Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal.

PubMed

Endo, Hidenori; Endo, Toshiki; Nakagawa, Atsuhiro; Fujimura, Miki; Tominaga, Teiji

2017-07-01

In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25 ml (p = 0.047, Mann-Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.

Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback.

PubMed

Alaraj, Ali; Luciano, Cristian J; Bailey, Daniel P; Elsenousi, Abdussalam; Roitberg, Ben Z; Bernardo, Antonio; Banerjee, P Pat; Charbel, Fady T

2015-03-01

With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. To develop and evaluate the usefulness of a new haptic-based virtual reality simulator in the training of neurosurgical residents. A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery. Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs.

Aortic aneurysm surgery: long-term patency of the reimplanted intercostal arteries.

PubMed

David, Nathalie; Roux, Nicolas; Douvrin, Françoise; Clavier, Erick; Bessou, Jean Paul; Plissonnier, Didier

2012-08-01

During aortic surgery, the long-term patency of reimplanted intercostal arteries is unknown, limiting the relevance to preserve spinal cord vascularization. Between January 2001 and January 2007, 40 patients were operated for either thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA). Twenty cases of aneurysms limited to the proximal descending thoracic aorta were treated using endovascular repair, without preoperative spinal cord artery identification. Twenty patients--seven with extensive TAA, seven with type I TAAA, two with type II TAAA, and four with type III TAAA--underwent open surgery. Before open surgery, preoperative angiography was performed to identify spinal cord vascularization; in one case, the angiography failed to identify it. The segmental artery destined to the spinal cord artery was identified as originating from outside the aneurysm in 7 patients and inside the aneurysm in 12 patients: T6 R (1), T8 L (2), T9 L (3), T10 L (3), T11 L (3), L1 L (1). During the surgery, normothermic and femorofemoral bypass was used for visceral protection. All segmental arteries identified as critical before surgery were reattached in the graft. Twenty-four months later, computed tomography scans were performed to assess the patency of the reattached segmental arteries. Three patients died, including one with paraplegia (T9 L). No other cases of paraplegia were reported. Computed tomography scans were performed in 10 patients. Segmental artery reattachment was patent in nine patients. Our experience indicates the long-term patency of reimplanted segmental artery, without any convincing evidence of its utility in preventing neurologic events during TAA and TAAA direct repair. Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes.

PubMed

Mahaney, Kelly B; Todd, Michael M; Bayman, Emine O; Torner, James C

2012-06-01

Subarachnoid hemorrhage (SAH) results in significant morbidity and mortality, even among patients who reach medical attention in good neurological condition. Many patients have neurological decline in the perioperative period, which contributes to long-term outcomes. The focus of this study is to characterize the incidence of, characteristics predictive of, and outcomes associated with acute postoperative neurological deterioration in patients undergoing surgery for ruptured intracranial aneurysm. The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) was a multicenter randomized clinical trial that enrolled 1001 patients and assesssed the efficacy of hypothermia as neuroprotection during surgery to secure a ruptured intracranial aneurysm. All patients had a radiographically confirmed SAH, were classified as World Federation of Neurosurgical Societies (WFNS) Grade I-III immediately prior to surgery, and underwent surgery to secure the ruptured aneurysm within 14 days of SAH. Neurological assessment with the National Institutes of Health Stroke Scale (NIHSS) was performed preoperatively, at 24 and 72 hours postoperatively, and at time of discharge. The primary outcome variable was a dichotomized scoring based on an IHAST version of the Glasgow Outcome Scale (GOS) in which a score of 1 represents a good outcome and a score > 1 a poor outcome, as assessed at 90-days' follow-up. Data from IHAST were analyzed for occurrence of a postoperative neurological deterioration. Preoperative and intraoperative variables were assessed for associations with occurrence of postoperative neurological deterioration. Differences in baseline, intraoperative, and postoperative variables and in outcomes between patients with and without postoperative neurological deterioration were compared with Fisher exact tests. The Wilcoxon rank-sum test was used to compare variables reported as means. Multiple logistic regression was used to adjust for covariates associated with occurrence of postoperative deficit. Acute postoperative neurological deterioration was observed in 42.6% of the patients. New focal motor deficit accounted for 65% of postoperative neurological deterioration, while 60% was accounted for using the NIHSS total score change and 51% by Glasgow Coma Scale score change. Factors significantly associated with occurrence of postoperative neurological deterioration included: age, Fisher grade on admission, occurrence of a procedure prior to aneurysm surgery (ventriculostomy), timing of surgery, systolic blood pressure during surgery, ST segment depression during surgery, history of abnormality in cardiac valve function, use of intentional hypotension during surgery, duration of anterior cerebral artery occlusion, intraoperative blood loss, and difficulty of aneurysm exposure. Of the 426 patients with postoperative neurological deterioration at 24 hours after surgery, only 46.2% had a good outcome (GOS score of 1) at 3 months, while 77.7% of those without postoperative neurological deterioration at 24 hours had a good outcome (p < 0.05). Neurological injury incurred perioperatively or in the acute postoperative period accounts for a large percentage of poor outcomes in patients with good admission WFNS grades undergoing surgery for aneurysmal SAH. Avoiding surgical factors associated with postoperative neurological deterioration and directing investigative efforts at developing improved neuroprotection for use in aneurysm surgery may significantly improve long-term neurological outcomes in patients with SAH.

Impending rupture of saphenous vein graft aneurysm with floating fractured bare metal stent treated by coil embolization and covered stent implantation.

PubMed

Kodama, Atsuko; Kurita, Tairo; Kato, Osamu; Suzuki, Takahiko

2016-11-01

Aneurysmal degeneration of a saphenous vein graft (SVG) is a rare, but potentially fatal complication of coronary artery bypass graft (CABG) surgery. In this case report, a patient that had undergone prior CABG surgery and bare metal stent (BMS) implantation at the site of a stenotic SVG lesion presented at our hospital with chest pain, and an SVG aneurysm was detected at the previous BMS implantation site. In addition, the implanted BMS was fractured and floating in the SVG aneurysm. The SVG aneurysm was successfully occluded by percutaneous intervention, using a combination of distal covered stent deployment at the site of the anastomosis between the native coronary artery and the SVG and proximal coil embolization of the aneurysm.

Abdominal aortic aneurysm repair - open

MedlinePlus

AAA - open; Repair - aortic aneurysm - open ... Open surgery to repair an AAA is sometimes done as an emergency procedure when there is bleeding inside your body from the aneurysm. You may have an ...

Unruptured Aneurysm of Sinus of Valsalva Coexisting with the Large Ventricular Septal Defect and Severe Aortic Regurgitation in a Young Man

PubMed Central

Nezafati, Pouya; Nezafati, Mohammad Hassan; Hoseinikhah, Hamid

2015-01-01

Introduction. Unruptured sinus of valsalva aneurysm (SVA) is a rare congenital anomaly, particularly, when it coexists with a ventricular septal defect (VSD) and aortic regurgitation due to the prolapse of the elongated aortic cusp into the VSD. In this report, we present the case of a 19-year-old young man with VSD challenging in spite of dyspnea and lower limb edema. Presentation of Case. Its diagnosis was made on the basis of transthoracic echocardiography results. Surgical management consisted of replacing the SVA with mechanical valve prosthesis. A Gore-Tex patch repaired the VSD. Discussion. In the follow-up periods, clinical and echocardiographic tests showed that the patient was in excellent status. Conclusion. SVA requires a surgical procedure due to its high risk of mortality in unoperated patients and a good safety of surgery. PMID:26236342

Fungal prosthetic valve endocarditis with mycotic aneurysm: Case report.

PubMed

Brandão, Mariana; Almeida, Jorge; Ferraz, Rita; Santos, Lurdes; Pinho, Paulo; Casanova, Jorge

2016-09-01

Fungal prosthetic valve endocarditis is an extremely severe form of infective endocarditis, with poor prognosis and high mortality despite treatment. Candida albicans is the most common etiological agent for this rare but increasingly frequent condition. We present a case of fungal prosthetic valve endocarditis due to C. albicans following aortic and pulmonary valve replacement in a 38-year-old woman with a history of surgically corrected tetralogy of Fallot, prior infective endocarditis and acute renal failure with need for catheter-based hemodialysis. Antifungal therapy with liposomal amphotericin B was initiated prior to cardiac surgery, in which the bioprostheses were replaced by homografts, providing greater resistance to recurrent infection. During hospitalization, a mycotic aneurysm was diagnosed following an episode of acute arterial ischemia, requiring two vascular surgical interventions. Despite the complications, the patient's outcome was good and she was discharged on suppressive antifungal therapy with oral fluconazole for at least a year. The reported case illustrates multiple risk factors for fungal endocarditis, as well as complications and predictors of poor prognosis, demonstrating its complexity. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

The marvel of percutaneous cardiovascular devices in the elderly.

PubMed

Guidoin, Robert; Douville, Yvan; Clavel, Marie-Annick; Zhang, Ze; Nutley, Mark; Pîbarot, Philippe; Dionne, Guy

2010-06-01

Thanks to minimally invasive procedures, frail and elderly patients can also benefit from innovative technologies. More than 14 million implanted pacemakers deliver impulses to the heart muscle to regulate the heart rate (treating bradycardias and blocks). The first human implantation of defibrillators was performed in early 2000. The defibrillator detects cardiac arrhythmias and corrects them by delivering electric shocks. The ongoing development of minimally invasive technologies has also broadened the scope of treatment for elderly patients with vascular stenosis and aneurysmal disease as well as other complex vascular pathologies. The nonsurgical cardiac valve replacement represents one of the most recent and exciting developments, demonstrating the feasibility of replacing a heart valve by way of placement through an intra-arterial or trans-ventricular sheath. Percutaneous devices are particularly well suited for the elderly as the surgical risks of minimally invasive surgery are considerably less as compared to open surgery, leading to a shorter hospital stay, a faster recovery, and improved quality of life.

Successful microscopic renal autotransplantation for left renal aneurysm associated with segmental arterial mediolysis.

PubMed

Yoshioka, Takashi; Araki, Motoo; Ariyoshi, Yuichi; Wada, Koichiro; Tanaka, Noriyuki; Nasu, Yasutomo

2017-07-01

Segmental arterial mediolysis (SAM) is an uncommon, nonarteriosclerotic vascular disease. SAM is characterized by lysis of arterial media and can lead to aneurysm formation. The renal arteries are the third most common arteries associated with SAM. We report the case of a 32-year-old man with left renal artery aneurysm associated with SAM. We successfully performed left renal autotransplantation using microscopic vascular reconstruction. SAM is characterized by vascular fragility; therefore, microscopic surgery is favorable for treating aneurysms associated with SAM. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Saphenous vein graft aneurysm fistula formation causing right heart failure: an unusual presentation.

PubMed

Boon, K J; Arshad, M A; Singh, H; Lainchbury, J G; Blake, J W H

2015-11-01

Saphenous vein graft aneurysm (SVG) formation after coronary artery bypass grafting is a rare complication of the surgery. We present a case of a 68-year-old man with an unusual presentation of such an aneurysm. Thirty-four years after his initial bypass surgery, the patient presented with a fistula formation into his right atrium from a vein graft aneurysm. Late aneurysm formation is thought to occur secondary to atherosclerotic degeneration of the SVG with background hypertension and dyslipidaemia accelerating the process. Diagnostic modalities used to investigate SVG aneurysms include computed tomography, transthoracic echocardiogram, magnetic resonance imaging and cardiac catheterisation. Aneurysms with fistula formation historically require aggressive surgical intervention. Resection of the aneurysm with subsequent revascularisation if required is the surgical norm. SVG aneurysm with fistula formation into a cardiac chamber is a rare complication of coronary artery bypass grafting (CABG), which can occur with atypical presenting symptoms. Physicians should keep in mind the possibility of this occurring in post-CABG patients presenting with heart failure and a new murmur. © 2015 Royal Australasian College of Physicians.

Laparoscopic radical right hemicolectomy for cecal cancer and middle colic artery aneurysm.

PubMed

Moritani, Konosuke; Wada, Osamu; Ozawa, Heita; Fujita, Shin; Kotake, Kenjiro

2015-05-06

Middle colic artery (MCA) aneurysms are very rare and exclusively reported with symptoms or rupture. We report successful laparoscopic elective surgery for both cecal cancer and MCA aneurysm in an 87-year-old man who presented with bloody stools. Diagnostic colonoscopy revealed a cecal tumor 40 mm in diameter that was histologically confirmed as a well-differentiated adenocarcinoma. The three-phase dynamic computed tomography showed a cecal tumor without any metastasis and an MCA aneurysm 10 mm in diameter. Radical right hemicolectomy with D3 lymph node dissection that included the MCA aneurysm was performed. The postoperative course was uneventful, and the patient survived without recurrence. Even though the present patient was very elderly, the postoperative course of laparoscopic radical surgery for both an MCA aneurysm and cecal cancer was uneventful with good short-term outcomes.

Virtual Reality Cerebral Aneurysm Clipping Simulation With Real-time Haptic Feedback

PubMed Central

Alaraj, Ali; Luciano, Cristian J.; Bailey, Daniel P.; Elsenousi, Abdussalam; Roitberg, Ben Z.; Bernardo, Antonio; Banerjee, P. Pat; Charbel, Fady T.

2014-01-01

Background With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. Objective To develop and evaluate the usefulness of a new haptic-based virtual reality (VR) simulator in the training of neurosurgical residents. Methods A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the Immersive Touch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomography angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-D immersive VR environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from three residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Results Residents felt that the simulation would be useful in preparing for real-life surgery. About two thirds of the residents felt that the 3-D immersive anatomical details provided a very close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They believed the simulation is useful for preoperative surgical rehearsal and neurosurgical training. One third of the residents felt that the technology in its current form provided very realistic haptic feedback for aneurysm surgery. Conclusion Neurosurgical residents felt that the novel immersive VR simulator is helpful in their training especially since they do not get a chance to perform aneurysm clippings until very late in their residency programs. PMID:25599200

The result of surgical treatment in patients with cerebral aneurysms in Maharaj Nakorn Chiang Mai Hospital: a report of 225 cases.

PubMed

Watcharasaksilp, Wanarak; Limpastan, Kriengsak; Norasathada, Tanya; Vaniyapong, Tanat

2013-07-01

Evaluate the result of intracranial aneurysm surgery in Maharaj Nakorn Chiang Mai Hospital. A retrospective study ofpatients who underwent surgery for intracranial aneurysms between 2003 and 2007. The patients'age, gender, signs and symptoms, CT brain findings, Subarachnoid hemorrhage (SAH), World Federation of Neurosurgical Society grading (WFNS), and aneurysm location were studied and correlated with outcome after surgery. Two hundred twenty five patients ofintracranial aneurysm were operated on between 2003 and 2007. Two hundred nine patients (92%) had anterior circulation aneurysms and 18 (8%) had posterior circulation aneurysms. The outcome, as evaluated by Glasgow Outcome Scale (GOS), showed good recovery and moderate disability patients (142, 62.9%) were classified as favorable outcome group whereas patients with severe disability, vegetative state, and dead (83, 36.9%) were classified as unfavorable outcome. According to WFNS grading, the patients with unruptured aneurysm and WFNS grade 1-2 had favorable outcome in 116 patients (78.37%) and unfavorable outcome in 32 patients (21.62%). Whereas the patients with WFNS grade 3-5 had favorable outcome in 32 patients (33.76%) and unfavorable outcome in 51 patients (66.23%). This study of 225 cases revealed 142 cases with favorable outcome and 83 cases with unfavorable outcome. Factors that affected the outcome were WFNS grading and age.

Delayed Vasospasm after Aneurysmal Subarachnoid Hemorrhage in Behcet Syndrome.

PubMed

Kim, Jun Hak; Lee, Si-Un; Huh, Choonwoong; Oh, Chang Wan; Bang, Jae Seung; Kim, Tackeun

2016-03-01

A man visited the emergency room with a headache. Brain computed tomography showed aneurysmal subarachnoid hemorrhage (SAH) and multiple aneurysms. After aneurysm clipping surgery, the patient was discharged. After 5 days, he was admitted to the hospital with skin ulceration and was diagnosed with Behcet syndrome. An angiogram taken 7 weeks after aneurysmal SAH showed intracranial vasospasm. Because inflammation in Behcet syndrome may aggravate intracranial vasospasm, intracranial vasospasm after aneurysmal SAH in Behcet syndrome should be monitored for longer compared to general aneurysmal SAH.

Delayed Vasospasm after Aneurysmal Subarachnoid Hemorrhage in Behcet Syndrome

PubMed Central

Kim, Jun Hak; Lee, Si-Un; Huh, Choonwoong; Oh, Chang Wan; Bang, Jae Seung

2016-01-01

A man visited the emergency room with a headache. Brain computed tomography showed aneurysmal subarachnoid hemorrhage (SAH) and multiple aneurysms. After aneurysm clipping surgery, the patient was discharged. After 5 days, he was admitted to the hospital with skin ulceration and was diagnosed with Behcet syndrome. An angiogram taken 7 weeks after aneurysmal SAH showed intracranial vasospasm. Because inflammation in Behcet syndrome may aggravate intracranial vasospasm, intracranial vasospasm after aneurysmal SAH in Behcet syndrome should be monitored for longer compared to general aneurysmal SAH. PMID:27114963

De novo giant A2 aneurysm following anterior communicating artery occlusion.

PubMed

Ibrahim, Tarik F; Hafez, Ahmad; Andrade-Barazarte, Hugo; Raj, Rahul; Niemela, Mika; Lehto, Hanna; Numminen, Jussi; Jarvelainen, Juha; Hernesniemi, Juha

2015-01-01

De novo intracranial aneurysms are reported to occur with varying incidence after intracranial aneurysm treatment. They are purported to be observed, however, with increased incidence after Hunterian ligation; particularly in cases of carotid artery occlusion for giant or complex aneurysms deemed unclippable. We report a case of right-sided de novo giant A2 aneurysm 6 years after an anterior communicating artery (ACoA) aneurysm clipping. We believe this de novo aneurysm developed in part due to patient-specific risk factors but also a significant change in cerebral hemodynamics. The ACoA became occluded after surgery that likely altered the cerebral hemodynamics and contributed to the de novo aneurysm. We believe this to be the first reported case of a giant de novo aneurysm in this location. Following parent vessel occlusion (mostly of the carotid artery), there are no reports of any de novo aneurysms in the pericallosal arteries let alone a giant one. The patient had a dominant right A1 and the sudden increase in A2 blood flow likely resulted in increased wall shear stress, particularly in the medial wall of the A2 where the aneurysm occurred 2 mm distal to the A1-2 junction. ACoA preservation is a key element of aneurysm surgery in this location. Suspected occlusion of this vessel may warrant closer radiographic follow-up in patients with other risk factors for aneurysm development.

Mechanical deterioration underlies malignant behavior of aneurysmal human ascending aorta.

PubMed

Koullias, George; Modak, Raj; Tranquilli, Maryann; Korkolis, Dimitris P; Barash, Paul; Elefteriades, John A

2005-09-01

The human ascending aorta becomes markedly prone to rupture and dissection at a diameter of 6 cm. The mechanical substrate for this malignant behavior is unknown. This investigation applied engineering analysis to human ascending aortic aneurysms and compared their structural characteristics with those of normal aortas. We measured the mechanical characteristics of the aorta by direct epiaortic echocardiography at the time of surgery in 33 patients with ascending aortic aneurysm undergoing aortic replacement and in 20 control patients with normal aortas undergoing coronary artery bypass grafting. Six parameters were measured in all patients: aortic diameter in systole and diastole, aortic wall thickness in systole and diastole, and blood pressure in systole and diastole. These were used to calculate mechanical characteristics of the aorta from standard equations. Aortic distensibility reflects the elastic qualities of the aorta. Aortic wall stress reflects the disrupting force experienced within the aortic wall. Incremental elastic modulus indicates loss of elasticity reserve. Aortic distensibility falls to extremely low levels as aortic dimension rises toward 6 cm (3.02 mm Hg(-1) for small aortas versus 1.45 mm Hg(-1) for aortas larger than 5 cm, P < .05). Aortic wall stress rises to 157.8 kPa for the aneurysmal aorta, compared with 92.5 kPa for normal aortas. For 6-cm aortas at pressures of 200 mm Hg or more, wall stress rises to 857 kPa, nearly exceeding the known maximal tensile strength of human aneurysmal aortic wall. Incremental elastic modulus deteriorates (1.93 +/- 0.88 MPa vs 1.18 +/- 0.21 MPa, P < .05) in aneurysmal aortas relative to that in normal aortas. The mechanical properties of the aneurysmal aorta deteriorate dramatically as the aorta enlarges, reaching critical levels associated with rupture by a diameter of 6 cm. This mechanical deterioration provides an explanation in engineering terms for the malignant clinical behavior (rupture and dissection) of the aorta at these dimensions. This work adds to our fundamental understanding of the biology of aortic aneurysms and promises to permit future application of engineering measurements to supplement aneurysm size in clinical decision making in aneurysmal disease.

Contemporary results of open aortic arch surgery.

PubMed

Thomas, Mathew; Li, Zhuo; Cook, David J; Greason, Kevin L; Sundt, Thoralf M

2012-10-01

The success of endovascular therapies for descending thoracic aortic disease has turned attention toward stent graft options for repair of aortic arch aneurysms. Defining the role of such techniques demands understanding of contemporary results of open surgery. The outcomes of open arch procedures performed on a single surgical service from July 1, 2001 to August 30, 2010, were examined as defined per The Society of Thoracic Surgeons national database. During the study period, 209 patients (median age, 65 years; range, 26-88) underwent arch operations, of which 159 were elective procedures. In 65 the entire arch was replaced, 22 of whom had portions of the descending thoracic aorta simultaneously replaced via bilateral thoracosternotomy. Antegrade cerebral perfusion was used in 78 patients and retrograde cerebral perfusion in 1. Operative mortality was 2.5% in elective circumstances and 10% in emergency cases (P = .04). The stroke rate was 5.0% when procedures were performed electively and 11.8% when on an emergency basis (P = .11). Procedure-specific mortality rates were 5.5% for elective and 10% for emergency procedures with total arch replacement, and 1.0% for elective and 10% for emergency procedures with hemiarch replacement. Stratified by extent, neurologic event rates were 5.5% for elective and 10% for emergency procedures with total arch and 4.8% for elective and 12.5% for emergency procedures with hemiarch replacement. Open aortic arch replacement can be performed with low operative mortality and stroke rates, especially in elective circumstances, by a team with particular focus on the procedure. The results of novel endovascular therapies should be benchmarked against contemporary open series performed in such a setting. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Hemiarch Reconstruction Vs Clamped Aortic Anastomosis for Concomitant Ascending Aortic Aneurysm.

PubMed

Sultan, Ibrahim; Bianco, Valentino; Yajzi, Ibrahim; Kilic, Arman; Dufendach, Keith; Cardounel, Arturo; Althouse, Andrew D; Masri, Ahmad; Navid, Forozan; Gleason, Thomas G

2018-05-03

Deep hypothermic circulatory arrest (DHCA) is often avoided in patients with concomitant ascending aortic pathology when treating other cardiac disease to avoid increased risk of morbidity and mortality. We hypothesized that the use of DHCA with retrograde cerebral perfusion (RCP) does not add incremental risk to ascending aortic replacement alone in the setting of concomitant cardiac surgery. 408 ascending aortic ± hemiarch replacements and aortic (root)/mitral/tricuspid valve(s), CABG, or MAZE procedures were performed for concomitant cardiac disease. DHCA with RCP was used for all hemiarch replacements or the ascending aorta was replaced with an aortic cross-clamp proximal to the innominate artery. Propensity-score matching was used to match similar ascending patients vs. hemiarch patients; the final propensity score matched patients on age, gender, BMI, previous heart surgery, pre-op aortic insufficiency, pre-op aortic stenosis, pre-op EF, and operative variables. Propensity-score matching yielded 116 pairs of Non-hemiarch patients vs. 116 hemiarch patients. Within the propensity-score matched cohort, there were no differences in postoperative stroke (1.7% vs. 3.4%, p = 0.41), new postoperative dialysis (6.0% vs. 5.2%, p = 0.78), postoperative renal insufficiency (27.6% vs. 19.8%, p = 0.16), 30-day mortality (2.6% vs. 3.4%, p = 0.701), or 1-year mortality (4.3% vs. 4.3%, p = 1.00) CONCLUSIONS: Hemiarch replacement using DHCA with RCP does not increase the risk of operative complications compared to a normothermic, clamped-distal aortic anastomosis, and therefore its use should not be limited when planning complex multi-procedural reconstructions during elective ascending thoracic aortic replacement with concomitant cardiac surgery. Copyright © 2018. Published by Elsevier Inc.

Replacement of the Thoracoabdominal Aorta after Endovascular Abdominal Aneurysm Repair for Ruptured Infected Aneurysm: A Case Report

PubMed Central

Kondo, Nobuo; Tamura, Kentaro; Sakaguchi, Taichi; Chikazawa, Genta; Yoshitaka, Hidenori

2017-01-01

A 73-year-old man underwent emergency endovascular abdominal aneurysm repair (EVAR) for a ruptured infected abdominal aortic aneurysm. Two years after EVAR, he was admitted with a spiking fever and left lower back pain. Computed tomography scan revealed not only recurrent graft infection with psoas abscess but also infection around the orifice of the superior mesenteric artery. Because conservative medical therapy with antibiotics could not control the infection, we performed complete removal of the infected stent graft, debridement of psoas abscess, and in situ replacement of the thoracoabdominal aorta using rifampicin-soaked prosthetic grafts, followed by the omental flap. He was discharged with no complications. PMID:29034025

Does specialization improve outcome in abdominal aortic aneurysm surgery?

PubMed

Rosenthal, Rachel; von Känel, Oliver; Eugster, Thomas; Stierli, Peter; Gürke, Lorenz

2005-01-01

Specialization and high volume are reported to be related to a better outcome after abdominal aortic aneurysm repair. The aim of this study was to compare, in patients undergoing abdominal aortic aneurysm repair, the outcomes of those whose surgery was done by general surgeons with the outcomes of those whose surgery was done by specialist vascular surgeons. All patients undergoing abdominal aortic aneurysm repair at the Basel University Hospital (referral center) from January 1990 to December 2000 were included. Patients with endovascular treatment were excluded. Operations in group A (n = 189), between January 1990 and May 1995, were done by general surgeons. Operations in group B (n = 291), between June 1995 and December 2000, were done by vascular surgeons. In-hospital mortality and local and systemic complications were assessed. In-hospital mortality rates were significantly lower for group B (with specialist surgeons) than for group A, both overall (group B, 11.7%; group A, 21.7%; p = .003) and for emergency interventions (group B, 28.1%; group A, 41.9%; p = .042). The reduction in mortality for elective surgery in group B was not statistically significant (group B, 1.1%; group A, 4.9%; p = .054). There were significantly fewer pulmonary complications in group B compared with group A (p = .000). We conclude that in patients undergoing abdominal aortic aneurysm repair, those whose surgery is done by a specialized team have a significantly better outcome than those whose surgery is done by general surgeons.

Numerical simulations of post-surgical flow and thrombosis in basilar artery aneurysms

NASA Astrophysics Data System (ADS)

Seshadhri, Santhosh; Lawton, Michael; Boussel, Loic; Saloner, David; Rayz, Vitaliy

2015-11-01

Surgical treatment of basilar artery aneurysms presents a major challenge since it is crucial to preserve the flow to the vital brainstem perforators branching of the basilar artery. In some cases, basilar aneurysms can be treated by clipping vessels in order to induce flow reduction and aneurysm thrombosis. Patient-specific CFD models can provide guidance to clinicians by simulating postoperative flows resulting from alternative surgeries. Several surgical options were evaluated for four basilar aneurysm patients. Patient-specific models were generated from preoperative MR angiography and MR velocimetry data and modified to simulate different procedures. The Navier-Stokes equations were solved with a finite-volume solver Fluent. Virtual contrast injections were simulated by solving the advection-diffusion equation in order to estimate the flow residence time and determine thrombus-prone regions. The results indicated on procedures that reduce intra-aneurysmal velocities and flow regions which are likely to become thrombosed. Thus CFD modeling can help improve the outcome of surgeries altering the flow in basilar aneurysms.

[The complex aortic abdominal aneurysm: is open surgery old fashion?].

PubMed

Saucy, F; Déglise, S; Doenz, F; Dubuis, C; Corpataux, J-M

2012-06-20

Open surgery is still the main treatment of complex abdominal aortic aneurysm. Nevertheless, this approach is associated with major complications and high mortality rate. Therefore the fenestrated endograft has been used to treat the juxtarenal aneurysms. Unfortunately, no randomised controlled study is available to assess the efficacy of such devices. Moreover, the costs are still prohibitive to generalise this approach. Alternative treatments such as chimney or sandwich technique are being evaluated in order to avoid theses disadvantages. The aim of this paper is to present the endovascular approach to treat juxtarenal aneurysm and to emphasize that this option should be used only by highly specialized vascular centres.

Mitral regurgitation after previous aortic valve surgery for bicuspid aortic valve insufficiency.

PubMed

Girdauskas, Evaldas; Disha, Kushtrim; Espinoza, Andres; Misfeld, Martin; Reichenspurner, Hermann; Borger, Michael A; Kuntze, Thomas

2017-06-01

Regurgitant bicuspid aortic valves (BAV) are reported to be associated with myxomatous degeneration of the anterior mitral leaflet. We examined the risk of late new-onset mitral regurgitation (MR) in patients who underwent aortic valve/aortic root surgery for BAV regurgitation and concomitant root dilatation. A total of 97 consecutive patients (47±11 years, 94% men) were identified from our institutional BAV database (N.=640) based on the following criteria: 1) BAV regurgitation; 2) aortic root diameter >40 mm; 3) no relevant mitral valve disease (i.e., MR<2+) and no simultaneous mitral intervention at the time of BAV surgery. All patients underwent isolated aortic valve replacement (AVR subgroup, N.=59) or aortic root replacement with a composite graft (i.e., for root aneurysm >50 mm) (ARR subgroup, N.=38) from 1995 through 2008. Echocardiographic follow-up (1009 patient-years) was obtained for all 96 (100%) hospital survivors. The primary endpoint was freedom from new-onset MR>2+ and redo mitral valve surgery. Nine patients (9.4%) showed new-onset MR>2+ after mean echocardiographic follow-up of 10.4±4.0 years postoperatively. Myxomatous degeneration and prolapse of the anterior mitral leaflet was found in all 9 patients, and the posterior leaflet was involved in 3 of them. Two patients (2%) in AVR subgroup underwent re-do mitral surgery. No MR>2+ occurred in ARR subgroup. Freedom from MR>2+ or mitral surgery at 15 years was significantly lower in AVR subgroup vs. ARR subgroup (i.e., 38% vs. 100%, P=0.01). The risk of new-onset MR is significantly increased in patients with BAV regurgitation and aortic root dilatation who undergo isolated AVR rather than root replacement. The mechanism by which aortic root replacement may prevent the occurrence of late MR in BAV root phenotype patients is to be determined.

Composite aortic root replacement using the classic or modified Cabrol coronary artery implantation technique.

PubMed

Garlicki, Miroslaw; Roguski, K; Puchniewicz, M; Ehrlich, Marek P

2006-08-01

We report in this study our results with composite aortic root replacement (CVR) using the classic or modified Cabrol coronary implantation technique. From October 2001 to March 2005, 25 patients underwent aortic root replacement. In all cases, the indication for surgery was a degenerative aneurysm with a diameter of more than 6 cm. Seven patients had undergone a previous aortic operation on the ascending aorta. Mean age was 53+/-13 years and 22 patients were male. Mean Euroscore was 5.2+/-2.4. Aortic insufficiency was present in all patients. Two patients had Marfan syndrome. The 30-day mortality was 0%. Two patients required profound hypothermic circulatory arrest. Mean aortic cross-clamp time was 91+/-24 minutes and the mean circulatory arrest time was 24+/-15 minutes. No patients developed a pseudoaneurysm after the operation. We conclude that composite aortic root replacement with the classic or modified Cabrol technique results in a low operative mortality. However, it should be only used when a "button" technique is not feasible.

Adipsic diabetes insipidus and venous thromboembolism (VTE): recommendations for addressing its hypercoagulability.

PubMed

Miljic, Dragana; Miljic, Predrag; Doknic, Mirjana; Pekic, Sandra; Stojanovic, Marko; Petakov, Milan; Popovic, Vera

2014-01-01

Adipsic diabetes insipidus (ADI) is a rare disorder. It can occur after transcranial surgery for craniopharyngeoma, suprasellar pituitary adenoma and anterior communicating artery aneurysm but also with head injury, toluene exposure and developmental disorders. It is often associated with significant hypothalamic dysfunction and complications like obesity, sleep apnea, thermoregulatory disorders, seizures and venous thromboembolism (VTE). Morbidity and mortality data have been reported as single case reports with only one large series suggesting increased risk for VTE in patients with ADI. Here we report a mini-series of four patients with ADI and VTE. Post-surgery immobilization, obesity, infection, with prolonged hospitalization, hemoconcentration and changes in coagulation which might be induced by inadequate hormone treatment in the postoperative period (high doses of glucocorticoids, sex steroids and DDAVP replacement) may all contribute to the pathogenesis of VTE. Thromboprophylactic treatment after pituitary surgery and during episodes of hypernatremia is therefore warranted.

Is there a prospect for hybrid aortic arch surgery?

PubMed

Bashir, Mohamad; Harky, Amer; Bilal, Haris

2018-05-16

The surge of endovascular repair of aortic aneurysm in current modern aortic surgery practice has been the key for surgical management of elective cases of thoracic aortic aneurysms. This has paved way for the combined hybrid approach to be amongst the armamentarium for the management of aortic arch disease. The pivotal understanding of the aortic arch natural history coupled with device technology advancement allowed surgeons insight into delivery of hybrid surgery with acceptable morbidity and mortality results. This review article provides current insights into hybrid technique of aortic arch aneurysm repair and the evidences behind its applicability to arch surgery. It is aimed to highlight the challenges encountered for this innovative approach and correlate its challenges to those that are met by the conventional open aortic arch repair.

Dual-Channel Endoscopic Indocyanine Green Fluorescence Angiography for Clipping of Cerebral Aneurysms.

PubMed

Cho, Won-Sang; Kim, Jeong Eun; Kang, Hyun-Seung; Ha, Eun Jin; Jung, Minwoong; Lee, Choonghee; Shin, Il Hyung; Kang, Uk

2017-04-01

Neuroendoscopy is useful for assessing status of perforators, parent arteries, and aneurysms beyond the straight line of microscopic view during aneurysm clipping. We aimed to evaluate the clinical usefulness of our endoscopic indocyanine green angiography (ICGA) system, which can simultaneously display visible light and indocyanine green fluorescent images. Surgical clipping of 16 unruptured aneurysms in 10 patients was performed via the keyhole approach. Using our endoscopic ICGA and commercial microscopic ICGA systems, we prospectively compared 10 targeted cerebral aneurysms at the posterior communicating (n = 4) and anterior choroidal (n = 6) arteries. Microscopic ICGA and endoscopic ICGA were feasible during surgery. Microscopic ICGA displayed 50% of branch orifices, 100% of branch trunks, and 20% of exact clip positions, whereas endoscopic ICGA showed 100% of these. Based on endoscopic ICGA findings such as incomplete clipping and compromise of parent arteries or branches, clips were repositioned in 2 cases, and additional clips were applied in 2 cases. Complete occlusion and residual neck states were achieved in 6 and 4 aneurysms after surgery. There were no neurologic deficits within 3 months after surgery except for frontalis palsy and anosmia in each patient. The endoscopic ICGA system with dual imaging of visible light and indocyanine green fluorescence was very useful for assessing geometry of aneurysms and surrounding vessels before clipping and for evaluating completeness of clip position after clipping. Copyright © 2017 Elsevier Inc. All rights reserved.

Management of concomitant large aortic aneurysm and severe stenosis of aortic arc.

PubMed

Ren, Shiyan; Sun, Guang; Yang, Yuguang; Liu, Peng

2014-01-01

Primary large saccular aortic aneurysm with high grade stenosis of aortic arc is rare, and no standard therapy is available. We have encountered one case and successfully treated using a hybrid interventional approach. A 59-year-old woman with a 7-day history of headache, dizziness and chest pain, and a 5-year history of hypertension admitted and was diagnosed with transverse aortic aneurysm with sever aortic stenosis, the huge saccular aneurysm was located behind the transverse aortic arc. During surgery, a bypass with graft from ascending aorta to left external iliac artery was made initially in order to ensure the blood supply to the left leg, afterward, a 40 mm × 160 mm covered stent was implanted to cover the orifice of aneurysm and was used as a supporting anchorage in the descending aorta, a second covered stent (20 mm × 100 mm) was implanted to expand the stenosis of aortic arc. Follow-up at 1.5-year after surgery, the patient has been doing well without any surgical complication. A collateral pathway between internal mammary artery and inferior epigastric artery via the superior epigastric artery was found on3-dimensional reconstruction before surgery. Interruption of the compensatory arterial collateral pathway in the patient with severe stenosis of aortic arc should be prevented if possible in order to ensure the satisfactory perfusion of the lower limbs of the body.In conclusion, a patient with transverse aortic aneurysm accompanied with severe aortic stenosis can be treated by hybrid surgery.

Endovascular Treatment of Distal Aortic Arch Aneurysm Associated with Coarctation of Aorta in a Jehovah's Witness

PubMed Central

Mannacio, Vito A.; Di Tommaso, Ettorino; Pinna, Giovanni B.; Fontana, Immacolata; Iannelli, Gabriele

2017-01-01

Late aneurysm formation in the proximal aorta or distal aortic arch is a recognized sequela of untreated stenosis of the aortic isthmus and is associated with substantial risk of aortic rupture. We describe the case of a 44-year-old man with untreated coarctation of the aorta who presented with a prestenotic dissecting thoracic aortic aneurysm. He declined surgery because he was a Jehovah's Witness. Instead, we performed emergency endovascular aortic repair in which 2 stent-grafts were placed in the descending aorta. Our experience suggests that this procedure is a useful and safe alternative to open surgery in patients who have aneurysms associated with coarctation of the aorta. PMID:29276439

The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms

PubMed Central

Lopez, J.; Chang, S.; Steinberg, G.

1999-01-01

OBJECTIVES—Somatosensory evoked potentials (SSEPs) and brainstem auditory evoked potentials (BAEPs) have been increasingly utilised during surgery for intracranial aneurysms to identify cerebral ischaemia. Between July 1994 and April 1996, we surgically treated 70 aneurysms in 49 consecutive patients (58 operations) with the aid of intraoperative evoked potential monitoring. This study sought to evaluate the usefulness of SSEP and BAEP monitoring during intracranial aneurysm surgery.
METHODS—Mean patient age was 51.9 (range 18-79) years. The sizes of the aneurysms were 3-4 mm (15), 5-9 mm (26), 10-14 mm (11), 15-19 mm (seven), 20-24 mm (six), and >25 mm (five). SSEPs were monitored in 58 procedures (100%) and BAEPs in 15 (26%). The neurological status of the patients was evaluated before and after surgery.
RESULTS—Thirteen of the 58 procedures (22%) monitored with SSEPs had SSEP changes (12 transient, one persistent); 45 (78%) had no SSEP changes. Three of 15 patients (20%) monitored with BAEPs had changes (two transient, one persistent); 12 (80%) had no BAEP changes. Of the 14 patients with transient SSEP or BAEP changes, these changes resolved with adjustment or removal of aneurysm clips (nine), elevating MAP (four), or retractor adjustment (one). Mean time from precipitating event to electrophysiological change was 8.9 minutes (range 3-32), and the mean time for recovery of potentials in patients with transient changes was 20.2 minutes (range 3-60). Clinical outcome was excellent in 39 patients, good in five, and poor in three (two patients died), and was largely related to pretreatment grade.
CONCLUSIONS—SSEPs and BAEPs are useful in preventing clinical neurological injury during surgery for intracranial aneurysms and in predicting which patients will have unfavourable outcomes.

 PMID:10071098

Multiple organ embolization with vegetation on an elephant trunk graft.

PubMed

Tashiro, Miwa; Yamamoto, Masaki; Nishimori, Hideaki; Fukutomi, Takashi; Handa, Takemi; Kondo, Nobuo; Orihashi, Kazumasa

2017-01-01

We encountered a rare case of infection in a vascular graft created using the elephant trunk technique. A 65-year-old woman who underwent total arch replacement with the elephant trunk technique was re-admitted with fever. She developed embolization of multiple organs from vegetation attached to the elephant trunk graft which was elucidated by transesophageal echocardiography. Surgery for ruptured jejunal artery aneurysm was performed, and the graft infection healed after long-term antibiotic therapy with the prosthesis left in situ. Graft infection may generate vegetations on an elephant trunk graft. Transesophageal echocardiography is a helpful tool for accurate diagnosis.

[A Case of Cervical Spinal Dural Arteriovenous Fistula with Extradural Drainage Presenting with Subarachnoid Hemorrhage due to a Ruptured Anterior Spinal Artery Aneurysm].

PubMed

Kurokawa, Yasuharu; Ikawa, Fusao; Hamasaki, Osamu; Hidaka, Toshikazu; Yonezawa, Ushio; Komiyama, Masaki

2015-09-01

We report a rare case of a cervical spinal dural arteriovenous fistula(AVF)at the C2 level presenting with subarachnoid hemorrhage(SAH)due to a ruptured anterior spinal artery aneurysm. A 61-year-old man presented with sudden onset headache. Initial computed tomography revealed SAH around the brainstem. Digital subtraction angiography(DSA)demonstrated a cervical dural AVF that was fed by the left C1 radicular, left C2 radicular, and anterior spinal arteries, and drained into the epidural plexus. An aneurysm in the branch of the cervical anterior spinal artery was considered the bleeding point. A left lateral suboccipital craniotomy and C1 hemilaminectomy were performed on day 43. The feeding arteries were clipped, followed by coagulation of the draining veins. However, the aneurysm was not clipped because we deemed that obliteration of the aneurysm would be difficult without disrupting the blood flow of the parent artery. The patient showed no neurological deterioration after the operation. Postoperative DSA revealed residual dural AVF. Therefore, a second surgery was performed. After the second open surgery, DSA showed that the dural AVF and aneurysm disappeared. The patient also showed no neurological deterioration after the second surgery.

Coiling of a Ruptured Large Internal Carotid Artery Aneurysm via Extracranial-Intracranial Saphenous Vein Bypass Graft Just After Proximal Ligation of the Internal Carotid Artery.

PubMed

Tajima, Hayato; Araki, Yoshio; Izumi, Takashi; Nishihori, Masahiro; Okamoto, Sho; Wakabayashi, Toshihiko

2017-02-01

Combined direct and endovascular surgery has been performed to treat large to giant internal carotid artery (ICA) aneurysms. This report describes successful treatment of a large ICA aneurysm by coiling of the aneurysm via an extracranial-intracranial saphenous vein (SV) graft just after bypass and ICA proximal ligation. A 66-year-old woman presented with a left ICA supraclinoid aneurysm with progressive visual field defect and impaired visual acuity in the left eye. While waiting for scheduled surgery, she experienced a subarachnoid hemorrhage. An extracranial-intracranial high-flow bypass using an SV graft and proximal ligation of the ICA were performed. Coiling of the aneurysm was immediately performed successfully via the SV bypass graft. The patient experienced no new neurologic deficit after this treatment. Follow-up radiologic evaluations using magnetic resonance imaging and magnetic resonance angiography revealed complete aneurysm occlusion. Aneurysm coiling via an extracranial-intracranial SV bypass graft could offer an alternative when an antegrade access route to the ICA is not used because of prior parent artery ligation. Copyright © 2016 Elsevier Inc. All rights reserved.

Idiopathic subvalvular aortic aneurysm masquerading as acute coronary syndrome.

PubMed

Natarajan, Balaji; Ramanathan, Sundar; Subramaniam, Natarajan; Janardhanan, Rajesh

2016-09-02

Subvalvular aneurysms are the least common type of left ventricular (LV) aneurysms and can be fatal. Subaortic LV aneurysms are much rarer than submitral LV aneurysms and mostly reported in infancy. They can be congenital or acquired secondary to infections, cardiac surgery or trauma. Here, we report a unique presentation of a large, idiopathic subaortic aneurysm in an adult masquerading as an acute coronary syndrome. Diagnosis was made with the help of a CT aortography. Aneurysm was surgically resected with good results. This case highlights the clinical presentation and management of subaortic aneurysms, an important differential for congenital aortic malformations. 2016 BMJ Publishing Group Ltd.

[Anesthesia for total and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis].

PubMed

Furuichi, Yuko; Shimizu, Jun; Sakamoto, Atsuhiro

2012-04-01

We experienced anesthesia for total arch and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis. Because there was possibility that post coarctectomy syndrome would occur after repair of coarctation of aorta, administration of depressor that acts on renin-angiotensin-aldosterone and careful observation were needed postoperatively. In consideration of the development of collateral vessels, preoperative imaging evaluation was added and operative method in cardiopulmonary bypass was adjusted. Careful preoperative evaluation is very important in cardiac anesthesia.

Progress in carotid artery surgery at the base of the skull.

PubMed

Sandmann, W; Hennerici, M; Aulich, A; Kniemeyer, H; Kremer, K W

1984-11-01

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly located lesions of the ICA. Although extracranial-intracranial anastomosis has been proposed in patients with planned ligation of the ICA, the anatomic reconstruction remains advantageous because flow is restored to normal and the source of emboli is eliminated. With the use of a special approach, graft replacement can be performed up to the base of the skull.

The History of the Department of Cardiovascular and Thoracic Surgery at Rush.

PubMed

Faber, L Penfield; Liptay, Michael J; Seder, Christopher W

2016-01-01

The Rush Department of Cardiovascular and Thoracic Surgery received certification by the American Board of Thoracic Surgery (ABTS) to train thoracic surgical residents in 1962. The outstanding clinical faculty, with nationally recognized technical expertise, was eager to provide resident education. The hallmark of the program has been clinical excellence, dedication to patient care, and outstanding results in complex cardiac, vascular, and general thoracic surgical procedures. A strong commitment to resident education has been carried to the present time. Development of the sternotomy incision, thoracic and abdominal aneurysm repair, carotid endarterectomy, along with valve replacement, have been the hallmark of the section of cardiovascular surgery. Innovation in bronchoplastic lung resection, aggressive approach to thoracic malignancy, and segmental resection for lung cancer identify the section of general thoracic surgery. A total of 131 thoracic residents have been trained by the Rush Thoracic Surgery program, and many achieved their vascular certificate, as well. Their training has been vigorous and, at times, difficult. They carry the Rush thoracic surgical commitment of excellence in clinical surgery and patient care throughout the country, both in practice groups and academic centers. Copyright © 2016 Elsevier Inc. All rights reserved.

Duplicated middle cerebral artery

PubMed Central

Perez, Jesus; Machado, Calixto; Scherle, Claudio; Hierro, Daniel

2009-01-01

Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion. PMID:22140405

Total laparorobotic repair of abdominal aortic aneurysm with sac exclusion obliteration and aortobifemoral bypass.

PubMed

Wu, Timothy; Prema, Jateen; Zagaja, Gregory; Shalhav, Arieh; Bassiouny, Hisham S

2009-01-01

A 65-year-old man with coronary artery disease, hypertension, and peripheral vascular disease was found to have an asymptomatic abdominal aortic aneurysm (AAA) of 5.5 cm on surveillance for his peripheral vascular disease. Cardiac stress testing demonstrated no evidence of myocardial ischemia, and he opted to undergo open repair of his aneurysm. Laparorobotic repair of the infrarenal AAA using the da Vinci robotic system was performed with an aortobifemoral bypass. We describe a novel technique for AAA exclusion using a cerclage method, which greatly facilitates repair of infrarenal AAAs using laparorobotic techniques. Laparorobotic repair of infrarenal AAA can be greatly facilitated by AAA sac exclusion and obliteration without the need to ligate all lumbar arteries or to open the aneurysm. This virtually avoids blood loss from the sac and minimizes the possibility for open conversion as a result of poor visualization. Minimally invasive aortic intervention for aneurysmal disease using laparascopic methods has been reported in the literature. Problems associated with this technique include a prolonged learning curve and difficulty completing intracorporeal anastomoses. Robotic surgery provides an advantage over laparoscopic surgery in its ability to provide greater degrees of freedom in a relatively small field of view along with superior high-definition, three-dimensional visualization. To date, there have been no known reports of using robotic surgery in the United States as a sole method for repair of AAA. We report our technique of combining robotic surgery with a novel procedure for sac exclusion and obliteration to successfully repair AAA without the need for opening the aneurysm sac and endoaneurysmorrhaphy.

No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial.

PubMed

Hindman, Bradley J; Bayman, Emine O; Pfisterer, Wolfgang K; Torner, James C; Todd, Michael M

2010-01-01

Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Direct Surgery of Previously Coiled Large Internal Carotid Ophthalmic Aneurysm for the Purpose of Optic Nerve Decompression

PubMed Central

Kawabata, Shuhei; Toyota, Shingo; Kumagai, Tetsuya; Goto, Tetsu; Mori, Kanji; Taki, Takuyu

2017-01-01

Background Progressive visual loss after coil embolization of a large internal carotid ophthalmic aneurysm has been widely reported. It is generally accepted that the primary strategy for this complication should be conservative, including steroid therapy; however, it is not well known as to what approach to take when the conservative therapy is not effective. Case Presentation We report a case of a 55-year-old female presenting with progressive visual loss after the coiling of a ruptured large internal carotid ophthalmic aneurysm. As the conservative therapy had not been effective, we performed neck clipping of the aneurysm with optic canal unroofing, anterior clinoidectomy, and partial removal of the embolized coils for the purpose of optic nerve decompression. After the surgery, the visual symptom was improved markedly. Conclusions It is suggested that direct surgery for the purpose of optic nerve decompression may be one of the options when conservative therapy is not effective for progressive visual disturbance after coil embolization. PMID:28229036

Bilateral true giant aneurysm of the profunda femoral artery: case report and review of the literature.

PubMed

Robaldo, Alessandro; Maselli, Mauro; Maggio, Daniele

2012-01-01

We report a rare case of a bilateral true giant aneurysm of the profunda femoral artery aneurysms (PFAAs) in a 80-year-old man with a previous history of "open" abdominal aortic surgery and small bilateral popliteal artery aneurysm. In the English Literature only seven previously cases of true bilateral PFAAs are reported. Due to its location, this lesion may require surgical intervention and removal. The presentation, the diagnostic evaluation, and the surgical management of the aneurysm are discussed.

Endovascular treatment of complicated aortic aneurysms in patients with underlying arteriopathies.

PubMed

Baril, Donald T; Carroccio, Alfio; Palchik, Eugene; Ellozy, Sharif H; Jacobs, Tikva S; Teodorescu, Victoria; Marin, Michael L

2006-07-01

Patients with arteriopathies including giant cell arteritis, Marfan syndrome, and Takayasu's disease are at risk for aneurysmal degeneration of the aorta. Aortic repair has been recommended for these patients to prevent rupture. The purpose of this study was to examine outcomes following endovascular stent graft (EVSG) repair of aortic aneurysms in this patient population. Over an 8-year period, 11 patients (six men, five women) with arteriopathies underwent endovascular aortic repair. The mean age was 50 (range 15-81). Diseases included Marfan syndrome (n = 6), Takayasu's disease (n = 3), and giant cell arteritis (n = 2). Success of EVSG repair was evaluated per the reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. Follow-up was a mean of 28.9 months (range 3-68). Six patients underwent EVSG repair of the thoracic aorta, four underwent EVSG repair of the abdominal aorta, and one underwent a staged repair of the thoracic and subsequently the abdominal aorta. Six true aneurysms and six pseudoaneurysms were repaired. Eight patients had previous aortic surgery, including four with multiple aortic operations. For the 12 aneurysms treated, technical success was achieved in 11 (91.7%). One technical failure occurred due to a small iliac access vessel, requiring an eventual iliac conduit for insertion. Early complications (<30 days) occurred in three patients. Type I or III endoleak developed following two repairs (16.7%). Aneurysm expansion occurred following one repair (8.3%). No aneurysm-related deaths occurred during follow-up. EVSG repair of aortic aneurysms is feasible and can be safely performed in patients with arteriopathies. Long-term durability in this younger group of patients who carry an ongoing risk of arterial degeneration remains to be determined.

Dor procedure for pulmonary atresia with intact ventricular septum in an infant.

PubMed

Kang, Yoonjin; Kwak, Jae Gun; Kim, Eung Rae; Kim, Woong-Han

2018-02-01

Pulmonary atresia with intact ventricular septum and right ventricle-dependent coronary circulation confers a high risk for myocardial infarction and complications of ischaemia, including left ventricle aneurysms. We describe an infant with pulmonary atresia with intact ventricular septum and right ventricle-dependent coronary circulation and a left ventricle apical aneurysm who successfully underwent the Dor procedure and a subsequent Fontan operation. Surgery for postinfarction left ventricle aneurysm can be considered in infants. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

[Management of isolated iliac aneurysms: A Tunisian center experience].

PubMed

Jmal, H; Ben Jmaà, H; Masmoudi, S; Cherif, T; Cheikhrouhou, H; Maalej, A; Elleuch, N; Jemel, A; Frikha, I

2017-12-01

Isolated aneurysms of the iliac arteries are rare. The diagnoses of these aneurysms become easier with non-invasive radiologic investigations. The development of endovascular treatment is a recent alternative to surgical treatment. We report our experience in the management of 8 cases of isolated iliac aneurysms in the department of cardiovascular and thoracic surgery of the Habib Bourguiba Hospital of Sfax. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Surgical approach to posterior inferior cerebellar artery aneurysms.

PubMed

La Pira, Biagia; Sturiale, Carmelo Lucio; Della Pepa, Giuseppe Maria; Albanese, Alessio

2018-02-01

The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference. We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured. Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

[Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm].

PubMed

Marjanović, Ivan; Jevtić, Miodrag; Misović, Sidor; Zoranović, Uros; Tomić, Aleksandar; Rusović, Sinisa; Sarac, Momir

2012-03-01

According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.

Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

PubMed Central

Koksal, Vaner; Kayaci, Selim

2016-01-01

Introduction The treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems of neurosurgery. We report the rupture of a giant, lobulated, and almost completely thrombosed middle cerebral artery (MCA) aneurysm that is the ninth such report in the literature. We also investigated additional solutions used in the treatment of this patient. Case Presentation A 58-year-old man had been admitted with headache 8 years previously (in 2005), and a giant MCA aneurysm was detected. Two separate endovascular interventions were performed, and both failed. The patient began to live with the giant aneurysm. As there was a large thrombosis filling the aneurysm lumen during the previous endovascular procedures, the aneurysm was not expected to rupture. However, a rupture eventually occurred, in 2013. Even if an aneurysm is very large, lobulated, old, and almost completely thrombosed, it can suddenly bleed. During surgery on this patient, we observed severe cerebral vasospasm caused by a giant thrombosed aneurysmal rupture. Despite the complications, surgery is a life-saving treatment for this emergency when other strategies are not possible. Thrombectomy and clipping are approaches that require a great deal of courage for the neurosurgeon, in terms of entering the risky area within the aneurysm. Conclusions We believe that it would be more appropriate to plan for combined treatment with surgical and endovascular approaches before the emergency condition could occur. PMID:27781115

Concomitant Persistent Atelectasis following TEVAR Due to a Descending Aortic Aneurysm: Hybrid Endovascular Repair and ECMO Therapy.

PubMed

Yavuz, Sadan; Arikan, Ali Ahmet; Ozbudak, Ersan; İrkil, Serhat; Hosten, Tulay; Gumustas, Sevtap; Berki, Kamil Turan

2015-10-28

Many thoracic aortic aneurysms are discovered incidentally, and most develop without symptoms. Symptoms are usually due to sudden expansion of the aneurysm, which can cause a vague pain in the back, or sometimes a sharp pain that may denote the presence of impending rupture. Other symptoms are related to pressure on adjacent structures, such as pressure on the bronchus that can cause respiratory distress, or pressure on the laryngeal nerve causing vocal hoarseness. Pressure on the esophagus can cause difficulty in swallowing. Currently, open surgery and thoracic endovascular aneurysm repair (TEVAR) are the choices of treatment for descending thoracic aneurysms (DTA). The decision to intervene on a DTA depends on its size, location, rate of growth and symptoms, and the overall medical condition of the patient. The indications for TEVAR should not differ from those for open surgery and typically include aneurysms larger than 6 cm in diameter. Saccular and symptomatic aneurysms are often repaired at a smaller size. It is also suggested that aneurysms with a growth rate more than 1 cm per year, or 0.5 cm in 6 months should be considered for early repair.Despite the close proximity of the aorta and left main bronchus, atelectasis caused by thoracic aortic aneurysms is rare. We review the case report of a patient with concomitant persistent left pulmonary atelectasis causing acute respiratory distress due to complete compression of the left main bronchus after TEVAR of a descending thoracic aortic aneurysm.

Abdominal aortic aneurysm: An update

PubMed

Chuen, Jason; Theivendran, Mayo

2018-05-01

Abdominal aortic aneurysm (AAA) remains one of the hallmark pathologies in vascular surgery and an area of intense research interest. Treatment options have expanded in recent years to increase the range of morphology suitable for endovascular aneurysm repair (EVAR), and with potential implications on treatment thresholds. This article is the first of two that will outline current treatment options for AAA, including areas of controversy and research in AAA disease, to inform the development of Australasian clinical guidelines and health policy. Medical therapy options remain limited and no aneurysm-specific pharmacotherapy is currently available. Recent years have witnessed a significant shift in AAA surgery from open repair to EVAR and expansion of EVAR techniques. General management of cardiovascular risk factors remains key to reducing all-cause mortality for patients with AAA.

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†.

PubMed

Hori, Daijiro; Okamura, Homare; Yamamoto, Takahiro; Nishi, Satoshi; Yuri, Koichi; Kimura, Naoyuki; Yamaguchi, Atsushi; Adachi, Hideo

2017-06-01

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28). Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

External-to-Internal Iliac Stent-Graft: Medium-Term Patency Following Exclusion of a Retrogradely Perfused Common Iliac Aneurysm

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nicholls, Marcus John, E-mail: marcusnicholls@hotmail.co; McPherson, Simon

2010-08-15

Following complicated aortic aneurysm surgery a complete left iliac occlusion resulted in buttock claudication. A retrogradely perfused right common iliac aneurysm expanded. Exclusion was by external-to-internal iliac stent-graft. No deterioration in claudication occurred with medium-term stent-graft patency.

Mortality outcomes of ruptured abdominal aortic aneurysms and rural presentation.

PubMed

Munday, Emily; Walker, Stuart

2016-10-01

Centralisation of vascular surgery services has coincided with a move towards endovascular repair of ruptured abdominal aortic aneurysms with the goal to improve patient outcomes. The aim of this study was to assess the effect of rural presentation and transfer times on survival from ruptured abdominal aortic aneurysm. A retrospective review. All patients presenting with ruptured abdominal aortic aneurysm to public hospitals in Tasmania between July 2006 and April 2013. Demographic data, Glasgow aneurysm score, Hardman index, transfer times, operative technique and 30-day mortality were collected from medical records. Over the study period 127 patients presented to public hospitals in Tasmania with ruptured abdominal aortic aneurysm. A total of 27 presented to north west hospitals where no vascular surgery service is provided (NWRH), 23 to a northern hospital where an intermittent vascular surgery service is provided (LGH) and 77 to the state tertiary vascular surgery service (RHH). Of these, 4 (14.8%) died at NWRH, 6 (26.1%) died at LGH and 43 (55.8%) died at RHH without operation. Of the 35 patients transferred from NWRH and LGH to RHH, 5 died without operation. Median time from presentation to theatre at RHH if transferred from NWRH was 6.25 hours, from the LGH 4.75 hours, compared to 2.75 hours when presenting directly to RHH. Open repair was performed in 41 patients and endovascular repair in 23 patients. Overall 30-day mortality in those treated at RHH was 26.6% (39.0% for open repair, 4.3% for endovascular repair). Mortality for intended operative patients initially presenting to non-RHH hospitals was 33.3% vs. 32.3% for those initially presenting to RHH. p Value 0.93. There was no clinical or statistical disadvantage to rural presentation and transfer for patients presenting with ruptured abdominal aortic aneurysm in Tasmania. Endovascular repair has a role despite long transfer times. © The Author(s) 2015.

Right ventricular outflow tract aneurysm with thrombus

PubMed Central

Peer, Syed Murfad; Bhat, P.S. Seetharama; Furtado, Arul Dominic; Chikkatur, Raghavendra

2012-01-01

Right ventricular outflow tract (RVOT) aneurysm is a known complication of tetralogy of Fallot repair when a ventriculotomy is done. It leads to RV dysfunction and may require re-operation. We describe a rare instance of a patient who developed an RVOT aneurysm after trans-ventricular repair of tetralogy of Fallot, which was complicated with the formation of a thrombus in the aneurysm sac. The patient underwent re-operation with thrombectomy, excision of the RVOT aneurysm and pulmonary valve replacement. To the best of our knowledge, the occurrence of this combination and its implications have not been reported. PMID:22232231

Perioperative hypothermia (33 degrees C) does not increase the occurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial.

PubMed

Nguyen, Hoang P; Zaroff, Jonathan G; Bayman, Emine O; Gelb, Adrian W; Todd, Michael M; Hindman, Bradley J

2010-08-01

Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

COMBINED REPLACEMENT OF THE AORTIC VALVE AND ASCENDING AORTA IN JEHOVAH'S WITNESSES: REPORT OF TWO CASES

PubMed Central

Beddermann, Christoph; Norman, John C.; Cooley, Denton A.

1979-01-01

Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aortic valve and the ascending aorta. One patient received a composite graft containing an aortic valve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aortic valve and left supracoronary ascending aneurysm replacement, with reimplantation of the right coronary ostium into the graft. No blood or blood derivatives were administered. Both patients had uneventful recoveries and continue to do well. To our knowledge, they represent the first reported cases of successful combined replacement of the aortic valve and ascending aorta in Jehovah's Witnesses. Images PMID:15216324

Advances in open microsurgery for cerebral aneurysms.

PubMed

Davies, Jason M; Lawton, Michael T

2014-02-01

Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. To review specific advances in open microsurgery for aneurysms. A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

Virtual Cerebral Aneurysm Clipping with Real-Time Haptic Force Feedback in Neurosurgical Education.

PubMed

Gmeiner, Matthias; Dirnberger, Johannes; Fenz, Wolfgang; Gollwitzer, Maria; Wurm, Gabriele; Trenkler, Johannes; Gruber, Andreas

2018-04-01

Realistic, safe, and efficient modalities for simulation-based training are highly warranted to enhance the quality of surgical education, and they should be incorporated in resident training. The aim of this study was to develop a patient-specific virtual cerebral aneurysm-clipping simulator with haptic force feedback and real-time deformation of the aneurysm and vessels. A prototype simulator was developed from 2012 to 2016. Evaluation of virtual clipping by blood flow simulation was integrated in this software, and the prototype was evaluated by 18 neurosurgeons. In 4 patients with different medial cerebral artery aneurysms, virtual clipping was performed after real-life surgery, and surgical results were compared regarding clip application, surgical trajectory, and blood flow. After head positioning and craniotomy, bimanual virtual aneurysm clipping with an original forceps was performed. Blood flow simulation demonstrated residual aneurysm filling or branch stenosis. The simulator improved anatomic understanding for 89% of neurosurgeons. Simulation of head positioning and craniotomy was considered realistic by 89% and 94% of users, respectively. Most participants agreed that this simulator should be integrated into neurosurgical education (94%). Our illustrative cases demonstrated that virtual aneurysm surgery was possible using the same trajectory as in real-life cases. Both virtual clipping and blood flow simulation were realistic in broad-based but not calcified aneurysms. Virtual clipping of a calcified aneurysm could be performed using the same surgical trajectory, but not the same clip type. We have successfully developed a virtual aneurysm-clipping simulator. Next, we will prospectively evaluate this device for surgical procedure planning and education. Copyright © 2018 Elsevier Inc. All rights reserved.

Heterogeneous histomorphology, yet homogeneous vascular smooth muscle cell dedifferentiation, characterize human aneurysm disease.

PubMed

Busch, Albert; Hartmann, Elena; Grimm, Caroline; Ergün, Süleyman; Kickuth, Ralph; Otto, Christoph; Kellersmann, Richard; Lorenz, Udo

2017-11-01

Abdominal aortic aneurysm (AAA) is a frequent, potentially life-threatening, disease that can only be treated by surgical means such as open surgery or endovascular repair. No alternative treatment is currently available, and despite expanding knowledge about the pathomechanism, clinical trials on medical aneurysm abrogation have led to inconclusive results. The heterogeneity of human AAA based on histologic examination is thereby generally neglected. In this study we aimed to further elucidate the role of these differences in aneurysm disease. Tissue samples from AAA and popliteal artery aneurysm patients were examined by histomorphologic analysis, immunohistochemistry, Western blot, and polymerase chain reaction. The results were correlated with clinical data such as aneurysm diameter and laboratory results. The morphology of human AAA vessel wall probes varies tremendously based on the grade of inflammation. This correlates with increasing intima/media thickness and upregulation of the vascular endothelial growth factor cascade but not with any clinical parameter or the aneurysm diameter. The phenotypic switch of vascular smooth muscle cells occurred regardless of the inflammatory state and expressional changes of the transcription factors Kruppel-like factor-4 and transforming growth factor-β lead to differential protein localization in aneurysmal compared with control arteries. These changes were in similar manner also observed in samples from popliteal artery aneurysms, which, however, showed a more homogenous phenotype. Heterogeneity of AAA vessel walls based on inflammatory morphology does not correlate with AAA diameter yet harbors specific implications for basic research and possible aneurysm detection. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Endovascular repair of an internal mammary artery aneurysm in a patient with SMAD-3 mutation.

PubMed

Burke, Chris; Shalhub, Sherene; Starnes, Benjamin W

2015-08-01

Aneurysms of the internal mammary artery are rare. We describe a case of a 49-year-old woman with a SMAD3 mutation who presented with left internal mammary artery aneurysm that was thought to have ruptured, causing a large spontaneous left mediastinal hematoma. The aneurysm was treated successfully months after initial presentation with coil embolization. SMAD3 mutations are linked to familial thoracic aortic aneurysms and dissections, peripheral aneurysms, and early-onset osteoarthritis, with an estimated incidence of 2% in families with familial thoracic aortic aneurysms and dissections. To our knowledge, this is the first case in the literature to link a SMAD3 mutation with internal mammary artery aneurysm. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Use of a surgical rehearsal platform and improvement in aneurysm clipping measures: results of a prospective, randomized trial.

PubMed

Chugh, A Jessey; Pace, Jonathan R; Singer, Justin; Tatsuoka, Curtis; Hoffer, Alan; Selman, Warren R; Bambakidis, Nicholas C

2017-03-01

OBJECTIVE The field of neurosurgery is constantly undergoing improvements and advances, both in technique and technology. Cerebrovascular neurosurgery is no exception, with endovascular treatments changing the treatment paradigm. Clipping of aneurysms is still necessary, however, and advances are still being made to improve patient outcomes within the microsurgical treatment of aneurysms. Surgical rehearsal platforms are surgical simulators that offer the opportunity to rehearse a procedure prior to entering the operative suite. This study is designed to determine whether use of a surgical rehearsal platform in aneurysm surgery is helpful in decreasing aneurysm dissection time and clip manipulation of the aneurysm. METHODS The authors conducted a blinded, prospective, randomized study comparing key effort and time variables in aneurysm clip ligation surgery with and without preoperative use of the SuRgical Planner (SRP) surgical rehearsal platform. Initially, 40 patients were randomly assigned to either of two groups: one in which surgery was performed after use of the SRP (SRP group) and one in which surgery was performed without use of the SRP (control group). All operations were videotaped. After exclusion of 6 patients from the SRP group and 9 from the control group, a total of 25 surgical cases were analyzed by a reviewer blinded to group assignment. The videos were analyzed for total microsurgical time, number of clips used, and number of clip placement attempts. Means and standard deviations (SDs) were calculated and compared between groups. RESULTS The mean (± SD) amount of operative time per clip used was 920 ± 770 seconds in the SRP group and 1294 ± 678 seconds in the control group (p = 0.05). In addition, the mean values for the number of clip attempts, total operative time, ratio of clip attempts to clips used, and time per clip attempt were all lower in the SRP group, although the between-group differences were not statistically significant. CONCLUSIONS Preoperative rehearsal with SRP increased efficiency and safety in aneurysm microsurgery as demonstrated by the statistically significant improvement in time per clip used. Although the rest of the outcomes did not demonstrate statistically significant between-group differences, the fact that the SRP group showed improvement in mean values for all measures studied suggests that preoperative rehearsal may increase the efficiency and safety of aneurysm microsurgery. Future studies aimed at improving patient outcome and safety during surgical clipping of aneurysms will be needed to keep pace with the quickly advancing endovascular field.

Risk factors and consequences of unexpected trapping for ruptured anterior communicating artery aneurysms

PubMed Central

Fukuda, Hitoshi; Iwasaki, Koichi; Murao, Kenichi; Yamagata, Sen; Lo, Benjamin W.Y.; Macdonald, R. Loch

2014-01-01

Background: While clipping cerebral aneurysms at the neck is optimal, in some cases this is not possible and other strategies are necessary. The purpose of this study was to describe the incidence, risk factors, and outcomes for inability to clip reconstruct ruptured anterior communicating artery (ACoA) aneurysms. Methods: Of the 70 cases of ruptured ACoA aneurysms between January 2006 and December 2013, our institutional experience revealed four cases of small ACoA aneurysms that had been considered clippable prior to operation but required trapping. When a unilateral A2 segment of anterior cerebral artery (ACA) was compromised by trapping, revascularization was performed by bypass surgery. Clinical presentation, angiographic characteristics, operative approach, intraoperative findings, and treatment outcomes were assessed. Results: Very small aneurysm under 3 mm was a risk factor for unexpected trapping. The reason for unexpected trapping was laceration of the aneurysmal neck in two cases, and lack of clippaple component due to disintegration of entire aneurysmal wall at the time of rupture in the others. Aneurysms with bilateral A1 were treated with sole trapping through pterional approach in two cases. The other two cases had hypoplastic unilateral A1 segment of ACA and were treated with combination of aneurysm trapping and revascularization of A2 segment of ACA through interhemispheric approach. No patients had new cerebral infarctions of cortical ACA territory from surgery. Cognitive dysfunction was observed in three cases, but all patients became independent at 12-month follow up. Conclusions: Unexpected trapping was performed when ruptured ACoA aneurysms were unclippable. Trapping with or without bypass can result in reasonable outcomes, with acceptable risk of cognitive dysfunction. PMID:25101201

Advantages of the L-incision approach comprising a combination of left anterior thoracotomy and upper half-median sternotomy for aortic arch aneurysms.

PubMed

Oishi, Yasuhisa; Sonoda, Hiromichi; Tanoue, Yoshihisa; Nishida, Takahiro; Tokunaga, Shigehiko; Nakashima, Atsuhiro; Shiokawa, Yuichi; Tominaga, Ryuji

2011-09-01

Although surgical outcomes of total arch replacement have improved, the strategy for extended arch aneurysms remains controversial. We have applied the L-incision approach (combination of left anterior thoracotomy and upper half-median sternotomy) for total arch replacement for single-stage repair of extensive arch aneurysms. We retrospectively reviewed the operative outcomes of patients who underwent total arch or extended total arch replacement for degenerative aneurysms from 1999 to 2010. Operations were performed via median sternotomy in 47 patients (M group) and the L-incision approach was used in 38 patients (L group). Through the L-incision approach, we were able to complete distal anastomosis below the pulmonary hilus. The L-incision approach has advantages of reducing selective antegrade cerebral perfusion and lower body circulatory arrest times compared with the M group. Recurrent laryngeal nerve palsy and renal dysfunction were less frequent in the L group than those in the M group. Respiratory dysfunction and wound infection were similar between the groups. Hospital mortalities were 5.3% in the L group and 6.4% in the M group. The L-incision approach has similar or better postoperative outcomes compared with the median sternotomy approach. This approach could be useful for single-stage extended total arch replacement with relatively low risk.

Spondylodiscitis and an aortic aneurysm due to Campylobacter coli

PubMed Central

2010-01-01

Campylobacter coli is a rare cause of bacteremia. We report here the first case of C.coli spondylodiscitis complicated by an aortic aneurysm. Outcome was favourable with surgery and antibiotic therapy. PMID:20132561

Endovascular repair of multiple infrageniculate aneurysms in a patient with vascular type Ehlers-Danlos syndrome.

PubMed

Domenick, Natalie; Cho, Jae S; Abu Hamad, Ghassan; Makaroun, Michel S; Chaer, Rabih A

2011-09-01

Patients with vascular type Ehler-Danlos syndrome can develop aneurysms in unusual locations. We describe the case of a 33-year-old woman with vascular type Ehlers-Danlos syndrome who developed metachronous tibial artery aneurysms that were sequentially treated with endovascular means. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Surgical management of unruptured asymptomatic aneurysms.

PubMed

Samsom, D S; Hodosh, R M; Clark, W K

1977-06-01

The natural history of unruptured asymptomatic aneurysms in nuclear. Because of this uncertainty regarding risk of ultimate enlargement and/or hemorrhage, and in view of the significant mortality and morbidity traditionally involved in aneurysm surgery, clinicans have varied in their advocacy of surgical management of such lesions. Forty-nine consecutive patients harboring 52 such aneurysms were treated surgically over a 57-month period. There were no surgical deaths and morbidity was within acceptable limits. Patient population characteristic and surgical technique are discussed.

Superficial Palmar Arch Aneurysm after Carpal Tunnel Decompression, a Rare Complication: A Case Report

PubMed Central

Gull, S.; Spence, R. A. J.; Loan, W.

2011-01-01

False aneurysms of the palmar arteries are rare. They are usually associated with traumatic injuries to the hand vasculature. We present a case of superficial palmar arch aneurysm (SPAA), complicating carpal tunnel decompression which presented as a pulsatile mass at the site of previous surgery. Initial diagnosis was made on clinical examination and confirmed on doppler ultrasound (US) and computed tomographic angiography (CTA). The feeding vessel of the aneurysm was subsequently occluded using coil embolization. PMID:21547251

Neuronavigated microvascular Doppler sonography for intraoperative monitoring of blood flow velocity changes during aneurysm surgery - a feasible monitoring technique.

PubMed

Malinova, Vesna; von Eckardstein, Kajetan; Rohde, Veit; Mielke, Dorothee

2015-10-01

The intraoperative microvascular Doppler sonography (iMDS) is a well-established tool in vascular surgery for blood flow velocity (BFV) monitoring, capable of detecting vessel occlusion. However, identification of subtotal vessel compromise is more difficult, since the measured BFV may substantially vary with changing insonation angles and insonated vessel segments. To keep these parameters constant we combined neuronavigation with iMDS (niMDS). The question was if niMDS allows the detection of subtotal vessel compromise in aneurysm surgery. During surgery, the 3-dimensional reconstruction of the CT-angiography, which was obtained routinely prior to surgery, was displayed by the neuronavigational system. Prior to clipping, neuronavigation was used to define target point and trajectory, which, by coupling the neuronavigational pointer with the Doppler probe, correspond to the insonated vessel segment and the insonation angle. After clipping, for each vessel segment, the same trajectory was used for all consecutive measurements. The mean BFVs pre- and post-clipping were documented. We performed 82 BFV-measurements in 39 aneurysm surgeries. Mean deviation between pre- and post-clipping BFV values was 2.12cm/s. There was a significant correlation between the mean BFV values before and after clipping (r=0.45 [95% CI 17-66%]; p=0.002). One patient experienced new neurological deficits due to occlusion of a perforating vessel that was not insonated. The study could not answer the question if niMDS can detect BFV changes after clipping indicating vessel compromise, as no subtotal vessel occlusion occurred in the 39 operations. However, we proofed that niMDS-measured BFVs only varied minimally in uncompromised vessels pre- and post-clipping, suggesting that vessel compromises might be easily detected during aneurysm surgery. Copyright © 2015 Elsevier B.V. All rights reserved.

Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study.

PubMed

Chung, Joonho; Seok, Jeong-Ho; Kwon, Min A; Kim, Yong Bae; Joo, Jin-Yang; Hong, Chang-Ki

2016-01-01

We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.

Endovascular Treatment of Splenic Artery Aneurysm With a Stent-Graft: A Case Report.

PubMed

Guang, Li-Jun; Wang, Jian-Feng; Wei, Bao-Jie; Gao, Kun; Huang, Qiang; Zhai, Ren-You

2015-12-01

Splenic artery aneurysm, one of the most common visceral aneurysms, accounts for 60% of all visceral aneurysm cases. Open surgery is the traditional treatment for splenic artery aneurysm but has the disadvantages of serious surgical injuries, a high risk of complications, and a high mortality rate.We report a case who was presented with splenic artery aneurysm. A 54-year-old woman complained of upper left abdominal pain for 6 months. An enhanced computed tomography scan of the upper abdomen indicated the presence of splenic artery aneurysm. The splenic artery aneurysm was located under digital subtraction angiography and a 6/60 mm stent graft was delivered and released to cover the aneurysm. An enhanced computed tomography scan showed that the splenic artery aneurysm remained well separated, the stent graft shape was normal, and the blood flow was unobstructed after 1 year.This case indicates a satisfactory efficacy proving the minimal invasiveness of stent graft exclusion treatment for splenic artery aneurysm.

Epidemiology and outcome of aortic aneurysms in Hong Kong.

PubMed

Cheng, Stephen W K; Ting, Albert C W; Tsang, Simon H Y

2003-02-01

The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4-24%) and 70% (range 38--100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.

Retrievable Stent-Assisted Coiling Technique Using a Solitaire Stent: Treatment of Pancreaticoduodenal Artery Aneurysm Associated With Celiac Artery Occlusion.

PubMed

Sanal, Bekir; Nas, Omer Fatih; Hacikurt, Kadir; Hakyemez, Bahattin; Erdogan, Cuneyt

2016-02-01

True aneurysm of pancreaticoduodenal arcade (PDA) is usually accompanied by stenosis or occlusion of celiac trunk (CeT). The up-to-date and first choice treatment modality of PDA aneurysm is the endovascular approach in nearly all cases except few selected ones necessitating surgery. The main approach in endovascular treatment is embolization of the aneurysm by preserving the parent artery. A case with concomitant CeT occlusion and PDA aneurysm was treated with coil embolization by preserving inferior pancreaticoduodenal artery with retrievable Solitaire(®) stent. In our knowledge, this is the first case with PDA aneurysm treated with this technique. © The Author(s) 2016.

Ascending aortic aneurysm causing hoarse voice: a variant of Ortner's syndrome

PubMed Central

Eccles, Sinan Robert; Banks, John; Kumar, Pankaj

2012-01-01

A 68-year-old man with a persistent hoarse voice was found to have a left vocal cord paralysis. Clinical examination revealed signs consistent with aortic regurgitation. Subsequent investigation revealed an ascending aortic aneurysm. He underwent aortic root and ascending aorta replacement and his hoarseness improved. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Recurrent laryngeal nerve palsy due to aneurysmal dilation of the ascending aorta is extremely rare, with aneurysms of the aortic arch being a more common cause. PMID:23060380

Application of Micromirror in Microsurgical Clipping to the Intracranial Aneurysms.

PubMed

Zhao, Chao; Ma, Zhiguo; Zhang, Yuhai; Mou, Shanling; Yang, Yunxue; Yang, Yonglin; Sun, Guoqing; Yao, Weicheng

2018-05-01

The aim of the study was to explore the values and disadvantages of micromirror in the intracranial aneurysm clipping surgery. Micromirror was used to assist microsurgical clipping to 36 intracranial aneurysms in 31 patients, of which 3 were carotid-ophthalmic artery aneurysms, 3 were anterior choroidal artery aneurysms, 11 were posterior communicating artery aneurysms, 7 were middle cerebral artery aneurysms, 10 were anterior communicating artery or anterior cerebral artery aneurysms, and the rest were a posterior cerebral artery aneurysm and a posterior inferior cerebellar artery aneurysm. The micromirror was used before and after clipping to observe the anatomic features of necks hidden behind and medial to aneurysms, to visualize surrounding neurovascular structures, and to verify the optimal clipping position. Intraoperative indocyanine green fluorescein angiography, postoperative computerized tomography angiography, and digital subtraction angiography confirmed the success of sufficient clipping. Intraoperative indocyanine green angiography, postoperative computerized tomography angiography , or digital subtraction angiography were performed and showed no case of wrong or insufficient clipping of aneurysm. Micromirror-assisted microsurgical clipping to the intracranial aneurysm is safe, sufficient, convenient, and practical.

Coil Embolization of Pancreaticoduodenal Artery Aneurysms Associated with Celiac Artery Stenosis: Report of Three Cases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ikeda, Osamu, E-mail: osamu-3643ik@do9.enjoy.ne.jp; Tamura, Yoshitaka; Nakasone, Yutaka

2007-06-15

Aneurysms of the pancreaticoduodenal artery are rare. Degeneration of pancreaticoduodenal arcade vessels due to these aneurysms is associated with celiac artery stenosis or occlusion. Untreated lesions enlarge progressively and may rupture spontaneously. As the location of aneurysms of pancreaticoduodenal arcade vessels renders their surgical extirpation a challenge, we examined whether endovascular techniques offer a treatment alternative. We report on 3 patients with aneurysms of the pancreaticoduodenal arcade vessels and concomitant celiac artery stenosis/occlusion due to compression by the median arcuate ligament or chronic pancreatitis. All patients were treated by percutaneous coil embolization of the aneurysm. The aneurysmal sac was successfullymore » excluded and the native circulation was preserved. Endovascular surgery can be used to treat these aneurysms safely and permits retention of the native circulation.« less

Microsurgical Treatment of Distal Anterior Cerebral Artery Aneurysms: 3-Dimensional Operative Video.

PubMed

Agarwal, Vijay; Barrow, Daniel L

2018-05-18

Selecting appropriate patient position for surgery must take into consideration a variety of factors. For an interhemispheric approach to distal anterior cerebral artery (DACA) aneurysms, the patient may be positioned with the head either horizontal or vertical with respect to the floor. We preferentially place the patient in the supine position with the shoulder elevated and the head turned parallel to the floor with the side of the approach down and the vertex tilted 45° up. In this way, gravity is utilized to allow the right frontal lobe to fall away from the falx, eliminating the need for retraction. To demonstrate the importance of individualizing the choice of position to each patient, we present here 2 illustrative cases of DACA aneurysms in which different positioning was selected. One patient presented with a 7-mm bilobed pericallosal artery aneurysm; the aneurysm was approached with the head horizontal with respect to the floor. The second patient had a 3-mm DACA aneurysm and a right frontal proliferative angiopathy and developmental venous anomaly with evidence of prior hemorrhage. Due to the vascular anomaly, we positioned the head in a vertical position for surgery to clip the aneurysm, which was thought to be the source of hemorrhage. The videos illustrate the approach to DACA aneurysms, which typically exposes the aneurysm before complete exposure of the proximal parent artery is obtained. In one case, the use of both frameless guidance and intraoperative angiography was useful in identifying a small previously ruptured aneurysm. All appropriate patient consents were obtained for this submission. Video and Figures (0:57-1:16 and 6:30-6:37), © 2017 Department of Neurosurgery, Emory University. Used with permission.

Formation and Rupture of the Internal Carotid Artery Aneurysm after Multiple Courses of Intensity-Modulated Radiation Therapy for Management of the Skull Base Ewing Sarcoma/PNET: Case Report.

PubMed

Tamura, Manabu; Kogo, Kasei; Masuo, Osamu; Oura, Yoshinori; Matsumoto, Hiroyuki; Fujita, Koji; Nakao, Naoyuki; Uematsu, Yuji; Itakura, Toru; Chernov, Mikhail; Hayashi, Motohiro; Muragaki, Yoshihiro; Iseki, Hiroshi

2013-12-01

Background Aneurysm formation after stereotactic irradiation of skull base tumors is rare. The formation and rupture of an internal carotid artery (ICA) aneurysm in a patient with skull base Ewing sarcoma/primitive neuroectodermal tumor (PNET), who underwent surgery followed by multiple courses of intensity-modulated radiation therapy (IMRT) and chemotherapy, is described. Case Description A 25-year-old man presented with a sinonasal tumor with intraorbital and intracranial growth. At that time cerebral angiography did not reveal any vascular abnormalities. The lesion was resected subtotally. Histopathologic diagnosis was Ewing sarcoma/PNET. The patient underwent multiple courses of chemotherapy and three courses of IMRT at 3, 28, and 42 months after initial surgery. The total biologically effective dose delivered to the right ICA was 220.2 Gy. Seven months after the third IMRT, the patient experienced profound nasal bleeding that resulted in hypovolemic shock. Angiography revealed a ruptured right C4-C5 aneurysm and irregular stenotic changes of the ICA. Lifesaving endovascular trapping of the right ICA was done. The patient recovered well after surgery but died due to tumor recurrence 6 months later. Conclusion Excessive irradiation of the ICA may occasionally result in aneurysm formation, which should be borne in mind during stereotactic irradiation of malignant skull base tumors.

Training in Cerebral Aneurysm Clipping Using Self-Made 3-Dimensional Models.

PubMed

Mashiko, Toshihiro; Kaneko, Naoki; Konno, Takehiko; Otani, Keisuke; Nagayama, Rie; Watanabe, Eiju

Recently, there have been increasingly fewer opportunities for junior surgeons to receive on-the-job training. Therefore, we created custom-built three-dimensional (3D) surgical simulators for training in connection with cerebral aneurysm clipping. Three patient-specific models were composed of a trimmed skull, retractable brain, and a hollow elastic aneurysm with its parent artery. The brain models were created using 3D printers via a casting technique. The artery models were made by 3D printing and a lost-wax technique. Four residents and 2 junior neurosurgeons attended the training courses. The trainees retracted the brain, observed the parent arteries and aneurysmal neck, selected the clip(s), and clipped the neck of an aneurysm. The duration of simulation was recorded. A senior neurosurgeon then assessed the trainee's technical skill and explained how to improve his/her performance for the procedure using a video of the actual surgery. Subsequently, the trainee attempted the clipping simulation again, using the same model. After the course, the senior neurosurgeon assessed each trainee's technical skill. The trainee critiqued the usefulness of the model and the effectiveness of the training course. Trainees succeeded in performing the simulation in line with an actual surgery. Their skills tended to improve upon completion of the training. These simulation models are easy to create, and we believe that they are very useful for training junior neurosurgeons in the surgical techniques needed for cerebral aneurysm clipping. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A splenic artery aneurysm presenting with multiple episodes of upper gastrointestinal bleeding: a case report.

PubMed

De Silva, W S L; Gamlaksha, D S; Jayasekara, D P; Rajamanthri, S D

2017-05-03

Splenic artery aneurysm is rare and its diagnosis is challenging due to the nonspecific nature of the clinical presentation. We report a case of a splenic artery aneurysm in which the patient presented with chronic dyspepsia and multiple episodes of minor intragastric bleeding. A 60-year-old, previously healthy Sri Lankan man presented with four episodes of hematemesis and severe dyspeptic symptoms over a period of 6 months. The results of two initial upper gastrointestinal endoscopies and an abdominal ultrasound scan were unremarkable. A third upper gastrointestinal endoscopy detected a pulsatile bulge at the posterior wall of the gastric antrum. A contrast-enhanced computed tomogram of his abdomen detected a splenic artery aneurysm measuring 3 × 3 × 2.5 cm. While awaiting routine surgery, he developed a torrential upper gastrointestinal bleeding and shock, leading to emergency laparotomy. Splenectomy and en bloc resection of the aneurysm with the posterior stomach wall were performed. Histology revealed evidence for a true aneurysm without overt, acute, or chronic inflammation of the surrounding gastric mucosa. He became completely asymptomatic 2 weeks after the surgery. Splenic artery aneurysms can result in recurrent upper gastrointestinal bleeding. The possibility of impending catastrophic bleeding should be remembered when managing patients with splenic artery aneurysms after a minor bleeding. Negative endoscopy and ultrasonography should require contrast-enhanced computed tomography to look for the cause of recurrent upper gastrointestinal bleeding.

The impact of changing intracranial aneurysm practice on the education of cerebrovascular neurosurgeons.

PubMed

Lai, Leon; Morgan, Michael Kerin

2012-01-01

Endovascular repair of intracranial aneurysms has transformed the practice of cerebrovascular surgery. We reviewed the National Hospital Morbidity Database in Australia for the years 2000 to 2008 and investigated the changing trends of aneurysm practice. During this period 7,503 craniotomies for aneurysm repair and 7,863 endovascular coiling procedures were performed. The number of aneurysm procedures performed surgically reduced from 9 cases per neurosurgeon per year to 4.2 cases, a reduction of 53.3%. The number of endovascular treatments increased 2.1 fold, from 3.6 aneurysms per neurosurgeon in 2000 to 7.5 in 2008. The implications of reduced numbers of surgically treated aneurysms were considered for the education of cerebrovascular neurosurgeons in Australia. Copyright © 2011 Elsevier Ltd. All rights reserved.

Robotic aortic surgery.

PubMed

Duran, Cassidy; Kashef, Elika; El-Sayed, Hosam F; Bismuth, Jean

2011-01-01

Surgical robotics was first utilized to facilitate neurosurgical biopsies in 1985, and it has since found application in orthopedics, urology, gynecology, and cardiothoracic, general, and vascular surgery. Surgical assistance systems provide intelligent, versatile tools that augment the physician's ability to treat patients by eliminating hand tremor and enabling dexterous operation inside the patient's body. Surgical robotics systems have enabled surgeons to treat otherwise untreatable conditions while also reducing morbidity and error rates, shortening operative times, reducing radiation exposure, and improving overall workflow. These capabilities have begun to be realized in two important realms of aortic vascular surgery, namely, flexible robotics for exclusion of complex aortic aneurysms using branched endografts, and robot-assisted laparoscopic aortic surgery for occlusive and aneurysmal disease.

Intracranial aneurysm and arachnoid cyst: just a coincidence? A case report.

PubMed

Aguiar, Guilherme Brasileiro de; Santos, Rafael Gomes Dos; Paiva, Aline Lariessy Campos; Silva, João Miguel de Almeida; Silva, Rafael Carlos da; Veiga, José Carlos Esteves

2017-12-18

Presence of an arachnoid cyst and a non-ruptured intracystic brain aneurysm is extremely rare. The aim of this paper was to describe a case of a patient with an arachnoid cyst and a non-ruptured aneurysm inside it. Clinical, surgical and radiological data were analyzed and the literature was reviewed. A patient complained of chronic headache. She was diagnosed as having a temporal arachnoid cyst and a non-ruptured middle cerebral artery aneurysm inside it. Surgery was performed to clip the aneurysm and fenestrate the cyst. This report raises awareness about the importance of intracranial vascular investigation in patients with arachnoid cysts and brain hemorrhage.

Surgical and medical management of extracranial carotid artery aneurysms.

PubMed

Fankhauser, Grant T; Stone, William M; Fowl, Richard J; O'Donnell, Mark E; Bower, Thomas C; Meyer, Fredric B; Money, Samuel R

2015-02-01

Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Subclavian artery aneurysm in a patient with vascular Ehlers-Danlos syndrome.

PubMed

Yasuda, Shota; Imoto, Kiyotaka; Uchida, Keiji; Uranaka, Yasuko; Kurosawa, Kenji; Masuda, Munetaka

2016-02-01

We describe our experience of surgical treatment in a 28-year-old woman with vascular Ehlers-Danlos syndrome. A right subclavian artery aneurysm was detected. The right vertebral artery arose from the aneurysm. Digital subtraction angiography showed interruption of the left vertebral artery. The aneurysm was excised and the right vertebral artery was anastomosed end-to-side to the right common carotid artery under deep hypothermia and circulatory arrest. The patient remained very well 4 years after surgery, with no late vascular complication. © The Author(s) 2014.

Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group.

PubMed

Silver, A; Eichorn, A; Kral, J; Pickett, G; Barie, P; Pryor, V; Dearie, M B

1996-06-01

Twenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administration's Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State. IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively. Eighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis. Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

Ross procedure for ascending aortic replacement.

PubMed

Elkins, R C; Lane, M M; McCue, C

1999-06-01

Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.

Diagnosing aneurysmal and unicameral bone cysts with magnetic resonance imaging.

PubMed

Sullivan, R J; Meyer, J S; Dormans, J P; Davidson, R S

1999-09-01

The differential between aneurysmal bone cysts and unicameral bone cysts usually is clear clinically and radiographically. Occasionally there are cases in which the diagnosis is not clear. Because natural history and treatment are different, the ability to distinguish between these two entities before surgery is important. The authors reviewed, in a blinded fashion, the preoperative magnetic resonance images to investigate criteria that could be used to differentiate between the two lesions. All patients had operative or pathologic confirmation of an aneurysmal bone cyst or unicameral bone cyst. The authors analyzed the preoperative magnetic resonance images of 14 patients with diagnostically difficult bone cysts (eight children with unicameral bone cysts and six children with aneurysmal bone cysts) and correlated these findings with diagnosis after biopsy or cyst aspiration and contrast injection. The presence of a double density fluid level within the lesion strongly indicated that the lesion was an aneurysmal bone cyst, rather than a unicameral bone cyst. Other criteria that suggested the lesion was an aneurysmal bone cyst were the presence of septations within the lesion and signal characteristics of low intensity on T1 images and high intensity on T2 images. The authors identified a way of helping to differentiate between aneurysmal bone cysts and unicameral bone cysts on magnetic resonance images. Double density fluid level, septation, and low signal on T1 images and high signal on T2 images strongly suggest the bone cyst in question is an aneurysmal bone cyst, rather than a unicameral bone cyst. This may be helpful before surgery for the child who has a cystic lesion for which radiographic features do not allow a clear differentiation of unicameral bone cyst from aneurysmal bone cyst.

Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm.

PubMed

Moreno, Daniel H; Cacione, Daniel G; Baptista-Silva, Jose C C

2016-05-13

An abdominal aortic aneurysm (AAA) is the pathological enlargement of the aorta and can develop in both men and women. Progressive aneurysm enlargement can lead to rupture. The rupture of an AAA is frequently fatal and accounts for the death from haemorrhagic shock of at least 45 people per 100,000 population. The outcome of people with ruptured AAA varies among countries and healthcare systems, with mortality ranging from 53% to 90%. Definitive treatment for ruptured AAA includes open surgery or endovascular repair. The management of haemorrhagic shock is crucial for the person's outcome and aims to restore organ perfusion and systolic blood pressure above 100 mm Hg through immediate and aggressive fluid replacement. This rapid fluid replacement is known as the normotensive resuscitation strategy. However, evidence suggests that infusing large volumes of cold fluid causes dilutional and hypothermic coagulopathy. The association of these factors may exacerbate bleeding, resulting in a 'lethal triad' of hypothermia, acidaemia, and coagulopathy. An alternative to the normotensive resuscitation strategy is the controlled (permissive) hypotension resuscitation strategy, with a target systolic blood pressure of 50 to 100 mm Hg. The principle of controlled or hypotensive resuscitation has been used in some management protocols for endovascular repair of ruptured AAA. It may be beneficial in preventing blood loss by avoiding the clot disruption caused by the rapid increase in systolic blood pressure; avoiding dilution of clotting factors, platelets and fibrinogen; and by avoiding the temperature decrease that inhibits enzyme activity involved in platelet and clotting factor function. To compare the effects of controlled (permissive) hypotension resuscitation and normotensive resuscitation strategies for people with ruptured AAA. The Cochrane Vascular Information Specialist searched the Specialised Register (April 2016) and the Cochrane Register of Studies (CENTRAL (2016, Issue 3)). Clinical trials databases were searched (April 2016) for details of ongoing or unpublished studies. We sought all published and unpublished randomised controlled trial (RCTs) that compared controlled hypotension and normotensive resuscitation strategies for the management of shock in patients with ruptured abdominal aortic aneurysms. Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. We identified no RCTs that met the inclusion criteria. We found no RCTs that compared controlled hypotension and normotensive resuscitation strategies in the management of haemorrhagic shock in patients with ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and renal failure. High quality studies that evaluate the best strategy for managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required.

Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm.

PubMed

Moreno, Daniel H; Cacione, Daniel G; Baptista-Silva, Jose Cc

2018-06-13

An abdominal aortic aneurysm (AAA) is the pathological enlargement of the aorta and can develop in both men and women. Progressive aneurysm enlargement can lead to rupture. The rupture of an AAA is frequently fatal and accounts for the death from haemorrhagic shock of at least 45 people per 100,000 population. The outcome of people with ruptured AAA varies among countries and healthcare systems, with mortality ranging from 53% to 90%. Definitive treatment for ruptured AAA includes open surgery or endovascular repair. The management of haemorrhagic shock is crucial for the person's outcome and aims to restore organ perfusion and systolic blood pressure above 100 mmHg through immediate and aggressive fluid replacement. This rapid fluid replacement is known as the normotensive resuscitation strategy. However, evidence suggests that infusing large volumes of cold fluid causes dilutional and hypothermic coagulopathy. The association of these factors may exacerbate bleeding, resulting in a 'lethal triad' of hypothermia, acidaemia, and coagulopathy. An alternative to the normotensive resuscitation strategy is the controlled (permissive) hypotension resuscitation strategy, with a target systolic blood pressure of 50 mmHg to 100 mmHg. The principle of controlled or hypotensive resuscitation has been used in some management protocols for endovascular repair of ruptured AAA. It may be beneficial in preventing blood loss by avoiding the clot disruption caused by the rapid increase in systolic blood pressure; avoiding dilution of clotting factors, platelets and fibrinogen; and by avoiding the temperature decrease that inhibits enzyme activity involved in platelet and clotting factor function. This is an update of a review first published in 2016. To compare the effects of controlled (permissive) hypotension resuscitation and normotensive resuscitation strategies for people with ruptured AAA. The Cochrane Vascular Information Specialist searched the Specialised Register (August 2017), the Cochrane Register of Studies (CENTRAL (2017, Issue 7)) and EMBASE (August 2017). The Cochrane Vascular Information Specialist also searched clinical trials databases (August 2017) for details of ongoing or unpublished studies. We sought all published and unpublished randomised controlled trial (RCTs) that compared controlled hypotension and normotensive resuscitation strategies for the management of shock in patients with ruptured abdominal aortic aneurysms. Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. We identified no RCTs that met the inclusion criteria. We found no RCTs that compared controlled hypotension and normotensive resuscitation strategies in the management of haemorrhagic shock in patients with ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and renal failure. High quality studies that evaluate the best strategy for managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required.

How to Perfuse: Concepts of Cerebral Protection during Arch Replacement

PubMed Central

Habertheuer, Andreas; Wiedemann, Dominik; Kocher, Alfred; Laufer, Guenther; Vallabhajosyula, Prashanth

2015-01-01

Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data. PMID:26713319

Management of a Fulminant Upper Gastrointestinal Bleeding Exteriorized Through Hemobilia Due to Arteriobiliary Fistula Between the Common Bile Duct and a Right Hepatic Artery Aneurysm – A Case Report

PubMed Central

BACALBASA, NICOLAE; BREZEAN, IULIAN; ANGHEL, CLAUDIU; BARBU, ION; PAUTOV, MIHAI; BALESCU, IRINA; BRASOVEANU, VLADISLAV

2017-01-01

Right hepatic artery aneurysms are rare events that might remain asymptomatic for a long period of time. However, in cases presenting large lesions, symptoms might develop especially due to the association of compression of the surrounding elements. Most often these symptoms and signs include diffuse abdominal pain, jaundice or portal vein compression signs. In rare cases life-threatening complications might develop due to the aneurysmal erosion of the biliary duct, portal vein or due to the aneurysmal rupture in the peritoneal cavity. In all these cases emergency surgery is imposed. We present the case of a 66-year-old patient diagnosed with a partially thrombosed right hepatic artery aneurysm compressing the common bile duct who was initially submitted to a percutaneous arterial embolization of the aneurysm in association with an external biliary drainage; three weeks later the patient presented a fulminant upper gastrointestinal bleeding exteriorized through the external biliary drainage, hematemesis and hematochezia. The patient was successfully submitted to surgery, intraoperatively a synchronous rupture of the portal vein being revealed. The right hepatic artery aneurysm was resected en bloc with common bile duct resection and segmental portal vein resection. The continuity of the portal vein was re-established through the interposition of a cadaveric allograft, the common bile duct was anastomosed with en Roux en Y limb while the right hepatic artery aneurysm was ligated and resected, the arterial vascularization of the liver being provided by the left hepatic artery. PMID:28882970

Recovery of cognitive function after surgery for aneurysmal subarachnoid hemorrhage.

PubMed

Samra, Satwant K; Giordani, Bruno; Caveney, Angela F; Clarke, William R; Scott, Phillip A; Anderson, Steven; Thompson, Byron G; Todd, Michael M

2007-06-01

Abnormalities in neurocognitive function are common after surgery for aneurysmal subarachnoid hemorrhage, even among patients with good functional outcomes. The time course of neurocognitive recovery, along with the long-term effects of mild intraoperative hypothermia (33 degrees C) and aneurysm location, is unknown. We determined these in a subset of subarachnoid hemorrhage patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST). We performed a longitudinal, multicenter, prospective, blinded study of adult IHAST patients with a Glasgow Outcome Score=1 or 2 (independent function), 3 months postsurgery and a matched control group (n=45). Subjects were tested with a 5-test cognitive function battery and standard neurological evaluations at 3, 9 and 15 months postsurgery. The primary outcome measure was a composite score on cognitive test performance. There were 303 IHAST patients available for inclusion: 218 eligible, 185 enrolled (89 hypothermic, 96 normothermic). Significant cognitive improvement was noted from 3 to 9 (P<0.001) and 3 to 15 (P<0.001) months in both hypothermic and normothermic groups, even after adjusting for practice effects observed in the control group. No significant change was identified between 9 and 15 months. Neither mild hypothermia nor aneurysm location (anterior communicating artery versus others) had a significant effect on recovery over time or frequency of cognitive impairment. Compared with control group, the frequency of cognitive impairment (Z score <-1.96) in all patients at 3, 9 and 15 months was 36%, 26% and 23%, respectively. In this population, cognitive improvement continued beyond 3 months, with a plateau between 9 and 15 months. This was not affected by the use of intraoperative hypothermia or anatomical location of aneurysm.

Evolution of Management of Intracranial Aneurysms in Children: A Systematic Review of the Modern Literature.

PubMed

Beez, Thomas; Steiger, Hans-Jakob; Hänggi, Daniel

2016-05-01

Pediatric intracranial aneurysms are rare. Management of their more common adult counterparts was profoundly influenced by recent high-quality clinical studies. The aim of this review was to aggregate the modern pediatric data published in the wake of these studies and to analyze their impact on management of aneurysms in children. A systematic PubMed search identified 135 publications published between 2000 and 2015, accounting for 573 children and 656 aneurysms. Descriptive statistical analyses revealed differences between children and adults concerning demographics and aneurysm characteristics. A significant proportion of patients were treated endovascularly, suggesting endovascular treatment has been established in the therapeutic armamentarium for pediatric aneurysms. However, these data highlight the unique nature of pediatric aneurysms, and neither this review nor generalization from adult data can replace high-quality clinical research. Multicenter registries and controlled trials are required to establish the natural history and evidence-based treatment of pediatric aneurysms. © The Author(s) 2015.

Associations of Age and Sex with Marfan Phenotype: The NHLBI GenTAC Registry

PubMed Central

Roman, Mary J.; Devereux, Richard B.; Preiss, Liliana R.; Asch, Federico M.; Eagle, Kim A.; Holmes, Kathryn W.; LeMaire, Scott A.; Maslen, Cheryl L.; Milewicz, Dianna M.; Morris, Shaine A.; Prakash, Siddharth K.; Pyeritz, Reed E.; Ravekes, William J.; Shohet, Ralph V.; Song, Howard K.; Weinsaft, Jonathan W.

2017-01-01

Background The associations of age and sex with phenotypic features of Marfan syndrome have not been systematically examined in a large cohort of both children and adults. Methods and Results We evaluated 789 Marfan patients enrolled in the NHLBI GenTAC Registry (53% male; mean age 31 [range: 1–86 years]). Females aged≥15 and males aged≥16 years were considered adults based on average age of skeletal maturity. Adults (n=606) were more likely than children (n=183) likely to have spontaneous pneumothorax, scoliosis, and striae, but were comparable in revised Ghent systemic score, ectopia lentis, and most phenotypic features, including prevalence of aortic root dilatation. Prophylactic aortic root replacement and mitral valve surgery were rare during childhood vs. adulthood (2 vs. 35% and 1 vs. 9%, respectively, both p<0.0001). Adult males were more likely than females to have aortic root dilatation (92 vs. 84%), aortic regurgitation (55 vs. 36%) and to have undergone prophylactic aortic root replacement (47 vs. 24%), all p<0.001. Prevalence of prior aortic dissection tended to be higher in males than females (25 vs. 18%, p=0.06); 44% of dissections were type B. Type B dissection was strongly associated with previous prophylactic aortic root replacement. Conclusions Pulmonary, skeletal and aortic complications, but not other phenotypic features, are more prevalent in adults than children in Marfan syndrome. Aortic aneurysms and prophylactic aortic surgery are more common in men. Aortic dissection, commonly type B, occurs in an appreciable proportion of Marfan patients, especially in men and following previous prophylactic aortic root replacement. PMID:28600386

Disseminated aspergillosis in an immunocompetent patient with detectable bis(methylthio)gliotoxin and negative galactomannan.

PubMed

Vidal-García, Matxalen; Sánchez-Chueca, Pilar; Domingo, María Pilar; Ballester, Carlos; Roc, Lourdes; Ferrer, Isabel; Revillo, María José; Pardo, Julián; Gálvez, Eva María; Rezusta, Antonio

Disseminated invasive aspergillosis is an exceptional finding in immunocompetent hosts. As in immunocompromised patients, it has high mortality rates. Early diagnostic methods are required in order to properly manage the patient. Bis(methylthio)gliotoxin (bmGT) is a novel biomarker, useful in onco-hematological patients. A 70-year-old male, with non-insulin dependent type II diabetes mellitus and a past surgery history of aortic valve replacement with coronary by-pass five years ago, was seen in the emergency department with blurred vision. Three days later, endogen endophthalmitis was diagnosed in the ophthalmology clinic. During admission for the vitrectomy, he suffered an ischemia of the right lower limb. A thoracic computed tomography revealed a mycotic aneurysm of the ascending thoracic aorta and parietal thrombus. The ascending aorta was replaced and abundant brittle material of infectious appearance, found between the aortic valve graft and the aneurysm, was removed. Aspergillus fumigatus sensu stricto grew in both vitreous and aorta cultures. BmGT was detected in two serum samples obtained prior to intravenous antifungal treatment, which was then reduced after voriconazole treatment was started. Disseminated invasive aspergillosis is a severe disease regardless of the immune status of the patient. This case report suggests that bmGT could be a suitable early diagnostic biomarker, not only in neutropenic patients, but also in immunocompetent hosts. Copyright © 2016 Asociación Española de Micología. Publicado por Elsevier España, S.L.U. All rights reserved.

Abdominal aortic aneurysm with periaortic malignant lymphoma differentiated from aneurysmal rupture by clinical presentation and magnetic resonance imaging.

PubMed

Kamata, Sokichi; Itou, Yoshito; Idoguchi, Koji; Imakita, Masami; Funatsu, Toshihiro; Yagihara, Toshikatsu

2018-06-01

Abdominal aortic aneurysm (AAA) associated with periaortic malignant lymphoma is difficult to differentiate from aneurysmal rupture because of similarities in their clinical presentation and appearance on computed tomography images. We here report a case of AAA associated with periaortic malignant lymphoma diagnosed preoperatively with an absence of typical symptoms, showing that AAA in periaortic malignant lymphoma can present without any clinical correlates. Magnetic resonance imaging was used to confirm the diagnosis. The patient was treated by endovascular repair, which may be safer and more effective than open surgery for AAA associated with malignant lymphoma because of the tight adhesion between the aneurysm and the lymphoid tissue.

Innovative Chimney-Graft Technique for Endovascular Repair of a Pararenal Abdominal Aortic Aneurysm

PubMed Central

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A.

2015-01-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta. PMID:25873796

Innovative chimney-graft technique for endovascular repair of a pararenal abdominal aortic aneurysm.

PubMed

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A; Krajcer, Zvonimir

2015-02-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta.

[Case of neuroleptic malignant syndrome following open heart surgery for thoracic aortic aneurysm with parkinson's disease].

PubMed

Shinoda, Maiko; Sakamoto, Mik; Shindo, Yuki; Ando, Yumi; Tateda, Takeshi

2013-12-01

An 80-year-old woman with Parkinson's disease was scheduled for open heart surgery to repair thoracic aortic aneurysm. Parkinson's symptoms were normally treated using oral levodopa (200 mg), selegiline-hydrochloride (5 mg), bromocriptine-mesilate (2 mg), and amantadine-hydrochloride (200 mg) daily. On the day before surgery, levodopa 50mg was infused intravenously. Another 25 mg of levodopa was infused immediately after surgery. Twenty hours later, the patient developed tremors, heyperventilation, but no obvious muscle rigidity. Two days after surgery, the patient exhibited high fever, hydropoiesis, elevated creatine kinase, and a rise in blood leukocytes. She was diagnosed with neuroleptic malignant syndrome. She was intubated, and received dantrolene sodium. Symptoms of neuroleptic malignant syndrome disappeared on the fourth postoperative day. The stress of open heart surgery, specifically extracorporeal circulation and concomitant dilution of levodopa, triggered neuroleptic malignant syndrome in this patient. Parkinson's patients require higher doses of levodopa prior to surgery to compensate and prevent neuroleptic malignant syndrome after surgery.

[False traumatic aneurysm of the ulnar artery in a teenager].

PubMed

Nour, M; Talha, H; El Idrissi, R; Lahraoui, Y; Ouazzani, L; Oubejja, H; Erraji, M; Zerhouni, H; Ettayebi, F

2014-12-01

Most aneurysms of hand arteries are traumatic. It is a generally rare unrecognized pathology. Complications are serious (embolism and thromboses of interdigital arteries). Two main causes can be recalled: acute trauma, with development of a false aneurysm; repeated microtrauma (hand hammer syndrome), with occurrence of an arterial dysplasic aneurysm. The diagnosis is based on the presence of a pulsatile mass, with finger dysesthesia, unilateral Raynaud's phenomenon. It is confirmed by duplex Doppler. Arteriography is necessary but can be replaced by an angio-MR. We report a case of false traumatic aneurysm of the ulnar artery in a teenager. This case illustrates this rare condition and opens discussion on therapeutic options. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

The nature of thrombosis induced by platinum and tungsten coils in saccular aneurysms.

PubMed

Byrne, J V; Hope, J K; Hubbard, N; Morris, J H

1997-01-01

To compare the efficacy and biocompatability of electrolytic and mechanically detachable embolization coils of two metal types. Experimental saccular aneurysms in pigs were used to assess embolization induced by platinum or tungsten coils. Longitudinal angiographic and histologic studies were performed on treated and untreated (control) aneurysms to compare thrombosis and cellular responses after embolization with electrolytically detachable platinum coils and with mechanically detached tungsten coils. Fewer tungsten than platinum coils were needed to induce thrombosis. The inflammatory response within the aneurysmal lumen was more florid in embolized aneurysms than in control aneurysms. No difference was found in the timing or extent of accumulation of eosinophils, lymphocytes, or polymorphs between the two coils used. Giant cell responses were more marked in treated aneurysms; tungsten coils more than platinum coils. The amount of collagen and fibrosis present increased over the study period and was similar in treated and control aneurysms. The coil type influenced the initial cellular response but had little effect on the rate or degree to which blood clot within the aneurysm was replaced by fibrous tissue.

Ruptured intracranial aneurysms: the outcome of surgical treatment in experienced hands in the period prior to the advent of endovascular coiling

PubMed Central

Lafuente, J; Maurice-Williams, R

2003-01-01

Objectives: To evaluate the results of treatment of patients with a ruptured intracranial aneurysm treated by a single experienced vascular neurosurgeon in the period prior to the introduction of endovascular coiling. Methods: Over a mean (SD) period of 9 (2) years, between January 1990 and June 1999, 245 consecutive patients with ruptured intracranial aneurysms were treated. Patients' details were obtained from a database that had been constructed prospectively. The patients consisted of all those patients treated by the senior author (Mr Maurice-Williams) over this period—that is, every third day on call at his unit. During this period, all patients under the age of 75 years with a diagnosis of subarachnoid haemorrhage were admitted to the neurosurgical unit as soon as was practicable regardless of clinical grade. Results: Of 245 patients, 190 (77.6%) underwent treatment by open surgery using standard microsurgical techniques. At 1 year, the mortality of the operated patients was 2.6%, while 89.5% of the patients had a Glasgow Outcome Score (GOS) of 4 and 5. The overall management outcome (all patients treated, including operated and non-operated cases) at 1 year was: 17.1 % dead while 74.3% had GOS 4 and 5. Of the 190 patients who underwent surgery, 38 (20%) required additional operations, totalling 72 operations in all. Of these, 32 were for hydrocephalus and 17 for the evacuation of intracranial haematomas/collections. Complications of surgery occurred in 56 patients (29.5%). Conclusion: Open surgery, despite good eventual results, is associated with a significant rate of re-operations and complications that would probably be largely avoided with endovascular treatment. Nevertheless, although endovascular coiling has these immediate advantages over surgery it is still not certain that the long term results will be superior to surgery which leads to permanent obliteration of the aneurysm. There may still be a need for open surgery in the future. PMID:14638889

Embolization of a large, symptomatic splenic artery pseudoaneurysm

PubMed Central

Kukliński, Adam; Batycki, Krzysztof; Matuszewski, Wiesław; Ostrach, Andrzej; Kupis, Zbigniew; Łęgowik, Tomasz

2014-01-01

Summary Background Splenic artery aneurysm is the third most common abdominal aneurysm. Most often it is due to pancreatitis. There were only 19 cases of aneurysms larger than 5 cm in diameter described in the literature. Management of splenic artery aneurysms depends on the size and symptoms. Invasive treatment modalities involve open procedures and interventional radiology methods (endovascular). Case Reports A 44-years-old male with chronic pancreatitis, in a gradually worsening general condition due to a large splenic artery aneurysm, was subjected to the procedure. Blood flow through the aneurysm was cut-off by implanting a covered stent between celiac trunk and common hepatic artery. Patient’s general condition rapidly improved, allowing discharge home in good state soon after the procedure. Conclusions Percutaneous embolization appears to be the best method of treatment of large splenic artery aneurysms. Complications of such treatment are significantly less dangerous than those associated with surgery. PMID:25009678

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis.

PubMed

Yamao, Yukihiro; Takahashi, Jun C; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis

PubMed Central

Yamao, Yukihiro; Takahashi, Jun C.; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Background: Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. Case Description: The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. Conclusions: M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators. PMID:25525556

Embolic Signals during Routine Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage

PubMed Central

Paschoal, Fernando Mendes; de Almeida Lins Ronconi, Karla; de Lima Oliveira, Marcelo; Nogueira, Ricardo de Carvalho; Paschoal, Eric Homero Albuquerque; Teixeira, Manoel Jacobsen; Figueiredo, Eberval Gadelha; Bor-Seng-Shu, Edson

2015-01-01

Introduction. Cerebral emboli may occur in subarachnoid hemorrhage (SAH) and intracranial aneurysm surgery. Although embolic signs (ES) have been reported in SAH, their origin remains unclear. The aim of this study was to report the detection of ES during routine TCD monitoring in patients with aneurysmal SAH. Methods. A total of 105 patients with aneurysmal SAH were submitted to TCD evaluation. Patients were monitored almost daily (5 times per week). In each monitoring session, one experienced operator performed TCD to detect or assess vasospasm and ES in arteries of the Willis polygon. Results. Four patients out of a total of 105 patients with aneurysmal SAH were found to present spontaneous cerebral embolization during routine TCD monitoring. The average age of the 4 patients (mean ± standard deviation) was 59.5 ± 8.34 years (range 49–68 ys); female patients predominated representing 75% (3/4) of subjects. Conclusion. Although detection of ES was relatively rare in this study, rates of emboli occurrence may be higher under systematic monitoring. The detection of ES after SAH surgery reinforces the need to study the role of embolus in this condition and may be an indicator for prophylactic antithrombotic treatment. PMID:25893190

Surgery of intracranial aneurysms at Yonsei University: 780 cases.

PubMed

Lee, K C

1991-03-01

Seven hundred and eighty patients with intracranial aneurysm, which were surgically treated by the author since 1976, were analyzed. Strategies important for intracranial aneurysm surgery were the timing of surgery, preoperative preparation and intraoperative management. The best management outcome could be achieved by early operation, removal of subarachnoid blood clot, maintenance of circulating blood volume, administration of nimodipine, and meticulous surgical tactics to avoid pitfalls. Indications for aneurysm surgery in the acute phase were determined by intracerebral hematoma, angiographic findings, clinical grade, general physical status and readiness of the surgical team. Important goals to be considered during the operation were obtaining a slack brain, preparation of proximal control, protection of the brain, awareness of microsurgical anatomy, and complete dissection of the sac. The morbidity and mortality were 2.7% and 4.0%, respectively. The mortality was attributed to intracranial causes in 20 cases (poor grade, delayed ischemic deficits, rebleeding, postoperative infarction, and postoperative epidural hematoma), extracranial causes in 7 cases (pulmonary embolism, heparin induced intracerebral hemorrhage, hepatic failure, myocardial infarction, and gastrointestinal bleeding), and unknown problems in 5 cases. The postoperative intracerebral hemorrhage occurred in 16 cases and seemed to be caused by one or more of the following events: cerebral infarction developed during the preoperative period, occlusion of the cerebral veins during the Sylvian dissection, cerebral retraction and/or sudden change of intracranial hemodynamics. Hydrocephalus, almost always a communicating type as confirmed by isotope cisternography, was managed by lumboperitoneal shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

[Renal failure in surgery of abdominal aorta aneurysms].

PubMed

Pokrovskiĭ, A V; Asamov, R E; Ermoliuk, R S; Iudin, V I; Kapanadze, G I

1994-09-01

The authors analyse the experience in operations for resection of an aneurysm of the abdominal aorta in 70 patients, which were performed at the Vishnevsky Institute of Surgery, AMS of Russia, from 1983 to 1991. Preoperative examination revealed renal insufficiency in 8 (11.4%) patients. Resection of the aneurysm of the abdominal aorta with one-stage prosthetics of the renal arteries was carried out in 10 cases. To prevent ischemic damage to the renal parenchyma and acute renal insufficiency, local methods of kidney protection (isolated cold perfusion--2 and normothermic aorto-renal perfusion--2) were applied in 4 of 70 cases. The work discusses the methods of kidney protection and the indications and contraindications for their use, and factors promoting the development of postoperative renal insufficiency. Postoperative complications are shown and their causes are identified.

Ten-Year Follow-Up of Endovascular Aneurysm Treatment with Talent Stent-Grafts

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pitton, Michael B., E-mail: pitton@radiologie.klinik.uni-mainz.de; Scheschkowski, Tobias; Ring, Markus

2009-09-15

The purpose of this study was to evaluate the clinical results, complications, and secondary interventions during long-term follow-up after endovascular aneurysm repair (EVAR) and to investigate the impact of endoleak sizes on aneurysm shrinkage. From 1997 to March 2007, 127 patients (12 female, 115 male; age, 73.0 {+-} 7.2 years) with abdominal aortic aneurysms were treated with Talent stent-grafts. Follow-up included clinical visits, contrast-enhanced MDCT, and radiographs at 3, 6, and 12 months and then annually. Results were analyzed with respect to clinical outcome, secondary interventions, endoleak rate and management, and change in aneurysm size. There was no need formore » primary conversion surgery. Thirty-day mortality was 1.6% (two myocardial infarctions). Procedure-related morbidity was 2.4% (paraplegia, partial infarction of one kidney, and inguinal bleeding requiring surgery). Mean follow-up was 47.7 {+-} 34.2 months (range, 0-123 months). Thirty-nine patients died during follow-up; three of the deaths were related to aneurysm (aneurysm rupture due to endoleak, n = 1; secondary surgical reintervention n = 2). During follow-up, a total of 29 secondary procedures were performed in 19 patients, including 14 percutaneous procedures (10 patients) and 15 surgical procedures (12 patients), including 4 cases with late conversion to open aortic repair (stent-graft infection, n = 1; migration, endoleak, or endotension, n = 3). Overall mean survival was 84.5 {+-} 4.7 months. Mean survival and freedom from any event was 66.7 {+-} 4.5 months. MRI depicted significantly more endoleaks compared to MDCT (23.5% vs. 14.3%; P < 0.01). Patients in whom all aneurysm side branches were occluded prior to stent-grafting showed a significantly reduced incidence of large endoleaks. Endoleaks >10% of the aneurysm area were associated with reduced aneurysm shrinkage compared to no endoleaks or <10% endoleaks ({Delta} at 3 years, -1.8% vs. -12.0%; P < 0.05). In conclusion, endovascular aneurysm treatment with Talent stent-grafts demonstrated encouraging long-term results with moderate secondary intervention rates. Primary occlusion of all aortic side branches reduced the incidence of large endoleaks. Large endoleaks significantly impaired aneurysm shrinkage, whereas small endoleaks did not.« less

Aneurysm of the right ventricular outflow following bovine valved venous conduit insertion.

PubMed

Boudjemline, Younes; Bonnet, Damien; Agnoletti, Gabriella; Vouhé, Pascal

2003-01-01

A case of aneurysm of the right ventricular outflow tract is described after repair of tetralogy of Fallot using a Contegra supported conduit. Angiograms revealed that the aneurysm was located between the ventricular anastomosis and the proximal ring of the conduit confirming echocardiographic data. Because the conduit between the rings was not dilated, the valve was perfectly functioning. Pulmonary anastomosis was severely stenosed explaining the dilatation seen below. Conduit replacement with resection of the aneurysmal part of the failing conduit was performed. Supported conduits do not eliminate the risk of secondary dilatation below the artificial ring but preserve valvular function.

Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification.

PubMed

Patel, Sanjay D; Constantinou, Jason; Simring, Dominic; Ramirez, Manfred; Agu, Obiekezie; Hamilton, Hamish; Ivancev, Krassi

2015-08-01

Advances in endovascular technology have led to the successful treatment of complex abdominal aortic aneurysms. However, there is currently no consensus on what constitutes a juxtarenal, pararenal, or suprarenal aneurysm. There is emerging evidence that the extent of the aneurysm repair is associated with outcome. We compare the outcomes of 150 consecutive patients treated with a fenestrated or branched stent graft and present the data stratified according to the Society for Vascular Surgery classification based on proximal anatomic landing zones. A prospectively collected database of consecutive patients undergoing fenestrated or branched stent graft insertion in a tertiary center between 2008 and 2013 was retrospectively analyzed. Aneurysms were subdivided into zones according to where the area of proximal seal could be achieved in relation to the visceral arteries. Zone 8 covers the renal arteries, zone 7 covers the superior mesenteric artery, and zone 6 covers the celiac axis. Patient demographics, operative variables, mortality, and major morbidity were analyzed by univariate and multivariate analysis to assess for differences between zones. During the study period, 150 patients were treated. There were 49 in zone 8, 76 in zone 7, and 25 in zone 6. Prior aortic surgery had been performed in 19 patients, which included 11 patients with previous endovascular aneurysm repairs. There was significantly increased blood loss (P < .001), operative time (P < .0001), total hospital stay (P = .018), and intensive care unit stay (P < .0001) as the zones ascended the aorta. There were 14 inpatient deaths recorded across all zones with a 30-day mortality rate of 8%. Logistic regression analysis for 30 day mortality showed a significant increase as the zones ascended (P = .007). Kaplan-Meier analysis showed that 5-year survival significantly deteriorated as the zones ascended (P = .039), with no significant difference in the freedom from reintervention curves between zones (P = .37). We have shown that the extent of the aneurysm repair as determined by the proximal sealing zone is associated with outcome. Mortality, operative duration, blood loss, and hospital stay all significantly increased as the zones ascended. These data also validate the use of the proposed new classification based on aortic anatomy. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm.

PubMed

Chee, Lai Chuang; Siregar, Johari Adnan; Ghani, Abdul Rahman Izani; Idris, Zamzuri; Rahman Mohd, Noor Azman A

2018-02-01

Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000-2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I-III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin's Scale (mRS). The mRS scores of 0 to 2 were grouped into the "favourable" category and mRS scores of 3 to 6 were grouped into the "unfavourable" category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P -value of < 0.05 was considered to be statistically significant. A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review ( n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient's surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient's follow up.

Intraluminal cell transplantation prevents growth and rupture in a model of rupture-prone saccular aneurysms.

PubMed

Marbacher, Serge; Frösén, Juhana; Marjamaa, Johan; Anisimov, Andrey; Honkanen, Petri; von Gunten, Michael; Abo-Ramadan, Usama; Hernesniemi, Juha; Niemelä, Mika

2014-12-01

Aneurysm occlusion by intraluminal thrombus formation is the desired effect of all endovascular treatments. Intraluminal thrombus may, however, recanalize and be absorbed, unless it is infiltrated by cells that turn it into fibrous tissue (neointima). Because ruptured aneurysm walls are characterized by loss of smooth muscle cells, we assessed the impact of mural cell loss on wall remodeling of thrombosed aneurysms and investigated whether neointima formation could be enhanced by direct transplantation of cells into the thrombus. Sidewall aneurysms were microsurgically created in rats (n=81). Certain aneurysms were decellularized. Thrombosis was induced using direct injection of a fibrin polymer into the aneurysm. CM-Dil-labeled smooth muscle cells were injected into 25 of 46 fibrin embolized aneurysms. Recanalization and aneurysm growth were monitored with magnetic resonance angiography. Endoscopy, optical projection tomography, histology, and immunohistochemistry were used to study the fate of transplanted cells, thrombus organization, and neointima formation. Decellularized embolized aneurysms demonstrated higher angiographic recurrence compared with decellularized embolized aneurysms with transplanted cells (P=0.037). Local cell replacement at the time of thrombosis resulted in better histological neointima formation than both nondecellularized embolized aneurysms (P<0.001) and decellularized embolized aneurysms (P=0.002). Aneurysm growth and rupture were observed exclusively in decellularized embolized aneurysms. Lack of smooth muscle cells in the aneurysm wall promotes wall degradation, aneurysm growth and rupture, even if the aneurysm is occluded by luminal thrombus. Transplantation of smooth muscle cells into the luminal thrombus can reduce this degenerative remodeling. © 2014 American Heart Association, Inc.

[Intraoperative lysis and neurostimulation as added therapy in surgery of popliteal artery aneurysm].

PubMed

Peiper, C; Heye, K; Ktenidis, K; Horsch, S

1997-01-01

Additional therapy of symptomatic popliteal artery aneurysm includes intraoperative lysis for the treatment of the descending thrombosis and spinal cord stimulation for cases of chronic deterioration of the peripheral perfusion state. Between 1989 and 1996, we treated 50 patients with 55 symptomatic aneurysms using this concept, 18 of them as emergency cases. We reached a postoperative amputation rate of 12.7% and good long-term functional results in 34 of 37 patients.

Stroke - discharge

MedlinePlus

... fatty foods and stay away from fast food restaurants to make your heart and blood vessels healthier. ... 22, 2016. Read More Brain aneurysm repair Brain surgery Carotid artery surgery High blood cholesterol levels Recovering ...

Pituitary Dysfunction from an Unruptured Ophthalmic Internal Carotid Artery Aneurysm with Improved 2-year Follow-up Results: A Case Report.

PubMed

Qi, Meng; Ye, Ming; Li, Meng; Zhang, Peng

2018-01-01

Internal carotid artery (ICA) supraclinoid segment aneurysms extending into the sellar region and leading to pituitary dysfunction are a rare occurrence. To date, long-term follow up of pituitary function 2 years post-treatment has never been reported. Herein, we present a case of pituitary dysfunction due to an unruptured ophthalmic segment internal carotid artery aneurysm and report improved 2-year follow-up results. A 76-year-old male presented with disturbed consciousness due to hyponatremia, which was caused by hypoadrenocorticism resulting from pituitary dysfunction complicated by hypogonadism and hypothyroidism. Computed tomography angiography revealed an intracranial aneurysm of the ophthalmic segment of the right ICA with an intrasellar extension. Thus, digital subtraction angiography and coil embolization were performed, followed by hormone replacement therapy. A 2-year follow-up revealed a partial improvement in the pituitary function, including complete restoration of thyroid-stimulating hormone level and other thyroid hormones levels, and partial restoration of testosterone levels, followed by discontinuation of thyroid hormone replacement therapy. However, the mechanisms of such pituitary dysfunction and the effects of various treatments, including clipping and coiling, on different hormones of pituitary function recovery remain unclear. A long-term follow-up of >2 years may elucidate the pituitary function recovery post-treatment and provide a medication adjustment for hormone replacement therapy.

Management of a Fulminant Upper Gastrointestinal Bleeding Exteriorized Through Hemobilia Due to Arteriobiliary Fistula Between the Common Bile Duct and a Right Hepatic Artery Aneurysm - A Case Report.

PubMed

Bacalbasa, Nicolae; Brezean, Iulian; Anghel, Claudiu; Barbu, Ion; Pautov, Mihai; Balescu, Irina; Brasoveanu, Vladislav

2017-01-01

Right hepatic artery aneurysms are rare events that might remain asymptomatic for a long period of time. However, in cases presenting large lesions, symptoms might develop especially due to the association of compression of the surrounding elements. Most often these symptoms and signs include diffuse abdominal pain, jaundice or portal vein compression signs. In rare cases life-threatening complications might develop due to the aneurysmal erosion of the biliary duct, portal vein or due to the aneurysmal rupture in the peritoneal cavity. In all these cases emergency surgery is imposed. We present the case of a 66-year-old patient diagnosed with a partially thrombosed right hepatic artery aneurysm compressing the common bile duct who was initially submitted to a percutaneous arterial embolization of the aneurysm in association with an external biliary drainage; three weeks later the patient presented a fulminant upper gastrointestinal bleeding exteriorized through the external biliary drainage, hematemesis and hematochezia. The patient was successfully submitted to surgery, intraoperatively a synchronous rupture of the portal vein being revealed. The right hepatic artery aneurysm was resected en bloc with common bile duct resection and segmental portal vein resection. The continuity of the portal vein was re-established through the interposition of a cadaveric allograft, the common bile duct was anastomosed with en Roux en Y limb while the right hepatic artery aneurysm was ligated and resected, the arterial vascularization of the liver being provided by the left hepatic artery. Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

A case of atherosclerotic inferior mesenteric artery aneurysm secondary to high flow state.

PubMed

Troisi, Nicola; Esposito, Giovanni; Cefalì, Pietro; Setti, Marco

2011-07-01

Inferior mesenteric artery aneurysms are very rare and they are among the rarest of visceral artery aneurysms. Sometimes, the distribution of the blood flow due to chronic atherosclerotic occlusion of some arteries can establish an increased flow into a particular supplying district (high flow state). A high flow state in a stenotic inferior mesenteric artery in compensation for a mesenteric occlusive disease can produce a rare form of aneurysm. We report the case of an atherosclerotic inferior mesenteric aneurysm secondary to high flow state (association with occlusion of the celiac trunk and severe stenosis of the superior mesenteric artery), treated by open surgical approach. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Heroin Use Is Associated with Ruptured Saccular Aneurysms.

PubMed

Can, Anil; Castro, Victor M; Ozdemir, Yildirim H; Dagen, Sarajune; Dligach, Dmitriy; Finan, Sean; Yu, Sheng; Gainer, Vivian; Shadick, Nancy A; Savova, Guergana; Murphy, Shawn; Cai, Tianxi; Weiss, Scott T; Du, Rose

2017-11-04

While cocaine use is thought to be associated with aneurysmal rupture, it is not known whether heroin use increases the risk of rupture in patients with non-mycotic saccular aneurysms. Our goal was to investigate the association between heroin and cocaine use and the rupture of saccular non-mycotic aneurysms. The medical records of 4701 patients with 6411 intracranial aneurysms, including 1201 prospective patients, diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were reviewed and analyzed. Patients were separated into ruptured and non-ruptured groups. Univariable and multivariable logistic regression analyses were performed to determine the association between heroin, cocaine, and methadone use and the presence of ruptured intracranial aneurysms. In multivariable analysis, current heroin use was significantly associated with rupture status (OR 3.23, 95% CI 1.33-7.83) whereas former heroin use (with and without methadone replacement therapy), and current and former cocaine use were not significantly associated with intracranial aneurysm rupture. In the present study, heroin rather than cocaine use is significantly associated with intracranial aneurysm rupture in patients with non-mycotic saccular cerebral aneurysms, emphasizing the possible role of heroin in the pathophysiology of aneurysm rupture and the importance of heroin cessation in patients harboring unruptured intracranial aneurysms.

Managing a Mycotic Thoracoabdominal Aneurysm: The Importance of Molecular Diagnostics.

PubMed

Bayliss, Christopher D; Booth, Karen L; Williams, Robin; Dark, John H; Gould, Kate F

2017-11-01

Pneumococcal mycotic aneurysms are rare and associated with significant mortality and morbidity. Early intravenous antibiotic therapy and surgical intervention is the mainstay of treatment. Pneumococci frequently autolyze in blood cultures, making microbiological diagnosis challenging. We present the case of a man in his mid 70s with multiple thoracoabdominal mycotic aneurysms. Surgery was performed to a threatening saccular aortic arch aneurysm. Samples were sent for microbiological analysis and all were culture negative. The samples were then referred for bacterial 16S ribosomal RNA sequencing, which revealed evidence of infection with Streptococcus pneumoniae. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Abdominal aortic aneurysm with ectopic renal artery origins: a case report.

PubMed

Kotsis, T; Mylonas, S; Katsenis, K; Arapoglou, V; Dimakakos, P

2007-01-01

The coexistense of an abdominal aortic aneurysm with ectopic main renal vasculature complicates aortic surgery and mandates a focused imaging evaluation and a carefully planned operation to minimize renal ischemia. We present the case of a 75-year-old man with an abdominal aortic aneurysm and a right kidney with two ectopic main renal arteries, one originating from the aneurysmal distal aorta and the other from the right common iliac artery; the patient underwent a surgical repair and followed an uneventful course with no deterioration of renal function. The preoperative and intraoperative details are reported, along with a review of the literature.

Hybrid treatment of a huge complex aortic pseudo-aneurysm subsequent to a coarctation.

PubMed

Rizza, Antonio; Barletta, Valentina; Palmieri, Cataldo; Berti, Sergio

2017-07-01

Endovascular treatment of pseudo-aneurysms subsequent to a pre-existing aortic coarctation is becoming a well-accepted technical solution especially in patients presenting anatomical challenges involving the aortic arch. We report the case of a 65-year-old woman with a huge pseudo-aneurysm of the descending thoracic aorta. Diagnostic imaging assessment documented also the presence of an aneurysmatic aberrant right subclavian artery. Due to patient's anatomical arterial condition, we decided to treat the aneurysm applying a hybrid approach. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Effect of nitrous oxide on neurologic and neuropsychological function after intracranial aneurysm surgery.

PubMed

McGregor, Diana G; Lanier, William L; Pasternak, Jeffrey J; Rusy, Deborah A; Hogan, Kirk; Samra, Satwant; Hindman, Bradley; Todd, Michael M; Schroeder, Darrell R; Bayman, Emine Ozgur; Clarke, William; Torner, James; Weeks, Julie

2008-04-01

Laboratory studies suggest that nitrous oxide augments brain injury after ischemia or hypoxia. The authors examined the relation between nitrous oxide use and outcomes using data from the Intraoperative Hypothermia for Aneurysm Surgery Trial. The Intraoperative Hypothermia for Aneurysm Surgery Trial was a prospective randomized study of the impact of intraoperative hypothermia (temperature = 33 degrees C) versus normothermia (temperature = 36.5 degrees C) in patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping. Anesthesia was dictated by a limited-options protocol with the use of nitrous oxide determined by individual anesthesiologists. All patients were assessed daily for 14 days after surgery or until hospital discharge. Neurologic and neuropsychological testing were conducted at 3 months after surgery. Outcome data were analyzed via both univariate tests and multivariate logistic regression analysis correcting for factors thought to influence outcome. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. Outcome data were available for 1,000 patients, of which 373 received nitrous oxide. There was no difference between groups in the development of delayed ischemic neurologic deficit. At 3 months after surgery, there were no significant differences between groups in any outcome variable: Glasgow Outcome Score (OR, 0.84; 95% confidence interval [CI], 0.63-1.14; P = 0.268), National Institutes of Health Stroke Scale (OR, 1.29; 95% CI, 0.96-1.73; P = 0.087), Rankin Disability Score (OR, 0.84; 95% CI, 0.61-1.15; P = 0.284), Barthel Activities of Daily Living Index (OR, 1.01; 95% CI, 0.68-1.51; P = 0.961), or neuropsychological testing (OR, 1.26; 95% CI, 0.85-1.87; P = 0.252). In a population of patients at risk for ischemic brain injury, nitrous oxide use had no overall beneficial or detrimental impact on neurologic or neuropsychological outcomes.

Cerebral Aneurysm from Cardiobacterium hominis Endocarditis.

PubMed

Glucksman, Aaron; Naut, Edgar

2016-05-01

A 43-year-old male with a history of bioprosthetic aortic valve replacement and tricuspid valve annuloplasty presented with vertigo and was found to have an acute infarct in the left superior cerebellum, as well as a left-middle cerebral artery mycotic aneurysm. Blood cultures grew Cardiobacterium hominis and bioprosthetic aortic valve vegetation was found on transthoracic echocardiogram.

Cardiovascular Risk Reduction is Important for Improving Patient and Graft Survival After Ligation and Bypass Surgery for Popliteal Artery Aneurysm.

PubMed

Dattani, N; Ali, M; Aber, A; Kannan, R Yap; Choke, E C; Bown, M J; Sayers, R D; Davies, R S

2017-07-01

To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival. A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively. Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively. This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.

Pathologic aneurysmal dilation of the ascending aorta and dilation of the main pulmonary artery in patients with Kabuki syndrome: valve-sparing aortic root replacement.

PubMed

Dyamenahalli, Umesh; Abraham, Boban; Fontenot, Eudice; Prasad, Vinay; Imamura, Michiaki

2007-01-01

We report the aneurysmal dilation of the ascending aorta and the main pulmonary artery in 2 children with Kabuki syndrome. In 1 patient, there was progressive aneurysmal dilation of the ascending aorta necessitating aortoplasty. Histologic examination of the resected aorta revealed disrupted and fragmented elastic fibers in the medial layer, along with mucinous degeneration of the aortic wall. This is the first recognition and report of these findings as part of the Kabuki syndrome.

Hyperperfusion syndrome after trapping with high-flow bypass for a giant paraclinoid internal carotid artery aneurysm.

PubMed

Mohri, Masanao; Ichinose, Toshiya; Uchiyama, Naoyuki; Misaki, Kouichi; Nambu, Iku; Takabatake, Yasushi; Nakada, Mitsutoshi

2018-04-21

Hyperperfusion syndrome associated with aneurysm surgery is rare. The occurrence of the syndrome after trapping with high-flow bypass has not been described previously. Herein, we present a case of the syndrome occurring after trapping with high-flow bypass of an unruptured giant paraclinoid internal carotid artery (ICA) aneurysm. The patient was a 68-year-old woman with progressive loss of vision in her left eye. After a diagnosis of a left giant ICA aneurysm, she underwent successful trapping with high-flow bypass. No new neurological deficits were observed after surgery. Computed tomography (CT) on the same day and magnetic resonance imaging (MRI) on the next day revealed no hemorrhage or infarction. The patient had a headache and transit motor aphasia on postoperative day (POD) 8. Arterial spin-labeling magnetic resonance perfusion image on the same day and single photon emission CT scan on POD 10 demonstrated hyperperfusion in the left cerebral cortex. The symptoms gradually improved over a week and she had no new neurological deficits when discharged from hospital. This report suggests that, although rare, hyperperfusion syndrome after trapping with high-flow bypass should be considered in giant aneurysmal patients if they present with headache and neurological deficits in a delayed period. Copyright © 2018. Published by Elsevier Inc.

Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background Subarachnoid hemorrhage is a common and dangerous disease with an unfavorable prognosis. Patients with poor-grade subarachnoid hemorrhage (Hunt & Hess Grades 4–5) are unconscious on admission. Because of the high mortality and disability rate associated with poor-grade subarachnoid hemorrhage, it is often treated conservatively. Timing of surgery for poor-grade aneurysmal subarachnoid hemorrhage is still controversial, therefore this study aims to identify the optimal time to operate on patients admitted in poor clinical condition. Methods/design Ninety-nine patients meeting the inclusion criteria were randomly assigned into three treatment groups. The early surgery group received operation within 3 days after onset of subarachnoid hemorrhage (day of SAH = day 1); the intermediate surgery group received operation from days 4 to 7, and surgery was performed on the late surgery group after day 7. Follow-up was performed 1, 3, and 6 months after aneurysm clipping. Primary indicators of outcome included the Extended Glasgow Outcome Scale and the Modified Rankin Scale, while secondary indicators of outcome were assessed using the Barthel Index and mortality. Discussion This is the first prospective, single-center, observer-blinded, randomized controlled trial to elucidate optimal timing for surgery in poor-grade subarachnoid hemorrhage patients. The results of this study will be used to direct decisions of surgical intervention in poor-grade subarachnoid hemorrhage, thus improving clinical outcomes for patients. Trial registration Chinese Clinical Trial Registry: ChiCTR-TRC-12002917 PMID:23957458

Current Treatment Strategies for Intracranial Aneurysms: An Overview

PubMed Central

Lin, Hao; Summers, Richard; Yang, Mingmin; Cousins, Brian G.

2017-01-01

Intracranial aneurysm is a leading cause of stroke. Its treatment has evolved over the past 2 decades. This review summarizes the treatment strategies for intracranial aneurysms from 3 different perspectives: open surgery approach, transluminal treatment approach, and new technologies being used or trialed. We introduce most of the available treatment techniques in detail, including contralateral clipping, wrapping and clipping, double catheters assisting coiling and waffle-cone technique, and so on. Data from major trials such as Analysis of Treatment by Endovascular approach of Non-ruptured Aneurysms (ATENA), Internal Subarachnoid Trial (ISAT), Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY), and Barrow Ruptured Aneurysm Trial (BRAT) as well as information from other clinical reports and local experience are reviewed to suggest a clinical pathway for treating different types of intracranial aneurysms. It will be a valuable supplement to the current existing guidelines. We hope it could help assisting real-time decision-making in clinical practices and also encourage advancements in managing the disease. PMID:28355880

Endovascular treatment of a spontaneous aneurysm in the axillary artery.

PubMed

Park, Sung Kyun; Hwang, Jeong Kye; Park, Sun Cheol; Kim, Sang Dong

2015-01-01

Spontaneous aneurysm in the axillary artery is extremely rare. The standard treatment for axillary artery aneurysm has been surgical repair, but endovascular management of select aneurysms using stent grafts has become more prevalent with the development of endoluminal technology. We report the case of a 36-year old man with a spontaneous aneurysm in the axillary artery. He experienced a tingling sensation and intermittent pain in the left upper extremity and had no history of trauma to the axilla. We performed endovascular treatment [placement of a Viabahn stent graft (W.L. Gore & Associates, Flagstaff, AZ, USA)] for a spontaneous aneurysm in the axillary artery. Following the procedure, his symptoms disappeared completely. After 6, 12 and 24 months, we carried out computed tomography angiography; all scans showed no complications. Now, the patient has no symptoms related to aneurysm in the axilla. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Surgical outcomes of Majewski osteodysplastic primordial dwarfism Type II with intracranial vascular anomalies.

PubMed

Teo, Mario; Johnson, Jeremiah N; Bell-Stephens, Teresa E; Marks, Michael P; Do, Huy M; Dodd, Robert L; Bober, Michael B; Steinberg, Gary K

2016-12-01

OBJECTIVE Majewski osteodysplastic primordial dwarfism Type II (MOPD II) is a rare genetic disorder. Features of it include extremely small stature, severe microcephaly, and normal or near-normal intelligence. Previous studies have found that more than 50% of patients with MOPD II have intracranial vascular anomalies, but few successful surgical revascularization or aneurysm-clipping cases have been reported because of the diminutive arteries and narrow surgical corridors in these patients. Here, the authors report on a large series of patients with MOPD II who underwent surgery for an intracranial vascular anomaly. METHODS In conjunction with an approved prospective registry of patients with MOPD II, a prospectively collected institutional surgical database of children with MOPD II and intracranial vascular anomalies who underwent surgery was analyzed retrospectively to establish long-term outcomes. RESULTS Ten patients with MOPD II underwent surgery between 2005 and 2012; 5 patients had moyamoya disease (MMD), 2 had intracranial aneurysms, and 3 had both MMD and aneurysms. Patients presented with transient ischemic attack (TIA) (n = 2), ischemic stroke (n = 2), intraparenchymal hemorrhage from MMD (n = 1), and aneurysmal subarachnoid hemorrhage (n = 1), and 4 were diagnosed on screening. The mean age of the 8 patients with MMD, all of whom underwent extracranial-intracranial revascularization (14 indirect, 1 direct) was 9 years (range 1-17 years). The mean age of the 5 patients with aneurysms was 15.5 years (range 9-18 years). Two patients experienced postoperative complications (1 transient weakness after clipping, 1 femoral thrombosis that required surgical repair). During a mean follow-up of 5.9 years (range 3-10 years), 3 patients died (1 of subarachnoid hemorrhage, 1 of myocardial infarct, and 1 of respiratory failure), and 1 patient had continued TIAs. All of the surviving patients recovered to their neurological baseline. CONCLUSIONS Patients with MMD presented at a younger age than those in whom aneurysms were more prevalent. Microneurosurgery with either intracranial bypass or aneurysm clipping is extremely challenging but feasible at expert centers in patients with MOPD II, and good long-term outcomes are possible.

Cerebral aneurysms following radiotherapy for medulloblastoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Benson, P.J.; Sung, J.H.

1989-04-01

Three patients, two males and one female aged 21, 14, and 31 years, respectively, developed cerebral saccular aneurysms several years after undergoing radiotherapy for cerebellar medulloblastoma at 2, 5, and 14 years of age, respectively. Following surgery, all three received combined cobalt-60 irradiation and intrathecal colloidal radioactive gold (/sup 198/Au) therapy, and died from rupture of the aneurysm 19, 9, and 17 years after the radiotherapy, respectively. Autopsy examination revealed no recurrence of the medulloblastoma, but widespread radiation-induced vasculopathy was found at the base of the brain and in the spinal cord, and saccular aneurysms arose from the posterior cerebralmore » arteries at the basal cistern or choroidal fissure. The aneurysms differed from the ordinary saccular aneurysms of congenital type in their location and histological features. Their locations corresponded to the areas where intrathecally administered colloidal /sup 198/Au is likely to pool, and they originated directly from a segment of the artery rather than from a branching site as in congenital saccular aneurysms. It is, therefore, concluded that the aneurysms in these three patients were most likely radiation-induced.« less

Endovascular repair of descending thoracic aortic aneurysm: an evidence-based analysis.

PubMed

2005-01-01

To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA). Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition. The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases. The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia. Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs. The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall. The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration. Objectives To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approachTo summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAsMeasures of Effectiveness Primary Outcome Mortality rates (30-day and longer term)Secondary Outcomes Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulationRate of reintervention (through surgical or endovascular approach)Measures of Safety Complications were categorized into 2 classes: Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; andThose due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.Inclusion Criteria Studies comparing the clinical outcomes of ESG treatment with surgical approachesStudies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAsExclusion Criteria Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aortaStudies investigating the aneurysms of the ascending and the arch of the aortaStudies using custom-made graftsLiterature Search The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies. One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria. Mortality The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.Technical Success Rate Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).Surgical Reintervention In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).Endovascular Revision In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.Graft Migration Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.Aortic Rupture In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.Postprocedural Complications In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.POOLED DATA FROM CASE SERIES SHOW THE FOLLOWING POSTPROCEDURAL COMPLICATION RATES IN THE ESG PLACEMENT GROUP: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).Time-Related Outcomes The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively. ONTARIO-BASED ECONOMIC ANALYSIS: In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as "not ruptured" with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as "ruptured," with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure. (ABSTRACT TRUNCATED)

Gastroduodenal artery aneurysm - Post traumatic pancreatic pseudocyst drainage - An interesting case.

PubMed

Zarin, Mohammad; Ali, Sajid; Majid, Abdul; Jan, ZakaUllah

2018-01-01

Pseudoaneurysms of the gastroduodenal artery (GDA) are rare and mostly associated with pancreatitis. However, they can occur as a possible complication following gastric or pancreatic surgery and thus prior recognition and prompt treatment is mandatory (Lee et al., 2009 [1]). We report a case of a ruptured GDA aneurysm in a patient who underwent roux-en-y-cystojejunostomy for traumatic pancreatic pseudocyst and this has rarely been reported in the literature. Our patient presented with melena one month post operatively. CT Angiogram showed pseudoaneurysm of the GDA and the origin of right gastroepiploic artery which was embolised. Our case highlights that GDA aneurysm must be considered in the differential for a patient who presents with melena following drainage of traumatic pancreatic pseudocyst and that it can be managed successfully with angioembolization. A young boy was operated for traumatic pancreatic pseudocyst. One month later, he presented with the complaints of melena. Patient was resuscitated initially and then CT Angiogram was planned that showed pseudo aneurysm of the GDA and the origin of right gastroepiploic artery. The aneurysm was embolised and patient was sent home later on. On two months follow up the patient was doing well and had no episode of melena. GDA aneurysm are rare and should be suspected in a patient with GI hemorrhage after surgery for traumatic pancreatic pseudocyst. The investigation of choice is CT Angiography and endovascular angioembolization is the treatment modality of choice. Copyright © 2017. Published by Elsevier Ltd.

Internal jugular vein aneurysm: A case report.

PubMed

Nasiri, Abdulrahman M; Rayes, Nora; Bakarman, Khaled A

2018-01-01

Aneurysm is a localized dilatation of an artery of at least 1.5 times the normal diameter that occurs when part of an artery wall weakens or is injured, allowing it to widen abnormally. In practice, an arterial aneurysm is more common in comparison to a venous aneurysm. Because of the rare incidence of venous aneurysms, treatment guidelines are not clearly established and thus treatment strategies vary. This is a case of a 57-year-old Saudi woman, with no significant medical history, who presented to Prince Sultan Military Hospital complaining of swelling in the right side of the neck that started 3 years ago. The patient reported that the swelling enlarged with coughing and straining, but there was no pain, change in skin color, dysphagia, change in voice, neurological defect, shortness of breath, history of any trauma to the neck, surgical intervention, or any lump. The condition can be diagnosed via ultrasonography, computed tomography, or magnetic resonance imaging. Despite the lack of guidelines, intervention was necessary because the patient was anxious regarding the increase in the size of the swelling, which she felt had a negative psychosocial impact. Moreover, because the sizable venous aneurysm harbored a mural thrombus that increased the risk of embolization and pulmonary embolism, surgery was offered.Indication for surgery includes pain, swelling, and cosmetic concerns. Conservative management of the condition is described in the literature. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Should surgical outcomes be published?

PubMed

Chou, Evelyn; Abboudi, Hamid; Shamim Khan, Mohammed; Dasgupta, Prokar; Ahmed, Kamran

2015-04-01

Despite publishing surgical outcomes being a positive step forwards in the progression of England's healthcare system, it has no doubt been faced with criticism and reservations. This review article aims to discuss the pros and cons of publishing individual surgical outcomes, as well as the challenges faced. Publishing outcomes requires data from a number of sources such as national clinical audits, hospital episode statistics, patient-reported outcomes, registers and information from revalidation. As yet, eight surgical specialties have begun publishing their data, including cardiac (coronary artery bypass graft, valve and aortic surgery), endocrine (thyroidectomy, lobectomy, isthmusectomy), orthopaedic (hip and knee replacement), urological (full and partial nephrectomies, nephroureterectomy), colorectal (bowel tumour removal), upper gastrointestinal (stomach cancer and oesophageal cancer removal, bariatric surgery), ear, nose and throat surgery (larynx, oral cavity, oropharynx, hypopharynx and salivary gland cancer removal), as well as vascular surgery (abdominal aortic aneurysm, carotid endarterectomy). However, not all procedures have been addressed. Despite the controversy surrounding the topic of publishing surgical outcomes, the advantages of reporting outcomes outweigh the disadvantages, and these challenges can be overcome, to create a more reliable, trustworthy and transparent NHS. Perhaps one of the main challenges has been the difficulty in collecting large amounts of clinically significant data able to quantify the performance of surgeons. © The Royal Society of Medicine.

Comparison of the structure of the aortic valve and ascending aorta in adults having aortic valve replacement for aortic stenosis versus for pure aortic regurgitation and resection of the ascending aorta for aneurysm.

PubMed

Roberts, William Clifford; Vowels, Travis James; Ko, Jong Mi; Filardo, Giovanni; Hebeler, Robert Frederick; Henry, Albert Carl; Matter, Gregory John; Hamman, Baron Lloyd

2011-03-01

There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken. Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.

Preoperative predictive factors of aneurysmal regression using the reporting standards for endovascular aortic aneurysm repair.

PubMed

Kaladji, Adrien; Cardon, Alain; Abouliatim, Issam; Campillo-Gimenez, Boris; Heautot, Jean François; Verhoye, Jean-Philippe

2012-05-01

Aneurysmal regression is a reliable marker for long-lasting success after endovascular aneurysm repair (EVAR). The aim of this study was to identify the preoperative factors that can predictably lead to aneurysmal sac regression after EVAR, according to the reporting standards of the Society for Vascular Surgery and the International Society of Cardiovascular Surgery (SVS/ISCVS). From 199 patients treated by EVAR between 2000 and 2009, 164 completed computed tomography angiographies and duplex scan follow-up images were available. All computed tomography angiographies for enrolled patients in this retrospective study were analyzed with Endosize software (Therenva, Rennes, France) to provide spatially correct 3-dimensional data in accordance with SVS/ISCVS recommendations. Anatomic parameters were graded according to the relevant severity grades. A severity score was calculated at the aortic neck, the abdominal aortic aneurysm, and the iliac arteries. Clinical and demographic factors were studied. Patients with aneurysmal regression >5 mm were assigned to group A (mean age, 71.4 ± 8.9 years) and the others to group B (76.3 ± 8.3 years). Aneurysmal regression occurred in 66 patients (40.2%; group A). Univariate analyses showed smaller severity scores at the aortic neck (P = .02) and the iliac arteries (P = .002) in group A and calcifications and thrombus were less significant at the aortic neck (P = .003 and P = .02) and at the iliac arteries (P = .001 and P = .02), and inferior mesenteric artery patency was less frequent (68.2% vs 82.7%, P = .04). Two multivariate analyses were done: one considered the scores and the other the variables included in the scores. In the first, the patients of group A were younger (P = .002) and aortic neck calcifications were less significant (P = .007). In the second, group A patients were younger (P < .001) and the aortic neck scores were smaller (P = .04). There was no difference between the two groups in the type of implanted endoprosthesis or in the follow-up (group A: 46.4 ± 24 months; group B: 47.2 ± 22 months; P = .35). In this study, the young age of the patients and their aortic neck quality, in particular the absence of neck calcification, appear to have been the main factors affecting aneurysm shrinkage, such that they represent a target population for the improvement of EVAR results. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Variation in readmission expenditures after high-risk surgery

PubMed Central

Jacobs, Bruce L.; He, Chang; Li, Benjamin Y.; Helfand, Alex; Krishnan, Naveen; Borza, Tudor; Ghaferi, Amir A.; Hollenbeck, Brent K.; Helm, Jonathan E.; Lavieri, Mariel S.; Skolarus, Ted A.

2017-01-01

Background The Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs. Materials and Methods We used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs. Results The 30-day readmission rate was 16% for major chest and 22% for major abdominal surgery (p<0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (OR 1.99; 95% CI 1.60-2.48) and abdominal surgeries (OR 1.86; 95% CI 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 weeks after discharge was associated with lower costs among abdominal surgery patients. Conclusions Readmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether. PMID:28601334

Quality of vascular surgery Web sites on the Internet.

PubMed

Grewal, Perbinder; Williams, Bryn; Alagaratnam, Swethan; Neffendorf, James; Soobrah, Ritish

2012-11-01

This study evaluated the readability, accessibility, usability, and reliability of vascular surgery information on the Internet in the English language. The Google, Yahoo, and MSN/Bing search engines were searched for "carotid endarterectomy," "EVAR or endovascular aneurysm repair," and "varicose veins or varicose veins surgery." The first 50 Web sites from each search engine for each topic were analyzed. The Flesch Reading Ease Score and Gunning Fog Index were calculated to assess readability. The LIDA tool (Minervation Ltd, Oxford, UK) was used to assess accessibility, usability, and reliability. The Web sites were difficult to read and comprehend. The mean Flesch Reading Ease scores were 53.53 for carotid endarterectomy, 50.53 for endovascular aneurysm repair, and 58.59 for varicose veins. The mean Gunning Fog Index scores were 12.3 for carotid endarterectomy, 12.12 for endovascular aneurysm repair, and 10.69 for varicose veins. The LIDA values for accessibility were good, but the results for usability and reliability were poor. Internet information on vascular surgical conditions and procedures is poorly written and unreliable. We suggest that health professionals should recommend Web sites that are easy to read and contain high-quality surgical information. Medical information on the Internet must be readable, accessible, usable, and reliable. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

[Late reoperations after repaired Stanford type A aortic dissection].

PubMed

Huang, F H; Li, L P; Su, C H; Qin, W; Xu, M; Wang, L M; Jiang, Y S; Qiu, Z B; Xiao, L Q; Zhang, C; Shi, H W; Chen, X

2017-04-01

Objective: To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection. Methods: From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun's procedure in 1 patient, Wheat combined with Sun's procedure in 1 patient, Bentall combined with Sun's procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun's procedure. Results: Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up. Conclusions: Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun's procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

Computational fluid dynamics modeling of intracranial aneurysms: effects of parent artery segmentation on intra-aneurysmal hemodynamics.

PubMed

Castro, M A; Putman, C M; Cebral, J R

2006-09-01

The purpose of this study is to show the influence of the upstream parent artery geometry on intraaneurysmal hemodynamics of cerebral aneurysms. Patient-specific models of 4 cerebral aneurysms (1 posterior communicating artery [PcomA], 2 middle cerebral artery [MCA], and 1 anterior communicating artery [AcomA]) were constructed from 3D rotational angiography images. Two geometric models were constructed for each aneurysm. One model had the native parent vessel geometry; the second model was truncated approximately 1 cm upstream from the aneurysm, and the parent artery replaced with a straight cylinder. Corresponding finite element grids were generated and computational fluid dynamics simulations were carried out under pulsatile flow conditions. The intra-aneurysmal flow patterns and wall shear stress (WSS) distributions were visualized and compared. Models using the truncated parent vessel underestimated the WSS in the aneurysms in all cases and shifted the impaction zone to the neck compared with the native geometry. These effects were more pronounced in the PcomA and AcomA aneurysms where upstream curvature was substantial. The MCA aneurysm with a long M1 segment was the least effected. The more laminar flow pattern within the parent vessel in truncated models resulted in a less complex intra-aneurysmal flow patterns with fewer vortices and less velocity at the dome. Failure to properly model the inflow stream contributed by the upstream parent artery can significantly influence the results of intra-aneurysmal hemodynamic models. The upstream portion of the parent vessel of cerebral aneurysms should be included to accurately represent the intra-aneurysmal hemodynamics.

Mild intraoperative hypothermia during surgery for intracranial aneurysm.

PubMed

Todd, Michael M; Hindman, Bradley J; Clarke, William R; Torner, James C

2005-01-13

Surgery for intracranial aneurysm often results in postoperative neurologic deficits. We conducted a randomized trial at 30 centers to determine whether intraoperative cooling during open craniotomy would improve the outcome among patients with acute aneurysmal subarachnoid hemorrhage. A total of 1001 patients with a preoperative World Federation of Neurological Surgeons score of I, II, or III ("good-grade patients"), who had had a subarachnoid hemorrhage no more than 14 days before planned surgical aneurysm clipping, were randomly assigned to intraoperative hypothermia (target temperature, 33 degrees C, with the use of surface cooling techniques) or normothermia (target temperature, 36.5 degrees C). Patients were followed closely postoperatively and examined approximately 90 days after surgery, at which time a Glasgow Outcome Score was assigned. There were no significant differences between the group assigned to intraoperative hypothermia and the group assigned to normothermia in the duration of stay in the intensive care unit, the total length of hospitalization, the rates of death at follow-up (6 percent in both groups), or the destination at discharge (home or another hospital, among surviving patients). At the final follow-up, 329 of 499 patients in the hypothermia group had a Glasgow Outcome Score of 1 (good outcome), as compared with 314 of 501 patients in the normothermia group (66 percent vs. 63 percent; odds ratio, 1.14; 95 percent confidence interval, 0.88 to 1.48; P=0.32). Postoperative bacteremia was more common in the hypothermia group than in the normothermia group (5 percent vs. 3 percent, P=0.05). Intraoperative hypothermia did not improve the neurologic outcome after craniotomy among good-grade patients with aneurysmal subarachnoid hemorrhage. Copyright 2005 Massachusetts Medical Society.

Evaluation of the Effect of Aneurysmal Clipping on Electrocardiography and Echocardiographic Changes in Patients With Subarachnoid Hemorrhage: A Prospective Observational Study.

PubMed

Jangra, Kiran; Grover, Vinod K; Bhagat, Hemant; Bhardwaj, Avanish; Tewari, Manoj K; Kumar, Bhupesh; Panda, Nidhi B; Sahu, Seelora

2017-07-01

Electrocardiographic (ECG) and echocardiographic changes that are subsequent to aneurysmal subarachnoid hemorrhage (a-SAH) are commonly observed with a prevalence varying from 27% to 100% and 13% to 18%, respectively. There are sparse data in the literature about the pattern of ECG and echocardiographic changes in patients with SAH after clipping of the aneurysm. Hence, we observed the effect of aneurysmal clipping on ECG and echocardiographic changes during the first week after surgery, and the impact of these changes on outcome at the end of 1 year. This prospective, observational study was conducted in 100 consecutive patients with a-SAH undergoing clipping of ruptured aneurysm. ECG and echocardiographic changes were recorded preoperatively and every day after surgery until 7 days. Outcome was evaluated using the Glasgow outcome scale at the end of 1 year. Of 100 patients, 75 had ECG changes and 17 had echocardiographic changes preoperatively. The ECG changes observed were QTc prolongation, conduction defects, ST-wave and T-wave abnormalities, tachyarrhythmias, and bradyarrhythmias. The echocardiography changes included global hypokinesia and regional wall motion abnormalities. Both echocardiographic and ECG changes showed significant recovery on the first postoperative day. Patients presenting with both echocardiographic and ECG changes were found to require higher ionotropic support to maintain the desired blood pressure, and were associated with poor outcome (Glasgow outcome scale, 1 to 2) at 1 year after surgery. There was no association of ECG and echocardiographic changes with mortality (both in-hospital or at 1 year). The ECG changes, such as QTc prolongation, bradycardia, conduction abnormality, and echocardiographic changes, recover on postoperative day-1, in most of the cases after clipping. Patients with combined ECG and echocardiographic changes tend to have poor neurological outcome at the end of 1 year.

Treatment of a Salmonella-induced rapidly expanding aortic pseudoaneurysm involving the visceral arteries using the Cardiatis multilayer stent.

PubMed

Reijnen, Michel M P J; van Sterkenburg, Steven M M

2014-10-01

Treatment of infection-induced aortic aneurysms is among the greatest challenges nowadays of vascular surgery because the use of prosthetic material is considered unsuitable. The Cardiatis multilayer stent (Cardiatis, Isnes, Belgium) is a flow-diverting bare stent with a proven efficacy in peripheral and visceral artery aneurysms. We present a unique case of a Salmonella serotype enteritidis-induced rapidly expanding aortic pseudoaneurysm with a penetrating ulcer that was treated with the Cardiatis multilayer stent. At 18 months of follow-up, the patient was in good clinical condition, with normalized C-reactive protein levels. Computed tomography angiography and 2-deoxy-2-[F18]-fluoro-d-glucose-positron-emission tomography/computed tomography showed a stable, mostly thrombosed aneurysm, with adequate perfusion of the side branches and no remaining signs of infection. Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Unruptured internal carotid-posterior communicating artery aneurysm splitting the oculomotor nerve: a case report and literature review.

PubMed

Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki

2014-08-01

Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases. Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks. Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare.

Unruptured Internal Carotid-Posterior Communicating Artery Aneurysm Splitting the Oculomotor Nerve: A Case Report and Literature Review

PubMed Central

Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki

2014-01-01

Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases. Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks. Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare. PMID:25083381

Spinal cord protection in descending thoracic and thoracoabdominal aortic aneurysm repair.

PubMed

Safi, H J; Campbell, M P; Ferreira, M L; Azizzadeh, A; Miller, C C

1998-01-01

During aneurysm repair of the descending thoracic or thoracoabdominal aorta, the likelihood of neurological complications increases greatly after only 30 minutes of spinal cord ischemia. However, the manifestation of paraplegia or paraparesis relates not only to aortic cross-clamping time, but to multiple factors that may include aortic dissection, previous aortic surgery, advanced age, preoperative renal insufficiency, rupture, and most significantly, aneurysm extent. At greatest risk is the patient with type II thoracoabdominal aortic aneurysm. For this patient the simple cross-clamp technique, which uses no protective surgical adjuncts, heightens the threat of neurological deficit. With the surgical adjuncts of cerebrospinal fluid drainage and distal aortic perfusion, the probability of neurological deficit is appreciably lowered.

Surgical treatment of an extracranial carotid artery aneurysm in a child by an arterial autograft.

PubMed

Gaudry, Marine; Al Farai, Abdallah; Fouilloux, Virginie; Piquet, Philippe

2017-11-01

We report a symptomatic aneurysm of the left common carotid artery (LCCA) in a 6-year-old boy. The patient had been diagnosed and treated 3 years earlier for an isolation of the LCCA with a right-sided aortic arch. At the age of 3 years, the LCCA was reimplanted in the ascending aorta. Three years later, the patient developed a voluminous aneurysm of the LCCA complicated by stroke. An arterial graft was used for the carotid reconstruction with good long-term patency and no aneurysm evolution. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Saccular aortic aneurysm that resembled a mediastinal neoplasm

PubMed Central

Nose, Naohiro; Kataoka, Hiroumi; Hamada, Masakatsu; Kosako, Yukio; Matsuno, Yasuji; Ishii, Takahiro

2012-01-01

INTRODUCTION Saccular aortic arch aneurysms in unusual sites may be misdiagnosed as a neoplasm. We present the case of a rare saccular aortic arch aneurysm between trachea and esophagus that resembled a mediastinal neoplasm in the preoperative findings. PRESENTATION OF CASE A 63-year-old male with an abnormal mediastinal shadow on chest X-ray was referred to the hospital. An axial plain computed tomogram of the chest revealed mediastinal soft tissue next to the right side of the aortic arch resembling a neoplasm originating from the gap between the trachea and the esophagus. The coronal view constructed by enhanced 64-row multi detector computed tomography revealed the soft tissue was an aneurysm arising from the inner side of the aortic arch. An aortic arch replacement was performed via a median sternotomy. DISCUSSION A thoracic aortic aneurysm sometimes behaves like a mediastinal neoplasm. The multiple cross-sectional image from multidetector computed tomography was useful for the correct diagnosis of such an aneurysm. CONCLUSION The possibility of an aneurysm should be considered whenever a mass in contact with the aortic wall is identified. PMID:22995656

First long-term evidence supporting endovascular repair of abdominal aortic aneurysms.

PubMed

Indes, Jeffrey E; Muhs, Bart E; Dardik, Alan

2013-04-01

The traditional method of treating abdominal aortic aneurysms with open surgical repair has been steadily replaced by endovascular repair, thought to be a more minimally invasive approach. It is not known, however, whether the endovascular approach is truly less invasive for operative physiology; in addition, this approach has a different spectrum of complications. As such, it is uncertain whether elective endovascular repair of nonruptured aortic aneurysms reduces long-term morbidity and mortality compared with traditional open approaches. In this article, the authors evaluate a recent publication investigating long-term outcomes of a prospective randomized multicenter trial evaluating patients with asymptomatic abdominal aortic aneurysms treated with either endovascular or open repair, and discuss the results in the context of current evidence.

Stromal Cell-Derived Factor-1 Is Associated with Angiogenesis and Inflammatory Cell Infiltration in Aneurysm Walls

PubMed Central

Hoh, Brian L.; Hosaka, Koji; Downes, Daniel P.; Nowicki, Kamil W.; Wilmer, Erin N.; Velat, Gregory J.; Scott, Edward W.

2013-01-01

Object A small percentage of cerebral aneurysms rupture, but when they do, the effects are devastating. Current management of unruptured aneurysms consist of surgery, endovascular treatment, or watchful waiting. If the biology of how aneurysms grow and rupture were better known, a novel drug could be developed to prevent unruptured aneurysms from rupturing. Ruptured cerebral aneurysms are characterized by inflammation-mediated wall remodeling. We studied the role of stromal cell-derived factor-1 (SDF-1) in inflammation-mediated wall remodeling in cerebral aneurysms. Methods Human aneurysms; murine carotid aneurysms; and murine intracranial aneurysms were studied by immunohistochemistry. Flow cytometry analysis was performed on blood from mice developing carotid aneurysms or intracranial aneurysms. The effect of SDF-1 on endothelial cells and macrophages was studied by chemotaxis cell migration assay and capillary tube formation assay. Anti-SDF-1 blocking antibody was given to mice and compared to control (vehicle)-administered mice for its effects on the walls of carotid aneurysms and the development of intracranial aneurysms. Results Human aneurysms, murine carotid aneurysms, and murine intracranial aneurysms, all express SDF-1; and mice with developing carotid aneurysms or intracranial aneurysms have increased progenitor cells expressing CXCR4, the receptor for SDF-1 (P<0.01 and P<0.001, respectively). Human aneurysms and murine carotid aneurysms have endothelial cells, macrophages, and capillaries in the walls of the aneurysms; and the presence of capillaries in the walls of human aneurysms is associated with presence of macrophages (P=0.01). SDF-1 promotes endothelial cell and macrophage migration (P<0.01 for each), and promotes capillary tube formation (P<0.001). When mice are given anti-SDF-1 blocking antibody, there is a significant reduction in endothelial cells (P<0.05), capillaries (P<0.05), and cell proliferation (P<0.05) in the aneurysm wall. Mice given anti-SDF-1 blocking antibody develop significantly fewer intracranial aneurysms (33% versus 89% in mice given control IgG)(P<0.05). Conclusions These data suggest SDF-1 associated with angiogenesis and inflammatory cell migration and proliferation in the walls of aneurysms, and may have a role in the development of intracranial aneurysms. PMID:24160472

True Aneurysm of the Inferior Thyroid Artery: A Case Report and Literature Review.

PubMed

Venturini, Luigi; Sapienza, Paolo; Grande, Raffaele; Scarano Catanzaro, Valerio; Fanelli, Fabrizio; di Marzo, Luca

2017-04-01

Aneurysms of the inferior thyroid artery (ITA) are extremely rare and potentially determine severe sequelae. We report a case of true ITA aneurysm in a 45-year-old Caucasian woman treated with endovascular embolization; postoperative course was uneventful and, at 6-month follow-up, the aneurysm is completely thrombized. A systematic review of the literature has been also performed to identify the epidemiologic and clinical characteristics and diagnostic and operative options of this disease. Size alone is not able to predict the fate of the aneurysm and an aggressive treatment seems to be justified because of the high risk of complications in case of rupture. In an emergency setting, the endovascular procedures associated to hematoma evacuation or open surgery should be rapidly performed to save patient life. Copyright © 2016 Elsevier Inc. All rights reserved.

[3-D angiography in diagnosis and treatment of intracranial aneurysm].

PubMed

Wang, D; Ling, F; Liu, S

2001-09-01

To summarize the results of initial application of three-dimensional angiography (3D-Angio) in diagnosis and treatment of intracranial aneurysms. From August 1999 to January 2001, standard digital subtraction angiography (two-dimensional angiography, 2D-Angio) and 3D-Angio(obtained by reconstruction of rotational angiography) were performed in 65 patients with confirmed or suspected aneurysms. Sixty-six aneurysms were found in 60 patients and nothing was found in 5. Of 66 the aneurysms (60 cases), 46 (43 cases) were treated by intrasaccule embolizotion with coils, 3 (3 cases) by occluding the parent artery with detachable balloon, 10 (10 cases) by surgery, and 1 (1 case) by combination of extracranial-intracranial bypass and balloon occlusion of parent artery. Six (3 cases) were not treated. Two aneurysms that could not be detected by 2D-Angio were diagnosed by 3D-Angio. Three aneurysms that were difficult or dangerous to embolize by 2D-Angio were embolized successfully with the help of 3D-Angio. Three aneurysms seemed to be embolized on 2D-Angio were proved impossible to be embolized on 3D-Angio. Of the 46 aneurysms embolized intrasaccularly, 38(82.6%) were completely embolized on 2D-Angio. In the 38, 8 had residual aneurysm on 3D-Angio. More accurate diagnosis and secure treatment of intracranial aneurysm can be reached by 3D-Angio.

Effect of improved endograft design on outcome of endovascular aneurysm repair.

PubMed

Torella, Francesco

2004-08-01

This study was undertaken to identify factors that lead to improvements in the results of endovascular aneurysm repair, with particular focus on new endograft design. We analyzed data for patients enrolled in the European Collaborators on Stent Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry, and compared those for endografts now withdrawn from the market with those for endografts currently in use. Patients in whom a variety of endograft types were used in small numbers were excluded. Postoperative and long-term outcomes were initially compared with univariate analyses, and subsequently multivariate tests were used to adjust for baseline differences between the 2 groups. The main outcome measures were freedom from a variety of secondary interventions, aneurysm rupture, and death. Some 1224 patients received "withdrawn" endografts, and 2768 patients received "current" endografts. The 2 groups were generally similar, but patients with current devices were more often men, significantly older, more frequently unfit for open surgery, and had larger aneurysms with wider necks. Of no surprise, current endografts were also more often used by experienced (>60 previous cases) surgical teams (44% vs 20%; P <.0001). Thirty-day clinical outcomes were comparable in the 2 groups, although patients with withdrawn devices were less likely to have type II endoleak (9.2% vs 5.5%; P <.0001), and those with current devices had a shorter mean hospital stay (5.4 vs 6.8 days; P <.0001). At 3 years more patients with current devices were free from secondary transfemoral intervention (88.4% vs 76%; P <.0001) and conversion to open repair (95.4% vs 93.4%; P =.007). Aneurysm-related mortality at 3 years, defined as death due to aneurysm rupture or within 30 days of a secondary intervention, was also less frequent with current endografts (2.7% vs 4.4%; P =.02). Aneurysm rupture at 3 years was infrequent (0.8% vs 1.8%; P =.07). At multivariate analysis the use of current devices was a protective factor against late conversion to open repair (hazard ratio, 0.49; 95% confidence interval, 0.28-0.86; P =.014) and aneurysm-related death (hazard ratio, 0.51, 95% confidence interval, 0.34-0.75; P =.0008). Larger aneurysm or neck diameter and shorter neck length were also associated with late conversion to open repair; larger aneurysm diameter, older age, and unfitness for open surgery were predictive of aneurysm-related death. Modern endograft design has improved the results of endovascular aneurysm repair.

Comparison of false-negative/positive results of intraoperative evoked potential monitoring between no and partial neuromuscular blockade in patients receiving propofol/remifentanil-based anesthesia during cerebral aneurysm clipping surgery: A retrospective analysis of 685 patients.

PubMed

Kim, Sung-Hoon; Jin, Seok-Joon; Karm, Myong-Hwan; Moon, Young-Jin; Jeong, Hye-Won; Kim, Jae-Won; Ha, Seung-Il; Kim, Joung-Uk

2016-08-01

Although the elicited responses of motor evoked potential (MEP) monitoring are very sensitive to suppression by anesthetic agents and muscle relaxants, the use of neuromuscular blockade (NMB) during MEP monitoring is still controversial because of serious safety concerns and diagnostic accuracy. Here, we evaluated the incidence of unacceptable movement and compared false-negative MEP results between no and partial NMB during cerebral aneurysm clipping surgery. We reviewed patient medical records for demographic data, anesthesia regimen, neurophysiology event logs, MEP results, and clinical outcomes. Patients were divided into 2 groups according to the intraoperative use of NMB: no NMB group (n = 276) and partial NMB group (n = 409). We compared the diagnostic accuracy of MEP results to predict postoperative outcomes between both groups. Additionally, we evaluated unwanted patient movement during MEP monitoring in both groups. Of the 685 patients, 622 (90.8%) manifested no intraoperative changes in MEP and no postoperative motor deficits. Twenty patients showed postoperative neurologic deficits despite preserved intraoperative MEP. False-positive MEP results were 3.6% in the no NMB group and 3.9% in the partial NMB group (P = 1.00). False-negative MEP results were 1.1% in the no NMB group and 4.2% in the partial NMB group (P = 0.02). No spontaneous movement or spontaneous respiration was observed in either group. Propofol/remifentanil-based anesthesia without NMB decreases the stimulation intensity of MEPs, which may reduce the false-negative ratio of MEP monitoring during cerebral aneurysm surgery. Our anesthetic protocol enabled reliable intraoperative MEP recording and patient immobilization during cerebral aneurysm clipping surgery.

Women undergoing aortic surgery are at higher risk for unplanned readmissions compared with men especially when discharged home.

PubMed

Flink, Benjamin J; Long, Chandler A; Duwayri, Yazan; Brewster, Luke P; Veeraswamy, Ravi; Gallagher, Katherine; Arya, Shipra

2016-06-01

Women undergoing vascular surgery have higher morbidity and mortality. Our study explores gender-based differences in patient-centered outcomes such as readmission, length of stay (LOS), and discharge destination (home vs nonhome facility) in aortic aneurysm surgery. Patients were identified from the American College of Surgeons National Surgical Quality Improvement Project database (2011-2013) undergoing abdominal, thoracic, and thoracoabdominal aortic aneurysms (N = 17,763), who were discharged and survived their index hospitalization. The primary outcome was unplanned readmission, and secondary outcomes were discharge to a nonhome facility, LOS, and reasons for unplanned readmission. Univariate, multivariate, and stratified analyses based on gender and discharge destination were used. Overall, 1541 patients (8.7%) experienced an unplanned readmission, with a significantly higher risk in women vs men (10.8% vs 8%; P < .001) overall (Procedure subtypes: abdominal aortic aneurysm [10.1% vs 7.7%; P < .001], thoracic aortic aneurysm [14.1% vs 13.5%; P = .8], and thoracoabdominal aortic aneurysm [14.8% vs 10%; P = .051]). The higher odds of readmission in women compared with men persisted in multivariate analysis after controlling for covariates (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4). Similarly, the rate of discharge to a nonhome facility was nearly double in women compared with men (20.6% vs 10.7%; P < .001), but discharge to a nonhome facility was not a significant predictor of unplanned readmission. Upon stratification by discharge destination, the higher odds of readmissions in women compared with men occurred in patients who were discharged home (OR, 1.2; 95% CI, 1.02-1.4) but not in those who were discharged to a nonhome facility (OR, 1.06; 95% CI, 0.8-1.4). Significant differences in LOS were seen in patients who were discharged home. No gender differences were found in reasons for readmission with the three most common reasons being thromboembolic events, wound infections, and pneumonia. Gender disparity exists in the risk of unplanned readmission among aortic aneurysm surgery patients. Women who were discharged home have a higher likelihood of unplanned readmission despite longer LOS than men. These data suggest that further study into the discharge planning processes, social factors, and use of rehabilitation services is needed for women undergoing aortic procedures to decrease readmissions. Published by Elsevier Inc.

JAG Tearing Technique with Radiofrequency Guide Wire for Aortic Fenestration in Thoracic Endovascular Aneurysm Repair

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ricci, Carmelo; Ceccherini, Claudio, E-mail: claudiocec@hotmail.it; Leonini, Sara

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.

Indocyanine Green Videoangiography Transoptic Visualization and Clipping Confirmation of an Optic Splitting Ophthalmic Artery Aneurysm.

PubMed

Rustemi, Oriela; Cester, Giacomo; Causin, Francesco; Scienza, Renato; Della Puppa, Alessandro

2016-06-01

Ophthalmic artery aneurysms with medial and superior projection in exceptionally rare cases can split the optic nerve. Treatment of these aneurysms is challenging, because the aneurysm dome is hidden from the optic nerve, rendering its visualization and clipping confirmation difficult. In addition, optic nerve function should be preserved during surgical maneuvers. Preoperative detection of this growing feature is usually missing. We illustrate the first case of indocyanine green videoangiography (ICG-VA) application in an optic penetrating ophthalmic artery aneurysm treatment. A 57-year-old woman presented with temporal hemianopsia, slight right visual acuity deficit, and new onset of headache. The cerebral angiography detected a right ophthalmic artery aneurysm medially and superiorly projecting. The A1 tract of the ipsilateral anterior cerebral artery was elevated and curved, being suspicious for an under optic aneurysm growth. Surgery was performed. Initially the aneurysm was not visible. ICG-VA permitted the transoptic aneurysm visualization. After optic canal opening, the aneurysm was clipped and transoptic ICG-VA confirmed the aneurysm occlusion. ICG-VA showed also the slight improvement of the optic nerve pial vascularization. Postoperatively, the visual acuity was 10/10 and the hemianopsia did not worsen. The elevation and curve of the A1 tract in medially and superiorly projecting ophthalmic aneurysms may be an indirect sign of under optic growth, or optic splitting aneurysms. ICG-VA transoptic aneurysm detection and occlusion confirmation reduces the surgical maneuvers on the optic nerve, contributing to function preservation. Copyright © 2016 Elsevier Inc. All rights reserved.

Aneurysm of the intradural artery of Adamkiewicz treated with muslin wrapping: technical case report.

PubMed

Vishteh, A G; Brown, A P; Spetzler, R F

1997-01-01

An exceedingly rare, isolated spinal arterial aneurysm and its management are presented. A 30-year-old man who presented with severe lower back pain and headache underwent a computed tomographic study of his head that disclosed nothing abnormal and a lumbar puncture that revealed bloody, xanthochromic cerebrospinal fluid. The findings from cerebral angiography were normal, and the results from spinal angiography were consistent with a diagnosis of an aneurysm of the artery of Adamkiewicz. A transthoracic approach with a partial T11 vertebrectomy gained exposure to this anteriorly located lesion. A fusiform aneurysm of the intradural portion of the artery of Adamkiewicz was discovered. Excision of the aneurysm with a vascular bypass was deemed impossible. The lesion was treated with muslin wrapping. One year after surgery, the patient remains at his baseline neurological condition. A review of the literature revealed only one other reported case of a ruptured aneurysm of the artery of Adamkiewicz, which was discovered postmortem. Therefore, this case represents the first report of a diagnosed and treated artery of Adamkiewicz aneurysm.

Aneurysm of Pancreatic Artery in Association with Celiac Axis Stenosis: Report of a Case and Review of the Literatures.

PubMed

Yamamoto, Takatsugu; Miyazaki, Toru; Kurashima, Yukiko; Ohata, Kazunori; Okawa, Masato; Tanaka, Shogo; Uenishi, Takahiro

2015-12-01

A 63-year-old Japanese woman with a history of pemphigus was referred to us for abnormal findings of dynamic abdominal CT where three aneurysms of splenic artery and pancreaticoduodenal artery, celiac axis compression, and gall stone. Superior mesenteric artery supplied hepatic arterial flow via pancreaticoduodenal artery. Avoiding transarterial embolization to prompt arterial ischemia of liver/pancreas head/duodenum, she laparotomically underwent cholecystectomy, splenectomy, transection of median arcurate ligament, and ligation of splenic and inferior pancreaticoduodenal artery all at once. Postoperative course was uneventful except drainage of abdominal abscess, and she remained well without aneurysm recurring 40 months post. Important point of treatment for pancreaticoduodenal artery aneurysm associated with celiac artery occlusion/stenosis is both preventive solutions for rupture of aneurysm and hepatic/duodenal/pancreatic arterial ischemia. Remaining main arterial supply for the liver via pancreaticoduodenal artery from superior mesenteric artery would prompt recurrent aneurysm of pancreaticoduodenal artery. When a clinician encounters a case of pancreatic aneurysm associated with celiac axis occlusion, the case should be treated using with multimodality such as interventional radiology, and vascular surgery.

The feasibility of detecting cerebral blood flow direction using the indocyanine green video angiography.

PubMed

Murai, Yasuo; Nakagawa, Syunsuke; Matano, Fumihiro; Shirokane, Kazutaka; Teramoto, Akira; Morita, Akio

2016-10-01

The intraoperative confirmation of blood flow direction is necessary in cerebral vascular surgery. Using indocyanine green video angiography (ICG-VAG) with the FLOW 800 system, we examined the transit time of the blood vessel of interest and semiquantitatively evaluated the delay time (T1/2max) from indocyanine green (ICG) injection into the donor artery in reconstructive surgery and the middle cerebral artery (MCA) in aneurysmal surgery. The direction of cerebral blood flow (CBF), which can often be confirmed by ICG-VAG, may be more difficult to determine with faster blood flow. Here, we report our findings regarding the feasibility of detecting CBF direction using the FLOW 800 system. Twenty patients undergoing superficial temporal artery (STA) to MCA anastomosis for carotid occlusive disease and 13 patients with a small MCA aneurysm clipping were evaluated using the T1/2max, semiquantitative method with the FLOW 800 system. In STA-MCA anastomosis cases, the regions of interest (ROIs) included: the proximal donor STA and a region more than 10 mm on the distal side of the donor STA near the anastomosis site. In MCA aneurysms, the ROIs included the proximal M1 and distal M2 sides of the MCA aneurysm. T1/2max was significantly shorter for the proximal sites compared to the distal sites for all subjects (ps < 0.01). T1/2max was shorter for all subjects in the proximal sites. The direction of CBF can be determined using the FLOW 800 system.

Microsurgery Simulator of Cerebral Aneurysm Clipping with Interactive Cerebral Deformation Featuring a Virtual Arachnoid.

PubMed

Shono, Naoyuki; Kin, Taichi; Nomura, Seiji; Miyawaki, Satoru; Saito, Toki; Imai, Hideaki; Nakatomi, Hirofumi; Oyama, Hiroshi; Saito, Nobuhito

2018-05-01

A virtual reality simulator for aneurysmal clipping surgery is an attractive research target for neurosurgeons. Brain deformation is one of the most important functionalities necessary for an accurate clipping simulator and is vastly affected by the status of the supporting tissue, such as the arachnoid membrane. However, no virtual reality simulator implementing the supporting tissue of the brain has yet been developed. To develop a virtual reality clipping simulator possessing interactive brain deforming capability closely dependent on arachnoid dissection and apply it to clinical cases. Three-dimensional computer graphics models of cerebral tissue and surrounding structures were extracted from medical images. We developed a new method for modifiable cerebral tissue complex deformation by incorporating a nonmedical image-derived virtual arachnoid/trabecula in a process called multitissue integrated interactive deformation (MTIID). MTIID made it possible for cerebral tissue complexes to selectively deform at the site of dissection. Simulations for 8 cases of actual clipping surgery were performed before surgery and evaluated for their usefulness in surgical approach planning. Preoperatively, each operative field was precisely reproduced and visualized with the virtual brain retraction defined by users. The clear visualization of the optimal approach to treating the aneurysm via an appropriate arachnoid incision was possible with MTIID. A virtual clipping simulator mainly focusing on supporting tissues and less on physical properties seemed to be useful in the surgical simulation of cerebral aneurysm clipping. To our knowledge, this article is the first to report brain deformation based on supporting tissues.

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow.

PubMed

Chung, Joon Ho; Shin, Yong Sam; Lim, Yong Cheol; Park, Minjung

2009-04-01

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.

Inferior Pancreaticoduodenal Artery Aneurysms Associated with Occlusive Lesions of the Celiac Axis: Diagnosis, Treatment Options, Outcomes, and Review of the Literature

DOE Office of Scientific and Technical Information (OSTI.GOV)

Flood, Karen, E-mail: karenrogers@doctors.org.uk; Nicholson, Anthony A.

2013-06-15

Purpose. To describe the presentation, treatment, and outcomes for 14 patients with aneurysms of the inferior pancreaticoduodenal arteries associated with occlusive lesions of the celiac axis, and to review the literature for similar cases. Methods, Over a period of 12 years, 14 patients (10 women and 4 men) ranging in age from 26 to 50 (mean 46) years were demonstrated to have aneurysms of the inferior pancreaticoduodenal artery origin associated with stenosis or occlusion of the celiac axis. All patients were treated by a combination of surgery and interventional radiology. Results. Outcome data collected between 3 months and 4 yearsmore » (mean 2 years) demonstrated that all aneurysms remained excluded, and all 14 patients were well. The 49 case reports in the literature confirm the findings of this cohort. Conclusion. In inferior pancreaticoduodenal artery aneurysm resulting from celiac occlusive disease, endovascular treatment is best achieved by stenting the celiac axis and/or embolizing the aneurysm when necessary.« less

Suspected leaking abdominal aortic aneurysm: use of sonography in the emergency room.

PubMed

Shuman, W P; Hastrup, W; Kohler, T R; Nyberg, D A; Wang, K Y; Vincent, L M; Mack, L A

1988-07-01

To determine the value of sonography in the emergent evaluation of suspected leaking abdominal aortic aneurysms, the authors examined 60 patients in the emergency department using sonography and a protocol involving advance radio notification from the ambulance; arrival of sonographic personnel and equipment in the triage room before patient arrival; and, during other triage activities, rapid sonographic evaluation of the aorta for aneurysm and of the paraaortic region for extraluminal blood. Sonographic findings were correlated with surgical results and clinical outcome. When performed under these circumstances, sonography was accurate in demonstrating presence or absence of aneurysm (98%), but its sensitivity for extraluminal blood was poor (4%). A combination of sonographic confirmation of aneurysm, abdominal pain, and unstable hemodynamic condition resulted in the correct decision to perform emergent surgery in 21 of 22 patients (95%). An abbreviated sonographic examination done in the emergency room can provide accurate, useful information about the presence of aneurysm; this procedure does not significantly delay triage of these patients.

[Non traumatic giant aneurysm of middle meningeal artery. Case report and review of the literature].

PubMed

Vilalta, Jordi; Martínez-Ricarte, Francisco; Martínez-Sáez, Elena A; Gándara, Darío; Arikan, Fuat

2017-12-29

A case of a non-traumatic giant aneurysm of the middle meningeal artery is presented in a 59-year-old patient with a history of liver transplantation, liver cirrhosis and hepatocarcinoma, chronic renal disease, hypertension and chronic bronchitis who presented with tonic-clonic seizures. CT and MRI showed a lesion suggestive of metastasis without ruling out a glial type tumor. He was operated through a left FT craniotomy. During the surgery there was an arterial hemorrhage. The histological sample oriented toward an aneurysmal origin that was confirmed with ARM and angiography. A second intervention allowed the removal of a giant middle meningeal aneurysm partially thrombosed. Aneurysms of the middle meningeal artery are rare and generally present a traumatic history. No case of giant aneurysm has been found in the medical literature. Copyright © 2017 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.

Diabetes may affect intracranial aneurysm stabilization in older patients: Analysis based on intraoperative findings

PubMed Central

Song, Jihye; Shin, Yong Sam

2016-01-01

Background: Only a small proportion of aneurysms progress to rupture. Previous studies have focused on predicting the rupture risk of intracranial aneurysms. Atherosclerotic aneurysm wall appears resistant to rupture. The purpose of this study was to evaluate clinical and morphological factors affecting atherosclerosis of an aneurysm and identify the parameters that predict aneurysm stabilization. Methods: We conducted a retrospective analysis of 253 consecutive patients with 291 unruptured aneurysms who underwent clipping surgery in a single institution between January 2012 and October 2013. Aneurysms were categorized based on intraoperative video findings and assessed morphologic and demographic data. Aneurysms which had the atherosclerotic wall without any super thin and transparent portion were defined as stabilized group and the others as a not-stabilized group. Results: Of the 207 aneurysms, 176 (85.0%) were assigned to the not-stabilized group and 31 (15.0%) to the stabilized group. The relative proportion of stabilized aneurysms increased significantly as the age increased (P < 0.001). Univariate logistic analysis showed that age ≥65 years (P < 0.001), hypertension (P = 0.012), diabetes (P = 0.007), and height ≥3 mm (P = 0.007) were correlated with stabilized aneurysms. Multivariate logistic analysis showed that age ≥65 years (P = 0.009) and hypertension (P = 0.041) were strongly correlated with stable aneurysms. In older patients (≥65 years of age), multivariate logistic regression revealed that only diabetes was associated with stabilized aneurysms (P = 0.027). Conclusions: In patients ≥65 years of age, diabetes mellitus may highly predict the stabilized aneurysms. These results provide useful information in determining treatment and follow-up strategies, especially in older patients. PMID:27313965

[Tricuspid insufficiency and right traumatic ventricular aneurysm. Apropos of a case].

PubMed

Boisselier, P; Lombaert, M; Rey, J L; Quiret, J C; Bernasconi, P

1981-12-01

Tricuspid incompetence associated with a right ventricular aneurysm wa discovered after a non-penetrating thoracic injury. The severity of the tricuspid lesion was confirmed by phonomechanography, catheterisation and angiography. The mechanism was demonstrated by two-dimensional echocardiography: the right ventricular aneurysm was located in the right ventricular outflow tract. As the hemodynamic tolerance was good, surgery was not performed. A review of the literature found 41 other reports of traumatic tricuspid incompetence, and 4 cases of right ventricular aneurysm, only one of which was associated with tricuspid regurgitation. The points of interest of ths case: the rarity of the association, the good hemodynamic tolerance and the value of two-dimensional echocardiography for the diagnosis of ruptured chordae in the absence of surgical observations.

Embolomycotic Aneurysm of External Iliac Artery

PubMed Central

Terán, Nemesio A.; Gonzalez, Nerio M.; García, Luis; Gonzalez, Freddy E.; Rivera, Humberto E.

1989-01-01

We report a case of embolomycotic aneurysm of the right iliac artery secondary to bacterial endocarditis. The patient, a 33-year-old woman, presented with unilateral hydronephrosis and lower extremity edema caused by aneurysmal compression of the ipsilateral ureter and the external iliac vein. She was treated with ligation and an extraperitoneal left-external-iliac-artery to right-femoral-artery bypass using a knitted Dacron prosthesis. Since her surgery, our patient has been well except for persistence of moderate leg edema. To the best of our knowledge, we are reporting the 1st case of embolomycotic external-iliac-artery aneurysm secondary to bacterial endocarditis and resulting in hydronephrosis and venous insufficiency. (Texas Heart Institute Journal 1989;16:51-55) Images PMID:15227238

Gorham disease of the lumbar spine with an abdominal aortic aneurysm: a case report.

PubMed

Kakuta, Yohei; Iizuka, Haku; Kobayashi, Ryoichi; Iizuka, Yoichi; Takahashi, Toru; Mohara, Jun; Takagishi, Kenji

2014-01-01

Reports of Gorham disease of the lumbar spine complicated by abdominal aortic aneurysms are rare. We herein report the case of a patient with Gorham disease of the lumber spine involving an abdominal aortic aneurysm (AAA). Case report. A 49-year-old man had a 1-month history of right leg pain and severe low back pain. Plain lumbar radiography revealed an osteolytic lesion in the L4 vertebral body. Computed tomography images demonstrated the presence of an extensive osteolytic lesion in the L4 vertebral body and an AAA in front of the L4 vertebral body. The patient underwent mass resection, spinal reconstruction, and blood vessel prosthesis implantation. During surgery, it was found that the wall of the aorta had completely disappeared and was shielded by the tumor mass; therefore, we speculated that the mass in the lumbar spine had directly invaded the aorta. The patient was able to walk without right leg or low back pain 1 year after undergoing surgery. No recurrence was demonstrated in the magnetic resonance images taken 1 year and 10 months after surgery. Copyright © 2014 Elsevier Inc. All rights reserved.

A simulator for training in endovascular aneurysm repair: The use of three dimensional printers.

PubMed

Torres, I O; De Luccia, N

2017-08-01

To develop an endovascular aneurysm repair (EVAR) simulation system using three dimensional (3D) printed aneurysms, and to evaluate the impact of patient specific training prior to EVAR on the surgical performance of vascular surgery residents in a university hospital in Brazil. This was a prospective, controlled, single centre study. During 2015, the aneurysms of patients undergoing elective EVAR at São Paulo University Medical School were 3D printed and used in training sessions with vascular surgery residents. The 3D printers Stratasys-Connex 350, Formlabs-Form1+, and Makerbot were tested. Ten residents were enrolled in the control group (five residents and 30 patients in 2014) or the training group (five residents and 25 patients in 2015). The control group performed the surgery under the supervision of a senior vascular surgeon (routine procedure, without simulator training). The training group practised the surgery in a patient specific simulator prior to the routine procedure. Objective parameters were analysed, and a subjective questionnaire addressing training utility and realism was answered. Patient specific training reduced fluoroscopy time by 30% (mean 48 min, 95% confidence interval [CI] 40-58 vs. 33 min, 95% CI 26-42 [p < .01]), total procedure time by 29% (mean 292 min [95% CI 235-336] vs. 207 [95% CI 173-247]; p < .01), and volume of contrast used by 25% (mean 87 mL [95% CI 73-103] vs. 65 mL [95% CI 52-81]; p = .02). The residents considered the training useful and realistic, and reported that it increased their self confidence. The 3D printers Form1+ (using flexible resin) and Makerbot (using silicone) provided the best performance based on simulator quality and cost. An EVAR simulation system using 3D printed aneurysms was feasible. The best results were obtained with the 3D printers Form1+ (using flexible resin) and Makerbot (using silicone). Patient specific training prior to EVAR at a university hospital in Brazil improved residents' surgical performance (based on fluoroscopy time, surgery time, and volume of contrast used) and increased their self confidence. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

The minimally invasive management of visceral artery aneurysms and pseudoaneurysms.

PubMed

Fankhauser, Grant T; Stone, William M; Naidu, Sailendra G; Oderich, Gustavo S; Ricotta, Joseph J; Bjarnason, Haraldur; Money, Samuel R

2011-04-01

Minimally invasive methods (MIMs) are now available for the management of visceral artery aneurysms and pseudoaneurysms (visceral artery aneurysms [VAA]). The purpose of this study was to review our 10-year experience with the MIM of treating VAA. All patients evaluated from June 1999 to June 2009 with VAAs were reviewed. Demographics, therapy, and results were analyzed. MIM was attempted in 185 aneurysms in 176 patients. Initial intervention was successful in 98% ofaneurysms. Sixty-three (34%) aneurysms were located in the splenic artery, 56 (30%) in the hepatic, 28 (15%) in the gastroduodenal, 16 (8.6%) in the pancreaticoduodenal, six (3.2%) in the superior mesenteric, four (2.1%) in the gastric, four (2.1%) in the celiac, four (2.1%) in the gastroepiploic, two (1%) in the inferior mesenteric, and one (0.5%) in the middle colic artery. Pseudoaneurysms were more common than true aneurysms (64% vs 36%). Bleeding was the indication for intervention in 86 aneurysms (46%). Initial treatment was successful in 177 aneurysms (98%). Reintervention was required in five (3%) aneurysms within 30 days. Coiling was used alone in 139 aneurysms (75%) and in combination with at least one other technique in 20 (11%) cases. Thirty-day aneurysm-related mortality was 3.4% (six deaths). Five additional deaths occurred during 30-day follow-up, although none was related to complications of the aneurysms (2.8%). MIM for visceral artery aneurysms can be used alone or in combination to effectively treat VAAs in elective or emergent conditions. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Aneurysmectomy and revascularization of a large hepatic artery aneurysm.

PubMed

Adkisson, Cameron D; Sibulesky, Lens; Collis, George N; McLaughlin, Daniel W; Oldenburg, W A; Nguyen, Justin H

2011-05-01

Aneurysms of the hepatic artery are rare, but are associated with significant mortality because of their lack of symptoms at presentation and risk of rupture. We report a case of an enlarging 4-cm hepatic artery aneurysm involving the proximal common hepatic artery to the bifurcation of the right and left hepatic arteries which was found incidentally on ultrasound examination. Endovascular treatment with a stent was considered, but because of the location of the aneurysm as well as the presence of significant thrombosis involving the right and left hepatic arteries, aneurysmectomy and revascularization using saphenous vein was performed. Doppler ultrasound measurements demonstrated good flow through the graft postoperatively and at 1-month follow-up. Although a variety of endovascular techniques exist to treat hepatic artery aneurysms, our results indicate that open excision and revascularization may be required and can have a good outcome. Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Long-Term Follow-Up for a Giant Basilar Trunk Aneurysm Surgically Treated by Proximal Occlusion and External Carotid Artery to Posterior Cerebral Artery Bypass Using a Saphenous Vein Graft.

PubMed

Yanagisawa, Toshiharu; Kinouchi, Hiroyuki; Sasajima, Toshio; Shimizu, Hiroaki

2016-11-01

The authors describe a case of a basilar trunk aneurysm with long-term follow-up after successful bypass and proximal occlusion. A 64-year-old woman had a giant aneurysm of the basilar trunk and underwent external carotid artery-to-posterior cerebral artery vein graft bypass surgery and proximal clipping of the basilar artery, which was followed by low-dose aspirin (100 mg/d) treatment. No ischemic symptoms and lesions developed and the thrombosed aneurysm was stable during 11 years of follow-up. An extracranial-intracranial high flow bypass combined with immediate proximal occlusion and aspirin administration may be an acceptable treatment option for patients with giant posterior circulation aneurysms. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Fat and neurosurgery: does obesity affect outcome after intracranial surgery?

PubMed

Schultheiss, Kim E; Jang, Yeon Gyoe; Yanowitch, Rachel N; Tolentino, Jocelyn; Curry, Daniel J; Lüders, Jürgen; Asgarzadie-Gadim, Farbod; Macdonald, R Loch

2009-02-01

Obesity has been linked to increased morbidity and mortality after some surgical procedures. The purpose of this study was to determine whether obesity affects outcome after general neurosurgery and subarachnoid hemorrhage (SAH). Three data sets were analyzed, including a retrospective review of 404 patients undergoing cranial and spinal neurosurgical procedures, a prospective collection of 100 patients with aneurysmal SAH, and data from 3567 patients with aneurysmal SAH who were entered into randomized clinical trials of tirilazad. For each data set, outcome was assessed by mortality, postoperative morbidity, and Glasgow Outcome Scale score. Prognostic factors, including body weight and body mass index, were tested for their effect on these outcomes using multivariable logistic regression. For patients undergoing general cranial and spinal neurosurgery, independent predictors of morbidity and mortality were age, American Society of Anesthesia class, disseminated malignancy, emergency surgery, and increased duration of surgery. For patients with SAH, score on the Glasgow Outcome Scale was associated with age and admission Glasgow Coma Scale score. In the tirilazad data set, multiple factors were associated with score on the Glasgow Outcome Scale, but, as with the other 2 data sets, body weight had no relationship to outcome. Obesity may have less effect on the outcome of patients with mainly cranial neurosurgical disease and aneurysmal SAH than it does on patients undergoing other types of surgery.

Recurrence of ICA-PCoA aneurysms after neck clipping.

PubMed

Sakaki, T; Takeshima, T; Tominaga, M; Hashimoto, H; Kawaguchi, S

1994-01-01

Between 1975 and 1992, 2211 patients underwent aneurysmal neck clipping at the Nara Medical University clinic and associated hospitals. The aneurysm in 931 of these patients was situated at the junction of the internal carotid artery (ICA) and posterior communicating artery (PCoA). Seven patients were readmitted 4 to 17 years after the first surgery because of regrowth and rupture of an ICA-PCoA aneurysmal sac that had arisen from the residual neck. On angiograms obtained following aneurysmal neck clipping, a large primitive type of PCoA was demonstrated in six patients and a small PCoA in one. A small residual aneurysm was confirmed in only two patients and angiographically complete neck clipping in five. Recurrent ICA-PCoA aneurysms were separated into two types based on the position of the old clip in relation to the new growth. Type 1 aneurysms regrow from the entire neck and balloon eccentrically. In this type, it is possible to apply the clip at the neck as in conventional clipping for a ruptured aneurysm. Type 2 includes aneurysms in which the proximal portion of a previous clip is situated at the corner of the ICA and aneurysmal neck and the distal portion on the enlarged dome of the aneurysm, because the sac is regrowing from a portion of the residual neck. In this type of aneurysm, a Sugita fenestrated clip can occlude the residual neck, overriding the old clip. Classifying these aneurysms into two groups is very useful from a surgical point of view because it is possible to apply a new clip without removing the old clip, which was found to be adherent to surrounding tissue.

Characterizing saccular aortic arch aneurysms from the geometry-flow dynamics relationship.

PubMed

Natsume, Kayoko; Shiiya, Norihiko; Takehara, Yasuo; Sugiyama, Masataka; Satoh, Hiroshi; Yamashita, Katsushi; Washiyama, Naoki

2017-06-01

Low wall shear stress (WSS) has been reported to be associated with accelerated atherosclerosis, aneurysm growth, or rupture. We evaluated the geometry of aortic arch aneurysms and their relationship with WSS by using the 4-dimensional flow magnetic resonance imaging to better characterize the saccular aneurysms. We analyzed the geometry in 100 patients using multiplanar reconstruction of computed tomography. We evaluated WSS and vortex flow using 4-dimensional flow magnetic resonance imaging in 16 of them, which were compared with 8 age-matched control subjects and eight healthy young volunteers. Eighty-two patients had a saccular aneurysm, and 18 had a fusiform aneurysm. External diameter/aneurysm length ratio and sac depth/neck width ratio of the fusiform aneurysms were constant at 0.76 ± 0.18 and 0.23 ± 0.09, whereas those of saccular aneurysms, especially those involving the outer curvature, were higher and more variable. Vortex flow was always present in the aneurysms, resulting in low WSS. When the sac depth/neck width ratio was less than 0.8, peak WSS correlated inversely with luminal diameter even in the saccular aneurysms. When this ratio exceeded 0.8, which was the case only with the saccular aneurysms, such correlation no longer existed and WSS was invariably low. Fusiform aneurysms elongate as they dilate, and WSS is lower as the diameter is larger. Saccular aneurysms dilate without proportionate elongation, and they, especially those occupying the inner curvature, have higher and variable sac depth/neck width ratio. When this ratio exceeds 0.8, WSS is low regardless of diameter, which may explain their malignant clinical behavior. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices.

PubMed

Clough, Rachel E; Martin-Gonzalez, Teresa; Van Calster, Katrien; Hertault, Adrien; Spear, Rafaëlle; Azzaoui, Richard; Sobocinski, Jonathan; Haulon, Stéphan

2017-10-01

Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51 ± 8 years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4 years (0.3-7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2 years after the procedure from nonaortic causes (endocarditis). The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered. Copyright © 2017 Elsevier Inc. All rights reserved.

Preoperative Prediction of the Necessity for Anterior Clinoidectomy During Microsurgical Clipping of Ruptured Posterior Communicating Artery Aneurysms.

PubMed

Kamide, Tomoya; Burkhardt, Jan-Karl; Tabani, Halima; Safaee, Michael M; Lawton, Michael T

2018-01-01

Although most posterior communicating artery (PCoA) aneurysms can be clipped easily with excellent results, some require anterior clinoidectomy for safe and complete clipping. To review our microsurgical series of ruptured PCoA aneurysms and identify the preoperative predictors for anterior clinoidectomy during microsurgical clipping for PCoA aneurysms. Results from microsurgical clipping of 104 patients with ruptured PCoA aneurysms were reviewed retrospectively. Distances and angles were obtained from computed tomographic angiography and compared between the anterior and nonanterior clinoidectomy groups. Anterior clinoidectomy was required in 19 of the 104 cases (18%). None developed surgical complications due to anterior clinoid process (ACP) resection, including postoperative visual deficit. Univariate and multivariate analyses revealed that the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were statistically significant predictive factors for the need of anterior clinoidectomy. Based on a receiver operating characteristic analysis, the distances from the ACP tip to the aneurysmal proximal neck <4.0 mm and from the ACP line to the aneurysmal proximal neck ≤2.0 mm were selected as optimal cutoff values for predicting the necessity of anterior clinoidectomy, and the area under the receiver operating characteristic curve values were 0.991 and 0.955, respectively. In case of ruptured PCoA aneurysm surgery, the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were both found to be useful predictors of whether anterior clinoidectomy was required. Copyright © 2017 Elsevier Inc. All rights reserved.

Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device: Histopathological investigation

PubMed Central

Ikeda, Hiroyuki; Kikuchi, Takayuki; Ando, Mitsushige; Chihara, Hideo; Arai, Daisuke; Hattori, Etsuko; Miyamoto, Susumu

2015-01-01

Cerebral aneurysm rupture is a serious complication that can occur after flow diverter (FD) placement, but the underlying mechanisms remain unclear. We encountered a case in which direct stress on the aneurysm wall caused by residual blood flow at the inflow zone near the neck during the process of thrombosis after FD placement appeared associated with aneurysm rupture. The patient was a 67-year-old woman with progressive optic nerve compression symptoms caused by a large intracranial paraclinoid internal carotid aneurysm. The patient had undergone treatment with a Pipeline embolization device (PED) with satisfactory adherence between the PED and vessel wall. Surgery was completed without complications, and optic nerve compression symptoms improved immediately after treatment. Postoperative clinical course was satisfactory, but the patient suddenly died 34 days postoperatively. Autopsy confirmed the presence of subarachnoid hemorrhage caused by rupture of the internal carotid aneurysm that had been treated with PED. Although the majority of the aneurysm lumen including the outflow zone was thrombosed, a non-thrombosed area was observed at the inflow zone. Perforation was evident in the aneurysm wall at the inflow zone near the neck, and this particular area of aneurysm wall was not covered in thrombus. Macrophage infiltration was not seen on immunohistochemical studies of the aneurysm wall near the perforation. A hemodynamically unstable period during the process of complete thrombosis of the aneurysm lumen after FD placement may be suggested, and blood pressure management and appropriate management with antiplatelet therapy may be important. PMID:26500232

Stent-assisted coil embolization for cavernous carotid artery aneurysms.

PubMed

Kono, Kenichi; Shintani, Aki; Okada, Hideo; Tanaka, Yuko; Terada, Tomoaki

2014-01-01

Internal carotid artery (ICA) occlusion with or without a bypass surgery is the traditional treatment for cavernous sinus (CS) aneurysms with cranial nerve (CN) dysfunction. Coil embolization without stents frequently requires retreatment because of the large size of CS aneurysms. We report the mid-term results of six unruptured CS aneurysms treated with stent-assisted coil embolization (SACE). The mean age of the patients was 72 years. The mean size of the aneurysms was 19.8 mm (range: 13-26 mm). Before treatment, four patients presented with CN dysfunction and two patients had no symptoms. SACE was performed under local or general anesthesia in three patients each. Mean packing density was 29.1% and tight packing was achieved. There were no neurological complications. CN dysfunction was cured in three patients (75%) and partly resolved in one patient (25%). Transient new CN dysfunction was observed in two patients (33%). Clinical and imaging follow-up ranged from 6 to 26 months (median: 16 months). Recanalization was observed in three patients (50%; neck remnant in two patients and dome filling in one patient), but no retreatment has yet been required. No recurrence of CN dysfunction has occurred yet. In summary, SACE increases packing density and may reduce requirement of retreatment with an acceptable cure rate of CN dysfunction. SACE may be a superior treatment for coiling without stents and be an alternative treatment of ICA occlusion for selected patients, such as older patients and those who require a high-flow bypass surgery or cannot receive general anesthesia.

[Rapid 3-Dimensional Models of Cerebral Aneurysm for Emergency Surgical Clipping].

PubMed

Konno, Takehiko; Mashiko, Toshihiro; Oguma, Hirofumi; Kaneko, Naoki; Otani, Keisuke; Watanabe, Eiju

2016-08-01

We developed a method for manufacturing solid models of cerebral aneurysms, with a shorter printing time than that involved in conventional methods, using a compact 3D printer with acrylonitrile-butadiene-styrene(ABS)resin. We further investigated the application and utility of this printing system in emergency clipping surgery. A total of 16 patients diagnosed with acute subarachnoid hemorrhage resulting from cerebral aneurysm rupture were enrolled in the present study. Emergency clipping was performed on the day of hospitalization. Digital Imaging and Communication in Medicine(DICOM)data obtained from computed tomography angiography(CTA)scans were edited and converted to stereolithography(STL)file formats, followed by the production of 3D models of the cerebral aneurysm by using the 3D printer. The mean time from hospitalization to the commencement of surgery was 242 min, whereas the mean time required for manufacturing the 3D model was 67 min. The average cost of each 3D model was 194 Japanese Yen. The time required for manufacturing the 3D models shortened to approximately 1 hour with increasing experience of producing 3D models. Favorable impressions for the use of the 3D models in clipping were reported by almost all neurosurgeons included in this study. Although 3D printing is often considered to involve huge costs and long manufacturing time, the method used in the present study requires shorter time and lower costs than conventional methods for manufacturing 3D cerebral aneurysm models, thus making it suitable for use in emergency clipping.

Azygos vein aneurysm resection concomitant with heart valve repair via right thoracotomy.

PubMed

Suzuki, Yota; Kaji, Masahiro; Hirose, Shigemichi; Ohtsubo, Satoshi

2016-12-01

Azygos vein aneurysm is very rare and is usually found incidentally because of its clinical silence. We report a case of recurrent pleural effusion caused by an azygos vein aneurysm in a patient with moderate mitral valve regurgitation (MR) and tricuspid valve regurgitation (TR). Since valve disease is considered a significant precipitating factor for both dyspnoea and pleural effusion, we decided to study the aetiologies of these conditions concomitantly. Azygos vein aneurysm resection in combination with tricuspid and mitral valve repair using cardiopulmonary bypass was performed successfully through a right anterior thoracotomy. The postoperative course was uneventful, and the patient reported improved exercise capacity. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Value of Indocyanine Green Videoangiography in Deciding the Completeness of Cerebrovascular Surgery

PubMed Central

Moon, Hyung-Sik; Joo, Sung-Pil; Seo, Bo-Ra; Jang, Jae-Won; Kim, Jae-Hyoo

2013-01-01

Objective Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. Methods Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. Results Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. Conclusion ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery. PMID:24003369

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136 cases

PubMed Central

Shi, Lei; Yu, Jing; Zhao, Ying; Xu, Kan; Yu, Jinlu

2018-01-01

It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I–III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms. PMID:29434749

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136 cases.

PubMed

Shi, Lei; Yu, Jing; Zhao, Ying; Xu, Kan; Yu, Jinlu

2018-02-01

It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I-III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms.

Prevalence of Synchronous and Metachronous Aneurysms in Women With Abdominal Aortic Aneurysm.

PubMed

Wallinder, Jonas; Georgiou, Anna; Wanhainen, Anders; Björck, Martin

2018-06-20

Abdominal aortic aneurysm (AAA) is three to five times more common among men compared with women, yet up to 38% of all aneurysm related deaths affect women. The aim of this study was to estimate the prevalence of synchronous or metachronous aneurysms among women with AAA, as diagnosis and treatment could improve survival. This is a retrospective study of prospectively registered patients. All women operated on, or under surveillance for, AAA were identified at two Swedish hospitals. Aneurysms in different locations were identified using available imaging studies. Aneurysms were defined according to location: thoracic ascending aorta ≥42 mm, descending ≥33 mm, abdominal aorta ≥30 mm, common iliac artery ≥20 mm or 50% wider than the contralateral artery, common femoral artery ≥12 mm, popliteal artery ≥10 mm. A total of 339 women with an AAA were included. The median follow up was 2.8 (range 0-15.7) years. Thirty-one per cent had an aneurysm in the thoracic aorta (67 of 217 investigated, 84% were located in the descending aorta), 13 (19%) underwent repair. Twelve per cent had a common iliac artery aneurysm (24/259, 76% were investigated). Common femoral artery aneurysms were identified in 4.3% (8/184, 54% investigated). Popliteal artery aneurysms were identified in 4.0% (6/149, 44% investigated). The prevalence of infrainguinal aneurysms was higher among patients with synchronous iliac aneurysms (40% vs. 1.6%, OR 42, 95% CI 6.4-279, p < .001). Thoracic aortic aneurysms are common among women with AAA, most commonly affecting the descending aorta, and detection frequently results in repair. Popliteal and femoral aneurysms are not rare among women with AAA, and even common if there is a synchronous iliac aneurysm. Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

A novel SMAD3 mutation caused multiple aneurysms in a patient without osteoarthritis symptoms.

PubMed

Courtois, Audrey; Coppieters, Wouter; Bours, Vincent; Defraigne, Jean-Olivier; Colige, Alain; Sakalihasan, Natzi

2017-04-01

Heterozygous mutations in the SMAD3 gene were recently described as the cause of a form of non-syndromic familial aortic thoracic aneurysm and dissection (FTAAD) transmitted as an autosomal dominant disorder and often associated with early-onset osteoarthritis. This new clinical entity, called aneurysms-osteoarthritis syndrome (AOS) or Loeys-Dietz syndrome 3 (LDS3), is characterized by aggressive arterial damages such as aneurysms, dissections and tortuosity throughout the arterial tree. We report, here, the case of a 45 year-old man presenting multiple visceral arteries and abdominal aortic aneurysms but without dissection of the thoracic aorta and without any sign of osteoarthritis. Exome-sequencing revealed a new frameshift heterozygous c.455delC (p.Pro152Hisfs*34) mutation in the SMAD3 gene. This deletion is located in the exon 3 coding for the linker region of the protein and causes a premature stop codon at positions 556-558 in the exon 4. The same mutation was found in the proband's mother and sister who had open surgery for abdominal aortic aneurysm and in one of his children who was 5 year-old and did not present aneurysm yet. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

[Cerebral aneurysms complicating bacterial endocarditis. Seven cases (author's transl)].

PubMed

Pecker, J; Vallée, B; Camuzet, J P; Faivre, J; Javalet, A

The authors report seven cases of cerebral aneurysms complicating bacterial endocarditis. The evolution was good in three cases, two of which without sequelae. The bacteries involved were staphylococcus, streptococcus, and enterobacter. The cardiopathy was mitral in four cases. Two patients presented an isolated focal neurological impairment, while the other five presented a severe coma either isolated (one case) or associated with focal neurological deficits (four cases). An intracerebral hematoma was diagnosed in five cases (four died). Only one patient was not operated. The surgical treatment was as follows: one carotid ligation (good result), two evacuations of intracerebral hematomas (both died), two evacuations of intracerebral hematomas with clipping of the aneurysms (one died, one had a fair result in despite of residual hemiplegia), one clipping of aneurysm (good result). Repeated cerebral angiographies should be systematically performed in cases of bacterial endocarditis in order to disclose and follow up cerebral aneurysms which may occur in this condition. Except in cases of emergency, surgery should be differed, in particular, in cases of proximal or multiple aneurysms. Aneurysms of the peripheral cortical arteries are more accessible to treatment and may be operated in the acute phase.

Biochemical changes related to hypoxia during cerebral aneurysm surgery: combined microdialysis and tissue oxygen monitoring: case report.

PubMed

Hutchinson, P J; Al-Rawi, P G; O'Connell, M T; Gupta, A K; Pickard, J D; Kirkpatrick, P J

2000-01-01

The objective of this study was to monitor brain metabolism on-line during aneurysm surgery, by combining the use of a multiparameter (brain tissue oxygen, brain carbon dioxide, pH, and temperature) sensor with microdialysis (extracellular glucose, lactate, pyruvate, and glutamate). The case illustrates the potential value of these techniques by demonstrating the effects of adverse physiological events on brain metabolism and the ability to assist in both intraoperative and postoperative decision-making. A 41-year-old woman presented with a World Federation of Neurological Surgeons Grade I subarachnoid hemorrhage. Angiography revealed a basilar artery aneurysm that was not amenable to coiling, so the aneurysm was clipped. Before the craniotomy was performed, a multiparameter sensor and a microdialysis catheter were inserted to monitor brain metabolism. During the operation, the brain oxygen level decreased, in relation to biochemical changes, including the reduction of extracellular glucose and pyruvate and the elevation of lactate and glutamate. These changes were reversible. However, when the craniotomy was closed, a second decrease in brain oxygen occurred in association with brain swelling, which immediately prompted a postoperative computed tomographic scan. The scan demonstrated acute hydrocephalus, requiring external ventricular drainage. The patient made a full recovery. The monitoring techniques influenced clinical decision-making in the treatment of this patient. On-line measurement of brain tissue gases and extracellular chemistry has the potential to assist in the perioperative and postoperative management of patients undergoing complex cerebrovascular surgery and to establish the effects of intervention on brain homeostasis.

Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery.

PubMed

Saratzis, A; Thatcher, A; Bath, M F; Sidloff, D A; Bown, M J; Shakespeare, J; Sayers, R D; Imray, C

2017-02-01

INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.

Strain measurement of abdominal aortic aneurysm with real-time 3D ultrasound speckle tracking.

PubMed

Bihari, P; Shelke, A; Nwe, T H; Mularczyk, M; Nelson, K; Schmandra, T; Knez, P; Schmitz-Rixen, T

2013-04-01

Abdominal aortic aneurysm rupture is caused by mechanical vascular tissue failure. Although mechanical properties within the aneurysm vary, currently available ultrasound methods assess only one cross-sectional segment of the aorta. This study aims to establish real-time 3-dimensional (3D) speckle tracking ultrasound to explore local displacement and strain parameters of the whole abdominal aortic aneurysm. Validation was performed on a silicone aneurysm model, perfused in a pulsatile artificial circulatory system. Wall motion of the silicone model was measured simultaneously with a commercial real-time 3D speckle tracking ultrasound system and either with laser-scan micrometry or with video photogrammetry. After validation, 3D ultrasound data were collected from abdominal aortic aneurysms of five patients and displacement and strain parameters were analysed. Displacement parameters measured in vitro by 3D ultrasound and laser scan micrometer or video analysis were significantly correlated at pulse pressures between 40 and 80 mmHg. Strong local differences in displacement and strain were identified within the aortic aneurysms of patients. Local wall strain of the whole abdominal aortic aneurysm can be analysed in vivo with real-time 3D ultrasound speckle tracking imaging, offering the prospect of individual non-invasive rupture risk analysis of abdominal aortic aneurysms. Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Atrial septal aneurysm--a potential cause of systemic embolism. An echocardiographic study.

PubMed Central

Gallet, B; Malergue, M C; Adams, C; Saudemont, J P; Collot, A M; Druon, M C; Hiltgen, M

1985-01-01

Atrial septal aneurysm is an uncommon condition. Between 1981 and 1984 10 cases of atrial septal aneurysm were diagnosed by real time cross sectional echocardiography performed in 4840 patients. The aneurysm was associated either with mitral valve prolapse (three patients) or with atrial septal defect (three patients) or occurred in isolation (four patients, two of whom had had a previous embolic event leading to the diagnosis of atrial septal aneurysm by cross sectional echocardiography). During cross sectional echocardiography the aneurysm appeared as a localised bulging of the interatrial septum, which was best seen in the subcostal four chamber view and in the parasternal short axis view at the level of the aortic root. The aneurysm either protruded into only the right atrium (five patients) or moved backwards and forwards between the right and the left atria during the cardiac cycle (five patients). This motion pattern might be related to changes in the interatrial pressure gradient. The two patients who had had a systemic embolism were given anticoagulant treatment, but none underwent surgery. It is concluded that the true prevalence of atrial septal aneurysm might have been underestimated before the routine use of cross sectional echocardiography, that cross sectional echocardiography enables definitive diagnosis of this condition by a non-invasive technique, and that an atrial septal aneurysm should be suspected and looked for by cross sectional echocardiography after an unexplained systemic embolism. Images PMID:3970786

[Isolated true aneurysm of the deep femoral artery].

PubMed

Salomon du Mont, L; Holzer, T; Kazandjian, C; Saucy, F; Corpataux, J M; Rinckenbach, S; Déglise, S

2016-07-01

Aneurysms of the deep femoral artery, accounting for 5% of all femoral aneurysms, are uncommon. There is a serious risk of rupture. We report the case of an 83-year-old patient with a painless pulsatile mass in the right groin due to an aneurysm of the deep femoral artery. History taking revealed no cardiovascular risk factors and no other aneurysms at other localizations. The etiology remained unclear because no recent history of local trauma or puncture was found. ACT angiography was performed, revealing a true isolated aneurysm of the deep femoral artery with a diameter of 90mm, beginning 1cm after its origin. There were no signs of rupture or distal emboli. Due to unsuitable anatomy for an endovascular approach, the patient underwent open surgery, with exclusion of the aneurysm and interposition of an 8-mm Dacron graft to preserve deep femoral artery flow. Due to their localization, the diagnosis and the management of aneurysms of the deep femoral artery can be difficult. Options are surgical exclusion or an endovascular approach in the absence of symptoms or as a bridging therapy. If possible, blood flow to the distal deep femoral artery should be maintained, the decision depending also on the patency of the superficial femoral artery. In case of large size, aneurysms of the deep femoral artery should be treated without any delay. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Valve-sparing aortic root replacement in Loeys-Dietz syndrome.

PubMed

Patel, Nishant D; Arnaoutakis, George J; George, Timothy J; Allen, Jeremiah G; Alejo, Diane E; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A

2011-08-01

Loeys-Dietz syndrome (LDS) is a recently recognized aggressive aortic disorder characterized by root aneurysm, arterial tortuosity, hypertelorism, and bifid uvula or cleft palate. The results of prophylactic root replacement using valve-sparing procedures (valve-sparing root replacement [VSRR]) in patients with LDS is not known. We reviewed all patients with clinical and genetic (transforming growth factor-β receptor mutations) evidence of LDS who underwent VSRR at our institution. Echocardiographic and clinical data were obtained from hospital and follow-up clinic records. From 2002 to 2009, 31 patients with a firm diagnosis of LDS underwent VSRR for aortic root aneurysm. Mean age was 15 years, and 24 (77%) were children. One (3%) patient had a bicuspid aortic valve. Preoperative sinus diameter was 3.9±0.8 cm (z score 7.0±2.9) and 2 (6%) had greater than 2+ aortic insufficiency. Thirty patients (97%) underwent reimplantation procedures using a Valsalva graft. There were no operative deaths. Mean follow-up was 3.6 years (range, 0 to 7 years). One patient required late repair of a pseudoaneurysm at the distal aortic anastomosis, and 1 had a conversion to a David reimplantation procedure after a Florida sleeve operation. No patient suffered thromboembolism or endocarditis, and 1 (3%) patient experienced greater than 2+ late aortic insufficiency. No patient required late aortic valve repair or replacement. Loeys-Dietz syndrome is an aggressive aortic aneurysm syndrome that can be addressed by prophylactic aortic root replacement with low operative risk. Valve-sparing procedures have encouraging early and midterm results, similar to those in Marfan syndrome, and are an attractive option for young patients. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Aortic aneurysm in a 74-year-old man with coronary disease and obstructive lung disease: is double jeopardy enough?

PubMed

Hagen, M D; Eckman, M H; Pauker, S G

1989-01-01

A previous decision analysis examined a patient with severe CAD, diminished ventricular function, and an abdominal aortic aneurysm and also concluded that CABG followed by aneurysm repair was optimal. This patient, who had well-preserved cardiac function but severely compromised pulmonary status, stood to gain less from CABG than would a patient with more severe coronary disease, thus accounting for the "close-call" between the CABG-AAA and AAA only strategies. Nevertheless, the analysis did emphasize the benefit of aneurysm repair, whether done alone or after CABG. The analysis also highlighted the significant risk of aneurysm rupture the patient is exposed to while recovering from CABG surgery. The operative mortality risks of the two procedures are similar; thus, the patient's total operative risk is approximately doubled if he undergoes both procedures rather than aneurysm repair alone. The key question raised by the analysis is whether this double jeopardy is more than compensated by the degree to which prior CABG reduces both short-term cardiac risk at subsequent aneurysm repair and long-term cardiac mortality. For this patient, who had good cardiac function, the gains appeared sufficient to offset the interval risk of aneurysm rupture and the additional risk associated with a surgical procedures. THE REAL WORLD The patient indeed underwent and tolerated CABG, although he had a stormy prolonged postoperative course due to pulmonary failure. After discharge from the hospital, he declined readmission for repair of the aneurysm. We did not model that possibility, clearly an inadequacy in our tree. Some six months later, the patient was still alive and was, reluctantly, readmitted for aneurysmorrhaphy. At that time, however, his pulmonary function had deteriorated and both the anesthesiologist and the pulmonary consultant stated unequivocally that further surgery was now impossible. In retrospect, the expected utility of CABG without aneurysm repair (thus providing only a decrease in the long-term mortality risk from his CAD) would have been 1.95 (DEALE) or 2.06 (Markov) years. Sensitivity analysis revealed that, even if long-term cardiac risk were completely eliminated by CABG, immediate aneurysm repair would have been a better approach had the patient's physicians known he would be likely to refuse or not be a candidate for the second operation. In summary, although the patient's comorbidities did indeed place him at significant operative risk for either aneurysmorrhaphy alone or two sequential procedures, the benefits to be gained were shown to far outweigh the risks when compared with expectant observation.(ABSTRACT TRUNCATED AT 400 WORDS)

Radiopaque Marker Addition During Aortic Root Replacement With the Use of a Freestyle Porcine Bioprosthesis.

PubMed

Crowley, Olivia M; Doty, John R

2017-07-01

Aortic root replacement is indicated for aortic root aneurysm, small aortic root, and most root abscesses. This report describes the placement of a radiopaque marker during aortic root replacement using a Freestyle porcine bioprosthesis. This marker is a useful landmark during fluoroscopy for transcatheter valve-in-valve aortic valve replacement in the event of bioprosthesis degeneration. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Gender differences in abdominal aortic aneurysm therapy - a systematic review.

PubMed

Stoberock, Konstanze; Kölbel, Tilo; Atlihan, Gülsen; Debus, Eike Sebastian; Tsilimparis, Nikolaos; Larena-Avellaneda, Axel; Behrendt, Christian Alexander; Wipper, Sabine

2018-06-01

This article analyses if and to what extent gender differences exist in abdominal aortic aneurysm (AAA) therapy. For this purpose Medline (PubMed) was searched from January 1999 to January 2018. Keywords were: "abdominal aortic aneurysm", "gender", "prevalence", "EVAR", and "open surgery of abdominal aortic aneurysm". Regardless of open or endovascular treatment of abdominal aortic aneurysms, women have a higher rate of complications and longer hospitalizations compared to men. The majority of studies showed that women have a lower survival rate for surgical and endovascular treatment of abdominal aneurysms after both elective and emergency interventions. Women receive less surgical/interventional and protective medical treatment. Women seem to have a higher risk of rupture, a lower survival rate in AAA, and a higher rate of complications, regardless of endovascular or open treatment. The gender differences may be due to a higher age of women at diagnosis and therapy associated with higher comorbidity, but also because of genetic, hormonal, anatomical, biological, and socio-cultural differences. Strategies for treatment in female patients must be further defined to optimize outcome.

Application of a vascular graft material (Solcograft-P) in experimental surgery.

PubMed

Nemes, A; Acsády, G; Fraefel, W; Lichti, H; Monos, E; Oertli, R; Somogyi, E; Sótonyi, P

1985-09-01

The implantation and post-implantation behaviour of a Solcograft-P vascular prosthesis in the aortic, aorto-iliac, carotid and vena caval positions in dogs was studied up to 100 d post-surgery in order to assess the suitability of this vascular material for use in man. Solcograft-P is prepared from the carotid arteries of calves by crosslinking the collagen stroma using adipyl dichloride. During the postoperative follow-up period of 3 month, 100% of the aortal grafts, 80% of the aorto-iliac bypasses, 60% of the vena caval grafts and 35% of the carotid implants remained patent. The biochemical properties of the Solcograft-P are better than those of Solcograft, its predecessor. The intimal lining was consistently smooth and homogeneous in grafts of biological origin, and no aneurysm was observed. Infection and early thrombosis occured no more frequently than with other grafts. The new Solcograft-P, crosslinked via ester and amide groups, seems to represent a real improvement over Solcograft. Our results suggest that Solcograft-P should prove valuable in various cases of reconstructive vascular surgery of the lower limb, especially when the autologous vena saphena magna is not available, and its mechanical properties may well prove suitable for both arterial and venous replacement.

Long-term patency of complex bilobular, bisaccular, and broad-neck aneurysms in the rabbit microsurgical venous pouch bifurcation model.

PubMed

Marbacher, Serge; Tastan, Ilhan; Neuschmelting, Volker; Erhardt, Salome; Coluccia, Daniel; Sherif, Camillo; Remonda, Luca; Fandino, Javier

2012-07-01

In experimental aneurysm models, long-term patency without spontaneous thrombosis is the most important precondition for analyses of embolization devices. We recently reported the feasibility of creating complex venous pouch bifurcation aneurysms in the rabbit with low morbidity, low mortality, and high short-term aneurysm patency. In order to further evaluate our model, we examined the long-term patency rate. Various sizes of complex bilobular, bisaccular, and broad-neck venous pouch aneurysms were surgically formed at an artificially created bifurcation of both common carotid arteries in 17 rabbits. Early aggressive anticoagulation was continued for 1 month. The rabbits were followed up using contrast-enhanced three-dimensional 1.5-T magnetic resonance angiography (CE-3D-MRA) at 1 month and up to 1 year after creation of the bifurcation. At 1-month follow-up, all but one of the created aneurysms and all parent vessels proved to be patent. Three animals (18%) were lost during follow-up for reasons unrelated to aneurysm surgery. At 1-year follow-up, one animal showed partial and one complete spontaneous aneurysm thrombosis (aneurysm patency rate: 86%). Six out of 42 parent vessels were occluded at that time (vessel patency rate: 86%). Complex bilobular, bisaccular, and broad-neck microsurgical aneurysm formation in the rabbit bifurcation model demonstrates a high long-term patency rate but is complicated by high rates of unrelated procedural mortality and morbidity. There is no need for prolonged (>4 weeks) anticoagulation to achieve good long-term patency in complex venous pouch bifurcation aneurysms.

Interventricular membranous septal aneurysm: CT and MR manifestations.

PubMed

Carcano, Carolina; Kanne, Jeffrey P; Kirsch, Jacobo

2016-02-01

Advanced cardiac imaging is a valuable method to investigate cardiac malformations. The detection of the interventricular membranous septum has clinical significance due to thrombogenic and arrythmogenic predisposition, as well as a role in obstructing the pulmonary flow. This review describes six clinical presentations in which advanced cardiac imaging has been the tool for evaluation, with special emphasis in CT angiography and cardiac MRI sequences. Teaching Points • The interventricular membranous septum can predispose patients to thrombogenic and arrythmogenic events. • Subpulmonic stenosis relates to the protrusion of the aneurysm into the right ventricle • During surgery, ventricular pressures of the opened heart become balanced, making the aneurysm less evident.

Numerical predictions of hemodynamics following surgeries in cerebral aneurysms

NASA Astrophysics Data System (ADS)

Rayz, Vitaliy; Lawton, Michael; Boussel, Loic; Leach, Joseph; Acevedo, Gabriel; Halbach, Van; Saloner, David

2014-11-01

Large cerebral aneurysms present a danger of rupture or brain compression. In some cases, clinicians may attempt to change the pathological hemodynamics in order to inhibit disease progression. This can be achieved by changing the vascular geometry with an open surgery or by deploying a stent-like flow diverter device. Patient-specific CFD models can help evaluate treatment options by predicting flow regions that are likely to become occupied by thrombus (clot) following the procedure. In this study, alternative flow scenarios were modeled for several patients who underwent surgical treatment. Patient-specific geometries and flow boundary conditions were obtained from magnetic resonance angiography and velocimetry data. The Navier-Stokes equations were solved with a finite volume solver Fluent. A porous media approach was used to model flow-diverter devices. The advection-diffusion equation was solved in order to simulate contrast agent transport and the results were used to evaluate flow residence time changes. Thrombus layering was predicted in regions characterized by reduced velocities and shear stresses as well as increased flow residence time. The simulations indicated surgical options that could result in occlusion of vital arteries with thrombus. Numerical results were compared to experimental and clinical MRI data. The results demonstrate that image-based CFD models may help improve the outcome of surgeries in cerebral aneurysms. acknowledge R01HL115267.

Case series of 64 slice computed tomography-computed tomographic angiography with 3D reconstruction to diagnose symptomatic cerebral aneurysms: new standard of care?

PubMed Central

Jehle, Dietrich; Chae, Floria; Wai, Jonathan; Cloud, Sam; Pierce, David; Meyer, Michael

2012-01-01

CT angiography (CTA) has improved significantly over the past few years such that the reconstructed images of the cerebral arteries may now be equivalent to conventional digital angiography. The new technology of 64 slice multi-detector CTA can reconstruct detailed images that can reliably identify small cerebral aneurysms, even those <3mm. In addition, it is estimated that CT followed by lumbar puncture (LP) misses up to 4% of symptomatic aneurysms. We present a series of cases that illustrates how CT followed by CTA may be replacing CT-LP as the standard of care in working up patients for symptomatic cerebral aneurysms and the importance of performing three dimensional (3D) reconstructions. A series of seven cases of symptomatic cerebral aneurysms were identified that illustrate the sensitivity of CT-CTA versus CT-LP and the importance of 3D reconstruction in identifying these aneurysms. Surgical treatment was recommended for 6 of the 7 patients with aneurysms and strict hypertension control was recommended for the seventh patient. Some of these patients demonstrated subarachnoid hemorrhage on presentation while others had negative LPs. A number of these patients with negative LPs were clearly symptomatic from their aneurysms. At least one of these cerebral aneurysms was not apparent on CTA without 3D reconstruction. 3D reconstruction of CTA is crucial to adequately identify cerebral aneurysms. This case series helps reinforce the importance of 3D reconstruction. There is some data to suggest that 64 slice CT-CTA may be equivalent or superior to CT-LP in the detection of symptomatic cerebral aneurysms. PMID:22593806

A Controlled Trial of the Efficacy of a Training Walking Program in Patients Recovering from Abdominal Aortic Aneurysm Surgery.

PubMed

Wnuk, Bartosz R; Durmała, Jacek; Ziaja, Krzysztof; Kotyla, Przemysław; Woźniewski, Marek; Błaszczak, Edward

2016-01-01

Major surgical procedures as well as general anesthesia contribute to muscle weakness and posture instability and may result in increased postoperative complications and functional disorders resulting from an elective operation. We aim to state the significance of backward walking as a form of interval march training with patients after abdominal aortic aneurysm surgery. Sixty-five patients were randomly divided into three subgroups and three various models of physiotherapy were applied. The participants were males, aged 65-75 years, with stable cardiologic status, absence of neurological disorders, and non-symptomatic aneurysm - non-ruptured, no pain complaints and no motor system impairments. The control group had only routine physiotherapy, since therapeutic groups I and II also had walking exercises, forward in group II and backward in group I. Both experimental groups were applied interval training. The patient data analyzed was as follows: hospitalization period-days; 6-min walking test-distance (m), training heart rate (1/min), mean speed (km/h), MET; spirometry test-FVC(L), FEV1(L), FEV1/FVC and PEF(L/s). The hospital stay period in all groups did not vary significantly. Statistical analysis showed that patients with backward walking had a statistically significantly lower reduction of walking distance in the corridor test when compared to the control group (p < 0.05). After the operation, a significant reduction of mean speed in the control group was noted in comparison with both the forward and backward walking groups (p < 0.05). No significant differences were noted between the experimental groups in average walking speed as well as in heart rate in all observed groups. Physical training applied to patients after major abdominal aortic aneurysm surgery influences sustaining the level of exercise tolerance to a small extent. Both backward and forward walking seem to be alternative methods when compared to classic post-surgery physiotherapy.

Ruptured blebs and racing hearts: autonomic cardiac changes in neurosurgeons during microsurgical clipping of aneurysms.

PubMed

Ganne, Chaitanya; Talkad, Sathyaprabha N; Srinivas, Dwarakanath; Somanna, Sampath

2016-08-01

In this study, we intend to evaluate the autonomic changes occurring in neurosurgeons and thus the stress during microsurgical clipping of aneurysms. The aim of the current study is to evaluate the heart rate variability (HRV) of the neurosurgeons during microsurgical clipping of aneurysm by using continuous real time monitoring of the ECG intraoperatively. Lead II ECG was recorded using Bioharness(®) (Zephyr Technologies, Annapolis, MD) in 4 healthy neurosurgeons who performed 29 microsurgical clipping of aneurysms. ECG from 21 surgeries was analysed (LabChart(®) software, ADInstruments, Dunedin, New Zealand) across five stages: Baseline (BL), sylvian fissure dissection (SFD), perianeurysmal dissection (PAD), clipping of the aneurysm (CLIP) and haemostasis (HEMO). There was a reduction in TP and an increased LF/HF ratio in spite of suppression of both LF and HF powers. Contrary to the common understanding that the sympathetic limb of the autonomic system mostly mediates responses during stress and anxiety, we found that there was a significant contribution of the parasympathetic system too.

Abdominal aortic aneurysms: pre- and post-procedural imaging.

PubMed

Hallett, Richard L; Ullery, Brant W; Fleischmann, Dominik

2018-05-01

Abdominal aortic aneurysm (AAA) is a relatively common, potentially life-threatening disorder. Rupture of AAA is potentially catastrophic with high mortality. Intervention for AAA is indicated when the aneurysm reaches 5.0-5.5 cm or more, when symptomatic, or when increasing in size > 10 mm/year. AAA can be accurately assessed by cross-sectional imaging including computed tomography angiography and magnetic resonance angiography. Current options for intervention in AAA patients include open surgery and endovascular aneurysm repair (EVAR), with EVAR becoming more prevalent over time. Cross-sectional imaging plays a crucial role in AAA surveillance, pre-procedural assessment, and post-EVAR management. This paper will discuss the current role of imaging in the assessment of AAA patients prior to intervention, in evaluation of procedural complications, and in long-term follow-up of EVAR patients.

[False aneurysm of the lateral superior genicular artery. A complication after the implantation of a knee prosthesis].

PubMed

Kirschner, S; Konrad, T; Weil, E J; Bühler, M

2004-07-01

Arterial complications after total knee arthroplasty are rare. If the formation of a false aneurysm does occur, it usually affects the popliteal artery. We report the case of an 77 year old female with a false aneurysm of the lateral superior genicular artery. The patient was suffering from gonarthrosis and received a duocondylar knee replacement without resurfacing of the patella. Postoperatively, she reported anterior knee pain and a revision of the joint with lateral release was carried out. In the third postoperative week, a painful swelling in the lateral and superior aspect of the knee occurred. A scintigraphic investigation with enrichment in the early period was misinterpreted as infection. Ultrasonographic and angiographic investigations gave the right diagnosis of a false aneurysm. In the same angiographic investigation, the aneurysm could be cured by coil embolisation. The interval between the operation leading to the problem and the formation of the aneurysm, as well as the low incidence of this complication, made it hard to diagnose. Ultrasonographic and angiographic examinations allow for proper diagnosis in cases of unclear painful swellings. When dealing with an arterial complication following total knee arthroplasty, a specialized radiologist or vascular surgeon should be consulted immediately.

Microcatheter Shaping for Intracranial Aneurysm Coiling Using the 3-Dimensional Printing Rapid Prototyping Technology: Preliminary Result in the First 10 Consecutive Cases.

PubMed

Namba, Katsunari; Higaki, Ayuho; Kaneko, Naoki; Mashiko, Toshihiro; Nemoto, Shigeru; Watanabe, Eiju

2015-07-01

An optimal microcatheter is necessary for successful coiling of an intracranial aneurysm. The optimal shape may be predetermined before the endovascular surgery via the use of a 3-dimensional (3D) printing rapid prototyping technology. We report a preliminary series of intracranial aneurysms treated with a microcatheter shape determined by the patient's anatomy and configuration of the aneurysm, which was fabricated with a 3D printer aneurysm model. A solid aneurysm model was fabricated with a 3D printer based on the data acquired from the 3D rotational angiogram. A hollow aneurysm model with an identical vessel and aneurysm lumen to the actual anatomy was constructed with use of the solid model as a mold. With use of the solid model, a microcatheter shaping mandrel was formed to identically line the 3D curvature of the parent vessel and the long axis of the aneurysm. With use of the mandrel, a test microcatheter was shaped and validated for the accuracy with the hollow model. All the planning processes were undertaken at least 1 day before treatment. The preshaped mandrel was then applied in the endovascular procedure. Ten consecutive intracranial aneurysms were coiled with the pre-planned shape of the microcatheter and evaluated for the clinical and anatomical outcomes and microcatheter accuracy and stability. All of pre-planned microcatheters matched the vessel and aneurysm anatomy. Seven required no microguidewire assistance in catheterizing the aneurysm whereas 3 required guiding of a microguidewire. All of the microcatheters accurately aligned the long axis of the aneurysm. The pre-planned microcatheter shapes demonstrated stability in all except in 1 large aneurysm case. When a 3D printing rapid type prototyping technology is used, a patient-specific and optimal microcatheter shape may be determined preoperatively. Copyright © 2015 Elsevier Inc. All rights reserved.

Conventional versus frozen elephant trunk surgery for extensive disease of the thoracic aorta.

PubMed

Di Eusanio, Marco; Borger, Michael; Petridis, Francesco D; Leontyev, Sergey; Pantaleo, Antonio; Moz, Monica; Mohr, Friedrich; Di Bartolomeo, Roberto

2014-11-01

To compare early and mid-term outcomes after repair of extensive aneurysm of the thoracic aorta using the conventional elephant trunk or frozen elephant trunk (FET) procedures. Fifty-seven patients with extensive thoracic aneurysmal disease were treated using elephant trunk (n = 36) or FET (n = 21) procedures. Patients with aortic dissection, descending thoracic aorta (DTA) diameter less than 40 mm, and thoracoabdominal aneurysms were excluded from the analysis, as were those who did not undergo antegrade selective cerebral perfusion during circulatory arrest. Short-term and mid-term outcomes were compared according to elephant trunk/FET surgical management. Preoperative and intraoperative variables were similar in the two groups, except for a higher incidence of female sex, coronary artery disease and associated procedures in elephant trunk patients. Hospital mortality (elephant trunk: 13.9% versus FET: 4.8%; P = 0.2), permanent neurologic dysfunction (elephant trunk: 5.7% versus FET: 9.5%; P = 0.4) and paraplegia (elephant trunk: 2.9% versus FET: 4.8%; P = 0.6) rates were similar in the two groups. Follow-up was 100% complete. In the elephant trunk group, 68.4% of patients did not undergo a second-stage procedure during follow-up for a variety of reasons. Of these patients, the DTA diameter was greater than 51 mm in 72.2% and two (6.7%) died due to aortic rupture while awaiting stage-two intervention. Endovascular second-stage procedures were successfully performed in all FET patients with residual DTA aneurysmal disease (n = 3), whereas nine of 11 elephant trunk patients who returned for second-stage procedures required conventional surgical replacement through a lateral thoracotomy. Kaplan-Meier estimate of 4-year survival was 75.8 ± 7.6 and 72.8 ± 10.6 in elephant trunk and FET patients, respectively (log-rank P = 0.8). In patients with extensive aneurysmal disease of thoracic aorta, elephant trunk and FET procedures seem to be associated with similar satisfactory early and mid-term outcomes. The FET approach leads to single-stage treatment of all aortic disease in most patients, and facilitates endovascular second-stage treatment in patients with residual DTA disease. The elephant trunk staged-approach appears to leave a considerable percentage of patients at risk for adverse aortic events.

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms.

PubMed

Elsharkawy, Ahmed; Niemelä, Mika; Lehečka, Martin; Lehto, Hanna; Jahromi, Behnam Rezai; Goehre, Felix; Kivisaari, Riku; Hernesniemi, Juha

2014-01-01

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique. A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field. The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches. The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.

Morbidity and mortality associated with creation of elastase-induced saccular aneurysms in a rabbit model

PubMed Central

Lewis, Debra A; Ding, Yong Hong; Dai, Daying; Kadirvel, Ramanathan; Danielson, Mark A; Cloft, Harry J; Kallmes, David F

2008-01-01

Background and Purpose Elastase-induced aneurysms in rabbits have been proposed as a useful preclinical tool for device development. The object of this study is to report rates of morbidity and mortality associated with creation and embolization of the elastase-induced rabbit aneurysm, and to assess the impact of operator experience on these rates. Methods Elastase-induced model aneurysms were created in New Zealand White rabbits (n=700). One neuroradiologist/investigator, naïve to the aneurysm creation procedure at the outset of the experiments, performed all surgeries. All morbidity and deaths related to aneurysm creation (n=700) and embolization procedures (n=529) were categorized into acute and chronic deaths. Data were analyzed with single regression analysis and ANOVA. To assess the impact of increasing operator experience, the number of animals was broken into 50 animal increments. Results There were 121 (17%) deaths among 700 subjects. Among 700 aneurysm creation procedures, 59 deaths (8.4%) were noted. Among 529 aneurysm embolization procedures, 43 deaths (8.1%) were noted. Nineteen additional deaths (2.7% of 700 subjects) were unrelated to procedures. Simple regression indicated mortality associated with procedures diminished with increasing operator experience (R2=0.38; p=0.0180) and that for each 50 rabbit increment mortality is reduced on average by 0.6 percent. Conclusions Mortality rates of approximately 8% are associated with both experimental aneurysm creation and with embolization in the rabbit, elastase-induced aneurysm model. Increasing operator experience is inversely correlated with mortality and the age of the rabbit is positively associated with morbidity. PMID:19001536

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization

PubMed Central

TOYOTA, Shingo; TAKI, Takuyu; WAKAYAMA, Akatsuki; YOSHIMINE, Toshiki

2015-01-01

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment. PMID:26437796

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization.

PubMed

Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki

2015-01-01

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment.

Revascularization of the anterior cerebral artery by Y-shaped superficial temporal artery interposition graft for the treatment of a de novo aneurysm arising at the site of A3-A3 bypass: technical case report.

PubMed

Endo, Hidenori; Sugiyama, Shin-Ichiro; Endo, Toshiki; Fujimura, Miki; Shimizu, Hiroaki; Tominaga, Teiji

2017-12-22

The most frequently used option to reconstruct the anterior cerebral artery (ACA) is an ACA-ACA side-to-side anastomosis. The long-term outcome and complications of this technique are unclear. The authors report a case of a de novo aneurysm arising at the site of A 3 -A 3 anastomosis. A 53-year-old woman underwent A 3 -A 3 side-to-side anastomosis for the treatment of a ruptured right A 2 dissecting aneurysm. At 44 months after surgery, a de novo aneurysm developed at the site of anastomosis. The aneurysm developed in the front wall of the anastomosis site, and projected to the anterosuperior direction. A computational fluid dynamics (CFD) study showed the localized region with high wall shear stress coincident with the pulsation in the front wall of the anastomosis site, where the aneurysm developed. A Y-shaped superficial temporal artery (STA) interposition graft was used successfully to reconstruct both ACAs, and then the aneurysm was trapped. To the authors' knowledge, this is the first case of a de novo aneurysm that developed at the site of an ACA-ACA side-to-side anastomosis. A CFD study showed that hemodynamic stress might be an underlying cause of the aneurysm formation. A Y-shaped STA interposition graft is a useful option to treat this aneurysm. Long-term follow-up is necessary to detect this rare complication after ACA-ACA anastomosis.

Treatment of Recurrent Intracranial Aneurysms After Clipping: A Report of 23 Cases and a Review of the Literature.

PubMed

Hokari, Masaaki; Kazumara, Ken; Nakayama, Naoki; Ushikoshi, Satoshi; Sugiyama, Taku; Asaoka, Katsunori; Uchida, Kazuki; Shimbo, Daisuke; Itamoto, Koji; Yokoyama, Yuka; Isobe, Masanori; Imai, Tetsuaki; Osanai, Toshiya; Houkin, Kiyohiro

2016-08-01

There are no established treatment strategies for aneurysms that recur after clipping. In this study, we present cases of patients who experienced recurrent aneurysms after clipping and subsequently underwent surgical intervention. Between 2004 and 2015, we surgically treated 23 aneurysms that recurred at a previously clipped site. Patient characteristics and clinical history were retrospectively reviewed. Patients included 19 women and 4 men 45-81 years old. Aneurysms recurred 3-31 years (mean, 15.4 years) after the initial operation. For 18 cases, the first clinical presentation was a subarachnoid hemorrhage; aneurysms were incidentally diagnosed in 5 patients. Aneurysm locations were as follows: 9 on the internal carotid artery; 4 on the middle cerebral artery; 7 on the anterior communicating artery; 2 on the distal anterior cerebral artery; and 1 on the basilar artery. The reasons for retreatment included subarachnoid hemorrhage (n = 9) and aneurysm regrowth detected on follow-up examinations (n = 14). Endovascular treatment was performed in 10 cases, and direct surgery was performed in 13 cases (clipping in 8, clipping or trapping with bypass in 5). Various complex vascular reconstructions, including high-flow bypass and intracranial-intracranial in situ bypass, were performed for recurrent aneurysms. In our experience, coil embolization is a safe and effective procedure for treating recurrent aneurysms. When cases are unsuitable for coil embolization, surgical treatment often requires neurosurgeons not only to overcome the general technical difficulty of reoperative clipping but also to perform challenging vascular reconstruction. Copyright © 2016. Published by Elsevier Inc.

The role of robotic surgical system in the management of vascular disease.

PubMed

Lin, Judith C

2013-10-01

The evolution of minimally invasive treatment for aneurysms and occlusive disease has led to the development of endovascular, laparoscopic, and robot-assisted techniques. This article reviews the current literature on the clinical use of robotic surgical systems in the treatment of patients with aneurysms and occlusive disease. A MEDLINE search was performed using the keywords "robotic, vascular, AND surgery." All pertinent articles concerning the use of the robotic surgical system on aneurysms and occlusive disease were reviewed. The author's personal experience consisted of a retrospective review of a prospectively maintained confidential database on all procedures performed with the da Vinci(®) surgical system. Several robot-assisted laparoscopic series on the treatment of aortic disease were identified, including review articles of potential clinical applications in hybrid, laparoscopic vascular, and endovascular treatments for vascular patients using robotic technology. The use of computer-enhanced or robotic technology as a sole modality for bypass of occlusive disease and repair of abdominal aortic, splenic, and renal aneurysms was described in case series with satisfactory patient outcomes. Current robotic endovascular technology was also described. Minimally invasive techniques using endovascular, laparoscopic, or robot-assisted technology have revolutionized the treatment of aortoiliac, splanchnic, and renal aneurysms and occlusive disease. However, robot-assisted techniques for aortic disease may involve a learning curve and increased operating times. Although endovascular therapy is preferred because of faster recovery, this preference for improved short-term outcomes will be balanced with the superiority and durability of robot-assisted endoscopic methods as comparable to open surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

In vitro strain measurements in cerebral aneurysm models for cyber-physical diagnosis.

PubMed

Shi, Chaoyang; Kojima, Masahiro; Anzai, Hitomi; Tercero, Carlos; Ikeda, Seiichi; Ohta, Makoto; Fukuda, Toshio; Arai, Fumihito; Najdovski, Zoran; Negoro, Makoto; Irie, Keiko

2013-06-01

The development of new diagnostic technologies for cerebrovascular diseases requires an understanding of the mechanism behind the growth and rupture of cerebral aneurysms. To provide a comprehensive diagnosis and prognosis of this disease, it is desirable to evaluate wall shear stress, pressure, deformation and strain in the aneurysm region, based on information provided by medical imaging technologies. In this research, we propose a new cyber-physical system composed of in vitro dynamic strain experimental measurements and computational fluid dynamics (CFD) simulation for the diagnosis of cerebral aneurysms. A CFD simulation and a scaled-up membranous silicone model of a cerebral aneurysm were completed, based on patient-specific data recorded in August 2008. In vitro blood flow simulation was realized with the use of a specialized pump. A vision system was also developed to measure the strain at different regions on the model by way of pulsating blood flow circulating inside the model. Experimental results show that distance and area strain maxima were larger near the aneurysm neck (0.042 and 0.052), followed by the aneurysm dome (0.023 and 0.04) and finally the main blood vessel section (0.01 and 0.014). These results were complemented by a CFD simulation for the addition of wall shear stress, oscillatory shear index and aneurysm formation index. Diagnosis results using imaging obtained in August 2008 are consistent with the monitored aneurysm growth in 2011. The presented study demonstrates a new experimental platform for measuring dynamic strain within cerebral aneurysms. This platform is also complemented by a CFD simulation for advanced diagnosis and prediction of the growth tendency of an aneurysm in endovascular surgery. Copyright © 2013 John Wiley & Sons, Ltd.

Solid variant of aneurysmal bone cyst of the thoracic spine: a case report

PubMed Central

2011-01-01

Introduction The solid variant of aneurysmal bone cyst is rare, and only 13 cases involving the spine have been reported to date, including seven in the thoracic vertebrae. The diagnosis is difficult to secure radiographically before biopsy or surgery. Case report An 18-year-old Hispanic man presented to our facility with a one-year history of left chest pain without any significant neurological deficits. An MRI scan demonstrated a 6 cm diameter enhancing multi-cystic mass centered at the T6 vertebral body with involvement of the left proximal sixth rib and extension into the pleural cavity; the spinal cord was severely compressed with evidence of abnormal T2 signal changes. Our patient was taken to the operating room for a total spondylectomy of T6 with resection of the left sixth rib from a single-stage posterior-only approach. The vertebral column was reconstructed in a 360° manner with an expandable titanium cage and pedicle screw fixation. Histologically, the resected specimen showed predominant solid fibroblastic proliferation, with minor foci of reactive osteoid formation, an area of osteoclastic-like giant cells, and cyst-like areas filled with erythrocytes and focal hemorrhage, consistent with a predominantly solid variant of aneurysmal bone cyst. At 16 months after surgery, our patient remains neurologically intact with resolution of his chest and back pain. Conclusions Because of its rarity, location, and radical treatment approach, we considered this case worthy of reporting. The solid variant of aneurysmal bone cyst is difficult to diagnose radiologically before biopsy or surgery, and we hope to remind other physicians that it should be included in the differential diagnosis of any lytic expansile destructive lesion of the spine. PMID:21718507

Ascending Aortic Stenting for Acute Supraaortic Stenosis From Graft Collapse.

PubMed

Lader, Joshua M; Smith, Deane E; Staniloae, Cezar; Fallahi, Arzhang; Iqbal, Sohah N; Galloway, Aubrey C; Williams, Mathew R

2018-06-01

A 78-year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a polyester graft (Dacron) using the graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120 mm Hg intragraft gradient. Computed tomography arteriography was unrevealing, but intraaortic ultrasound demonstrated critical intragraft stenosis. A balloon expandable stent (Palmaz stent, Cordis, Milpitas, CA) was deployed in the stenotic region with gradient resolution. The patient later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Adjusted Hospital Outcomes of Abdominal Aortic Aneurysm Surgery Reported in the Dutch Surgical Aneurysm Audit.

PubMed

Lijftogt, N; Vahl, A C; Wilschut, E D; Elsman, B H P; Amodio, S; van Zwet, E W; Leijdekkers, V J; Wouters, M W J M; Hamming, J F

2017-04-01

The Dutch Surgical Aneurysm Audit (DSAA) is mandatory for all patients with primary abdominal aortic aneurysms (AAAs) in the Netherlands. The aims are to present the observed outcomes of AAA surgery against the predicted outcomes by means of V-POSSUM (Vascular-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity). Adjusted mortality was calculated by the original and re-estimated V(physiology)-POSSUM for hospital comparisons. All patients operated on from January 2013 to December 2014 were included for analysis. Calibration and discrimination of V-POSSUM and V(p)-POSSUM was analysed. Mortality was benchmarked by means of the original V(p)-POSSUM formula and risk-adjusted by the re-estimated V(p)-POSSUM on the DSAA. In total, 5898 patients were included for analysis: 4579 with elective AAA (EAAA) and 1319 with acute abdominal aortic aneurysm (AAAA), acute symptomatic (SAAA; n = 371) or ruptured (RAAA; n = 948). The percentage of endovascular aneurysm repair (EVAR) varied between hospitals but showed no relation to hospital volume (EAAA: p = .12; AAAA: p = .07). EAAA, SAAA, and RAAA mortality was, respectively, 1.9%, 7.5%, and 28.7%. Elective mortality was 0.9% after EVAR and 5.0% after open surgical repair versus 15.6% and 27.4%, respectively, after AAAA. V-POSSUM overestimated mortality in most EAAA risk groups (p < .01). The discriminative ability of V-POSSUM in EAAA was moderate (C-statistic: .719) and poor for V(p)-POSSUM (C-statistic: .665). V-POSSUM in AAAA repair overestimated in high risk groups, and underestimated in low risk groups (p < .01). The discriminative ability in AAAA of V-POSSUM was moderate (.713) and of V(p)-POSSUM poor (.688). Risk adjustment by the re-estimated V(p)-POSSUM did not have any effect on hospital variation in EAAA but did in AAAA. Mortality in the DSAA was in line with the literature but is not discriminative for hospital comparisons in EAAA. Adjusting for V(p)-POSSUM, revealed no association between hospital volume and treatment or outcome. Risk adjustment for case mix by V(p)-POSSUM in patients with AAAA has been shown to be important. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm.

PubMed Central

Ameen, A A; Illingworth, R

1981-01-01

One hundred consecutive patients treated with epsilon aminocaproic acid 24 grams daily prior to surgery for ruptured intracranial aneurysms have been compared with the previous 100 patients managed similarly but without anti-fibrinolytic drugs. No other alterations in management were made and the two series are closely comparable in all other respects. Fewer episodes of recurrent haemorrhage and deaths from this cause occurred in the treated patients, but more cases of cerebral ischaemia occurred. Neither difference is statistically significant and overall more deaths occurred in the patients treated with antifibrinolytic drugs. The value of this method of treatment in the management of aneurysmal subarachnoid haemorrhage is questioned. PMID:7229645

Stenting complex aorta aneurysms with the Cardiatis multilayer flow modulator: first impressions.

PubMed

Debing, E; Aerden, D; Gallala, S; Vandenbroucke, F; Van den Brande, P

2014-06-01

Our aim was to assess the feasibility and efficacy of the Cardiatis multilayer flow modulator in the treatment of complex aorta aneurysms. This is a single-center prospective registry. Six patients (4 males and 2 females; mean age 74 years) with complex aorta aneurysms (unsuitable for endovascular repair with standard, fenestrated, or branched stent grafts) were treated with the Cardiatis multilayer flow modulator. Clinical success was 100%. Median follow-up was 10 months. One patient died the third postoperative day due to aneurysm rupture. Four aneurysms were completely thrombosed between 1 and 6 months after the procedure. The patency of the covered aortic branches was 100%. At 6 months, the sac volume was decreased in two patients, increased in two patients and remains stable in one patient. There were no stent migrations, retractions, thrombosis, fractures, or reinterventions. The device preserves flow into the covered aortic branches and completed aneurysm thrombosis occurs gradually; however, the stent did not prevent rupture immediately after the implantation. Longer follow-up is mandatory to prove the efficacy of this technology. Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Historical landmarks in vascular neurosurgery "On July 10th 2006, at the 70th Anniversary of the Department of Neurosurgery of Zürich Medical School".

PubMed

Hernesniemi, J; Dashti, R; Mateo, O; Cancela, P; Karatas, A; Niemelä, M

2008-01-01

Direct aneurysm surgery started more than 70 years ago. Introduction of cerebral angiography by Moniz in 20s and operating microscope by Yaşargil in 60s were the real cornerstones in vascular neurosurgery. Since then the development of neuroanestesiology and further development of non-invasive imaging (MRA and CTA) together with the latest development of operating microscopes with intraoperative ICG angio have shifted vascular microneurosurgery to a different level to still compete with the 'non-invasiness' of endovascular therapy. There is an increasing demand to perform the already forgotten bypasses mastered only by few and with the high-flow techniques (e.g. ELANA) we can treat lesions that some time ago were considered impossible. Endovascular embolization to reduce the flow in AVM before surgery is very helpful in those cases that can not be treated by embolization or radiosurgery alone. We still need to find a way to detect aneurysms before they rupture and especially those thin-walled that are in an increased risk of rupture. Recent data on the pathobiology of the aneurysm wall may help us to better understanding of the growth mechanisms and it might be possible to develop more potent local or systemic pharmaceutical therapy to induce myo-intimal hyperplasia occluding the aneurysm and strengthening the wall to prevent rupture.

Higher leukocyte count predicts 3-month poor outcome of ruptured cerebral aneurysms.

PubMed

Yao, Pei-Sen; Chen, Guo-Rong; Xie, Xue-Ling; Shang-Guan, Huang-Cheng; Gao, Jin-Zhen; Lin, Yuan-Xiang; Zheng, Shu-Fa; Lin, Zhang-Ya; Kang, De-Zhi

2018-04-11

It is not fully established whether leukocyte can predict the poor outcome for ruptured cerebral aneurysms (CA) or not. Here, we retrospectively analyzed the clinical data of 428 patients with ruptured CA between 2010 and 2015. Patients' demographic data, including gender, age, history of smoking, alcohol, hypertension, diabetes and hypercholesterolemia, Hunt-Hess and Fisher grade, occurrence of hydrocephalus, aneurysm location, time to surgery, delayed ischemic neurological deficit (DIND) and peak leukocyte of blood test from day 1 to 3 after aneurysmal rupture were recorded and analyzed. In the multivariable analysis model, gender, Fisher grade, time to surgery and hydrocephalus were not relevant to poor outcome. However, Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were significantly associated with adverse outcome. The respective increased risks were 5.2- (OR5.24, 95% CI 1.67-16.50, p = 0.005), 6.2-(OR 6.24, 95% CI 3.55-10.99, p < 0.001) and 10.9-fold (OR 9.35, 95% CI 5.98-19.97, p < 0.001). The study revealed that Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were independent risk factors for poor outcome of ruptured CA at 3 months. Higher leukocyte count is a convenient and useful marker to predict 3-month poor outcome for ruptured CA.

Case report of an unusual combination of purulent pericarditis and false aneurysm of the ascending aorta.

PubMed

Meier, David; Kirsch, Matthias; Qanadli, Salah Dine; Muller, Olivier; Fishman, Daniel; Trana, Catalina

2018-01-29

Purulent pericarditis is an uncommon entity, which is, in very rare cases, associated to infection of the aorta. We present the case of a 42-year-old male patient, who was admitted to hospital complaining of tiredness, diarrhea and leg edema. Clinical examination revealed a hypotensive and obviously shocked patient. He was ultimately diagnosed with a rare combination of purulent pericarditis followed by false aneurysm of the ascending aorta. He was successfully treated by surgical pericardial drainage, replacement of the ascending aorta and antibiotics. Mycotic aneurysms can rarely be associated with purulent pericarditis. Our literature review shows that there are two mechanisms explaining this association and that in most of the published cases infective endocarditis could not be demonstrated.

Aortoiliac aneurysm with congenital right pelvic kidney.

PubMed

Date, Kazuma; Okada, Shuuichi; Ezure, Masahiko; Takihara, Hitomi; Okonogi, Shuuichi; Hasegawa, Yutaka; Sato, Yasushi; Kaneko, Tatsuo

2015-05-01

The association of congenital pelvic kidney with abdominal aortoiliac aneurysm is an extremely rare clinical finding. Previous reports have described various methods of aneurysm repair with successful preservation of the function of pelvic kidney. However, to our knowledge, reconstruction of more than two renal arteries has not been established. We report a case of abdominal aortic aneurysm complicated by congenital right pelvic kidney in a 72-year-old man. Computed tomography (CT) revealed an abdominal aortic aneurysm with a maximum diameter of 54 mm and a right common iliac aneurysm of 45 mm. In addition, he had a congenital right pelvic kidney and CT angiography identified three right pelvic renal arteries. The upper artery originated from the bifurcation of the terminal aorta and the lower two originated from the right common iliac artery. Three-dimensional CT was helpful for the accurate planning of the operation. Open surgical repair of the aortoiliac aneurysm with a Dacron bifurcated graft replacement was decided and reimplantation of all three right pelvic kidney arteries to the right limb of the graft was also performed. For renal preservation, the right pelvic kidney arteries were perfused with cold Ringer's lactate using a rapid infusion pump and coronary perfusion cannula. The patient's postoperative course was uneventful, and worsening of renal function was not observed. The perfusion of renal arteries with cold Ringer's solution was thought to be a simple and appropriate procedure for renal protection.

Long-Term Risk for Aortic Complications After Aortic Valve Replacement in Patients With Bicuspid Aortic Valve Versus Marfan Syndrome.

PubMed

Itagaki, Shinobu; Chikwe, Joanna P; Chiang, Yuting P; Egorova, Natalia N; Adams, David H

2015-06-09

Bicuspid aortic valves are associated with valve dysfunction, ascending aortic aneurysm and dissection. Management of the ascending aorta at the time of aortic valve replacement (AVR) in these patients is controversial and has been extrapolated from experience with Marfan syndrome, despite the absence of comparative long-term outcome data. This study sought to assess whether the natural history of thoracic aortopathy after AVR in patients with bicuspid aortic valve disease is substantially different from that seen in patients with Marfan syndrome. In this retrospective comparison, outcomes of 13,205 adults (2,079 with bicuspid aortic valves, 73 with Marfan syndrome, and 11,053 control patients with acquired aortic valve disease) who underwent primary AVR without replacement of the ascending aorta in New York State between 1995 and 2010 were compared. The median follow-up time was 6.6 years. The long-term incidence of thoracic aortic dissection was significantly higher in patients with Marfan syndrome (5.5 ± 2.7%) compared with those with bicuspid valves (0.55 ± 0.21%) and control group patients (0.41 ± 0.08%, p < 0.001). Thoracic aortic aneurysms were significantly more likely to be diagnosed in late follow-up in patients with Marfan syndrome (10.8 ± 4.4%) compared with those with bicuspid valves (4.8 ± 0.8%) and control group patients (1.4 ± 0.2%) (p < 0.001). Patients with Marfan syndrome were significantly more likely to undergo thoracic aortic surgery in late follow-up (10.4 ± 4.3%) compared with those with bicuspid valves (2.5 ± 0.6%) and control group patients (0.50 ± 0.09%) (p < 0.001). The much higher long-term rates of aortic complications after AVR observed in patients with Marfan syndrome compared with those with bicuspid aortic valves confirm that operative management of patients with bicuspid aortic valves should not be extrapolated from Marfan syndrome and support discrete treatment algorithms for these different clinical entities. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Effect of nitrous oxide use on long-term neurologic and neuropsychological outcome in patients who received temporary proximal artery occlusion during cerebral aneurysm clipping surgery.

PubMed

Pasternak, Jeffrey J; McGregor, Diana G; Lanier, William L; Schroeder, Darrell R; Rusy, Deborah A; Hindman, Bradley; Clarke, William; Torner, James; Todd, Michael M

2009-03-01

The authors explored the relationship between nitrous oxide use and neurologic and neuropsychological outcome in a population of patients likely to experience intraoperative cerebral ischemia: those who had temporary cerebral arterial occlusion during aneurysm clipping surgery. A post hoc analysis of a subset of the data from the Intraoperative Hypothermia for Aneurysm Surgery Trial was conducted. Only subjects who had temporary arterial occlusion during surgery were included in the analysis. Metrics of short-term and long-term (i.e., 3 months after surgery) outcome were evaluated via both univariate and multivariate logistic regression analysis. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. The authors evaluated 441 patients, of which 199 received nitrous oxide. Patients receiving nitrous oxide had a greater risk of delayed ischemic neurologic deficits (i.e., the clinical manifestation of vasospasm) (OR, 1.78, 95% confidence interval [CI], 1.08-2.95; P = 0.025). However, at 3 months after surgery, there was no difference in any metric of gross neurologic outcome: Glasgow Outcome Score (OR, 0.67; CI, 0.44-1.03; P = 0.065), Rankin Score (OR, 0.74; CI, 0.47-1.16; P = 0.192), National Institutes of Health Stroke Scale (OR, 1.02; CI, 0.66-1.56; P = 0.937), or Barthel Index (OR, 0.69; CI, 0.38-1.25; P = 0.22). The risk of impairment on at least one test of neuropsychological function was reduced in those who received nitrous oxide (OR, 0.56; CI, 0.36-0.89; P = 0.013). In this patient population, use of nitrous oxide was associated with an increased risk for the development of delayed ischemic neurologic deficits; however, there was no evidence of detriment to long-term gross neurologic or neuropsychological outcome.

Impact of Right-Sided Aneurysm, Rupture Status, and Size of Aneurysm on Perforator Infarction Following Microsurgical Clipping of Posterior Communicating Artery Aneurysms with a Distal Transsylvian Approach.

PubMed

Tanabe, Jun; Ishikawa, Tatsuya; Moroi, Junta; Sakata, Yoshinori; Hadeishi, Hiromu

2018-03-01

Posterior communicating artery (PCoA) aneurysms are among the most common aneurysms. Because blockage of the PCoA and perforators can cause adverse outcomes, occlusion of these arteries by surgical clipping should be avoided. The impact of factors on PCoA perforator infarction when using a distal transsylvian approach for PCoA aneurysms was examined. A total of 183 patients underwent PCoA aneurysm clipping, excluding application of fenestrated clips. Patients were divided into 2 groups: patients with PCoA perforator infarction (infarction group) and patients without infarction (noninfarction group). Multiple factors were analyzed in the 2 groups. Twenty-two of the 183 patients (12.0%) showed perforator infarction, mainly on magnetic resonance imaging evaluation, resulting in permanent deficits in 2 patients (1.1%). The proportion of right-sided operations (86.4% vs. 53.4%; P = 0.005) and surgery for rupture (90.9% vs. 55.9%; P = 0.002) were significantly higher in the infarction group than in the noninfarction group. Aneurysms were significantly larger in the infarction group (8.4 ± 3.8 mm) than in the noninfarction group (6.3 ± 3.0 mm; P = 0.02). Ruptured status (odds ratio [OR], 7.35; P = 0.01), right side (OR, 5.19; P = 0.01), and aneurysm size (OR, 1.18; P = 0.02) remained independent predictors of perforator infarction on multivariate logistic regression analysis. Ruptured status, right side, and large PCoA aneurysm were independent predictors of PCoA perforator infarction. Symptoms due to PCoA perforating infarction were mostly transient and rarely affected outcomes. Copyright © 2018 Elsevier Inc. All rights reserved.

Four Surgical Modifications to the Classic Elastase Perfusion Aneurysm Model Enable Haemodynamic Alterations and Extended Elastase Perfusion.

PubMed

Busch, Albert; Chernogubova, Ekaterina; Jin, Hong; Meurer, Felix; Eckstein, Hans-Henning; Kim, Mia; Maegdefessel, Lars

2018-04-24

Abdominal aortic aneurysm (AAA) is an individual and socioeconomic burden in today's ageing society. Treatment relies on surgical exclusion of the dilated aorta by open or endovascular repair. For research purposes, animal models are necessary and the elastase induced aneurysm model closely mimics end stage human aneurysm disease. To improve the translational value of this model, four modifications to the classic elastase perfusion procedure (PPE) in relation to human aneurysm morphology were conducted. In ten week old male C57BL/6J wild type mice the PPE procedure was modified in four ways using two different techniques. Flow alteration was simulated by partial ligation of the common iliac artery or the distal aorta. Additionally, careful exploration of the abdominal aortic branches allowed PPE induction at the suprarenal and iliac level. Molecular biology, ultrasound, and immunohistochemistry were used to evaluate these pilot results. Two aortic outflow obstructions simulating distal aortic or iliac stenosis significantly increase murine AAA diameter (p = .046), and affect local vascular wall remodelling. Suprarenal aortic dissection allows a juxtarenal aneurysm to be induced, similar to the angiotensin II induced aneurysm model. A separate investigation for canonical activation of transforming growth factor β in the two embryonically distinct juxtarenal and infrarenal segments showed no distinct difference. Creating an aortoiliac bifurcated aneurysm completes the mimicry of human aneurysm morphology. The alteration of the classic PPE aneurysm by outflow modulation and further elastase perfusion to the juxtarenal and aortoiliac segment modifies morphology and diameter, and thus increases the translational value in future research. Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Maximum Diameter Measurements of Aortic Aneurysms on Axial CT Images After Endovascular Aneurysm Repair: Sufficient for Follow-up?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Baumueller, Stephan, E-mail: Stephan.Baumueller@usz.ch; Nguyen, Thi Dan Linh, E-mail: ThiDanLinh.Nguyen@usz.ch; Goetti, Robert Paul, E-mail: RobertPaul.Goetti@usz.ch

2011-12-15

Purpose: To assess the accuracy of maximum diameter measurements of aortic aneurysms after endovascular aneurysm repair (EVAR) on axial computed tomographic (CT) images in comparison to maximum diameter measurements perpendicular to the intravascular centerline for follow-up by using three-dimensional (3D) volume measurements as the reference standard. Materials and Methods: Forty-nine consecutive patients (73 {+-} 7.5 years, range 51-88 years), who underwent EVAR of an infrarenal aortic aneurysm were retrospectively included. Two blinded readers twice independently measured the maximum aneurysm diameter on axial CT images performed at discharge, and at 1 and 2 years after intervention. The maximum diameter perpendicular tomore » the centerline was automatically measured. Volumes of the aortic aneurysms were calculated by dedicated semiautomated 3D segmentation software (3surgery, 3mensio, the Netherlands). Changes in diameter of 0.5 cm and in volume of 10% were considered clinically significant. Intra- and interobserver agreements were calculated by intraclass correlations (ICC) in a random effects analysis of variance. The two unidimensional measurement methods were correlated to the reference standard. Results: Intra- and interobserver agreements for maximum aneurysm diameter measurements were excellent (ICC = 0.98 and ICC = 0.96, respectively). There was an excellent correlation between maximum aneurysm diameters measured on axial CT images and 3D volume measurements (r = 0.93, P < 0.001) as well as between maximum diameter measurements perpendicular to the centerline and 3D volume measurements (r = 0.93, P < 0.001). Conclusion: Measurements of maximum aneurysm diameters on axial CT images are an accurate, reliable, and robust method for follow-up after EVAR and can be used in daily routine.« less

Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki.

PubMed

Thiarawat, Peeraphong; Jahromi, Behnam Rezai; Kozyrev, Danil A; Intarakhao, Patcharin; Teo, Mario K; Choque-Velasquez, Joham; Hernesniemi, Juha

2017-05-01

The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate. Copyright © 2017 Elsevier Inc. All rights reserved.

Microsurgical Clipping of an Unruptured Carotid Cave Aneurysm: 3-Dimensional Operative Video.

PubMed

Tabani, Halima; Yousef, Sonia; Burkhardt, Jan-Karl; Gandhi, Sirin; Benet, Arnau; Lawton, Michael T

2017-08-01

Most aneurysms originating from the clinoidal segment of the internal carotid artery (ICA) are nowadays managed conservatively, treated endovascularly with coiling (with or without stenting) or flow diverters. However, microsurgical clip occlusion remains an alternative. This video demonstrates clip occlusion of an unruptured right carotid cave aneurysm measuring 7 mm in a 39-year-old woman. The patient opted for surgery because of concerns about prolonged antiplatelet use associated with endovascular therapy. After patient consent, a standard pterional craniotomy was performed followed by extradural anterior clinoidectomy. After dural opening and sylvian fissure split, a clinoidal flap was opened to enter the extradural space around the clinoidal segment. The dural ring was dissected circumferentially, freeing the medial wall of the ICA down to the sellar region and mobilizing the ICA out of its canal of the clinoidal segment. With the aneurysm neck in view, the aneurysm was clipped with a 45° angled fenestrated clip over the ICA. Indocyanine green angiography confirmed no further filling of the aneurysm and patency of the ICA. Complete aneurysm occlusion was confirmed with postoperative angiography, and the patient had no neurologic deficits (Video 1). This case demonstrates the importance of anterior clinoidectomy and thorough distal dural ring dissection for effective clipping of carotid cave aneurysms. Control of venous bleeding from the cavernous sinus with fibrin glue injection simplifies the dissection, which should minimize manipulation of the optic nerve. Knowledge of this anatomy and proficiency with these techniques is important in an era of declining open aneurysm cases. Copyright © 2017 Elsevier Inc. All rights reserved.

Dilatation of the initially non-aneurysmal ascending aorta after replacement of a bicuspid versus tricuspid aortic valve.

PubMed

Zhang, Jing; Fan, Guangpu; Zhao, Hui; Wang, Xu; Wang, Zhiwei; Zhang, Peide; Wang, Wei

2016-12-01

Objective To compare the aortic diameter after isolated aortic valve replacement (AVR) in patients with a bicuspid (BAV) or tricuspid aortic valve (TAV) and an initially normal ascending aorta. Methods Patients with an ascending aortic diameter of < 45 mm who had undergone isolated AVR were studied. Ultrasonic cardiographic measurements of the ascending aortic diameter made pre- and postoperatively and follow-up data concerning adverse aortic events and death were analyzed. Results A total of 613 patients were included in this retrospective study; of these, 211 had a BAV and 402 had a TAV. In both groups, the ascending aorta significantly expanded but was non-aneurysmal during follow-up; however, the difference between the two groups was not significant. Cox regression analysis showed no significant effect associated with the presence of a BAV on adverse aortic events or death. Conclusion Dilatation of the ascending aorta was observed after AVR in both groups, but was not more pronounced in patients with a BAV. Long-term follow-up for ascending aortic aneurysm is necessary after AVR in both patients with a BAV and those with a TAV.

Dilatation of the initially non-aneurysmal ascending aorta after replacement of a bicuspid versus tricuspid aortic valve

PubMed Central

Zhang, Jing; Fan, Guangpu; Zhao, Hui; Wang, Xu; Wang, Zhiwei; Zhang, Peide

2016-01-01

Objective To compare the aortic diameter after isolated aortic valve replacement (AVR) in patients with a bicuspid (BAV) or tricuspid aortic valve (TAV) and an initially normal ascending aorta. Methods Patients with an ascending aortic diameter of < 45 mm who had undergone isolated AVR were studied. Ultrasonic cardiographic measurements of the ascending aortic diameter made pre- and postoperatively and follow-up data concerning adverse aortic events and death were analyzed. Results A total of 613 patients were included in this retrospective study; of these, 211 had a BAV and 402 had a TAV. In both groups, the ascending aorta significantly expanded but was non-aneurysmal during follow-up; however, the difference between the two groups was not significant. Cox regression analysis showed no significant effect associated with the presence of a BAV on adverse aortic events or death. Conclusion Dilatation of the ascending aorta was observed after AVR in both groups, but was not more pronounced in patients with a BAV. Long-term follow-up for ascending aortic aneurysm is necessary after AVR in both patients with a BAV and those with a TAV. PMID:27484890

Complicated infective endocarditis: a case series.

PubMed

Kim, Joo Seop; Kang, Min-Kyung; Cho, A Jin; Seo, Yu Bin; Kim, Kun Il

2017-05-08

Infective endocarditis is associated with not only cardiac complications but also neurologic, renal, musculoskeletal, and systemic complications related to the infection, such as embolization, metastatic infection, and mycotic aneurysm. We report three cases (the first patient is Chinese and the other two are Koreans) of complicated infective endocarditis; two of the cases were associated with a mycotic aneurysm, and one case was associated with a splenic abscess. One case of a patient with prosthetic valve endocarditis was complicated by intracerebral hemorrhage caused by mycotic aneurysm rupture. A second case of a patient with right-sided valve endocarditis associated with a central catheter was complicated by an abdominal aortic mycotic aneurysm. The third patient had a splenic infarction and abscess associated with infected cardiac thrombi. Complicated infective endocarditis is rare and is associated with cardiac, neurologic, renal, musculoskeletal, and systemic complications related to infection, such as embolization, metastatic infection, and mycotic aneurysm. Infective endocarditis caused by Staphylococcus aureus is more frequently associated with complications. Because the mortality rate increases when complications develop, aggressive antibiotic therapy and surgery, combined with specific treatments for the complications, are necessary.

Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome.

PubMed

Sala Almonacil, Vicente Andrés; Zaragozá García, José Miguel; Gómez Palonés, Francisco Julián; Plaza Martínez, Ángel; Ortíz Monzón, Eduardo

2012-08-01

Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS. Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Etiology and Treatment Modalities of Occipital Artery Aneurysms.

PubMed

Chaudhry, Nauman S; Gaynor, Brandon G; Hussain, Shahrose; Dernbach, Paul D; Aziz-Sultan, Mohammad A

2017-06-01

Aneurysms of the external carotid artery represent approximately 2% of cervical carotid aneurysms, with the majority being traumatic pseudoaneurysms. Given the paucity of literature available for guidance, the diagnosis, treatment, and follow-up of such lesions are completely individualized. We report an 83-year-old woman with an 8-week history of headache in the occipital region, transient episode of gait disturbance, and pulsatile tinnitus on the right. She had no history of trauma, surgery, autoimmune disease, or infection. Physical examination revealed a pulsatile mass tender to palpation in the right occipital scalp. The mass was surgically excised, and histopathological diagnosis of a true aneurysm was made. Postoperatively, the patient's symptoms resolved; however, 1 month after the procedure, she developed occipital neuralgia, which was successfully treated with a percutaneous nerve block. To the best of our knowledge, this is the second reported case of a true aneurysm of the occipital artery in a patient with no history of trauma. The clinical examination, diagnosis, and treatment are discussed and the literature is reviewed for previously reported cases. Copyright © 2017 Elsevier Inc. All rights reserved.

A hemodynamic-based dimensionless parameter for predicting rupture of intracranial aneurysms

NASA Astrophysics Data System (ADS)

Asgharzadeh, Hafez; Varble, Nicole; Meng, Hui; Borazjani, Iman

2016-11-01

Rupture of an intracranial aneurysm (IA) is a disease with high rates of mortality. Given the risk associated with the aneurysm surgery, quantifying the likelihood of aneurysm rupture is essential. There are many risk factors that could be implicated in the rupture of an aneurysm. However, the hemodynamic factors are believed to be the most influential ones. Here, we carry out three-dimensional high resolution simulations on human subjects IAs to test a dimensionless number, denoted as An number, to classify the flow mode. An number is defined as the ratio of the time takes the parent artery flow transports through the expansion region to the time required for vortex formation. Furthermore, we investigate the correlation of IA flow mode and WSS/OSI on the human subject IAs. Finally, we test if An number can distinguish ruptured from unruptured IAs on a database containing 204 human subjects IAs. This work was supported by National Institute Of Health (NIH) Grant R03EB014860 and the Center of Computational Research (CCR) of University at Buffalo.

Social outcome related to cognitive performance and computed tomographic findings after surgery for a ruptured intracranial aneurysm.

PubMed

Vilkki, J; Holst, P; Ohman, J; Servo, A; Heiskanen, O

1990-04-01

A series of 83 patients was examined with a battery of cognitive tests, a clinical interview, and computed tomography 1 year after surgery for a ruptured intracranial aneurysm. Disability on the Glasgow Outcome Scale (33%), failure to return to work (25%), impaired social relations (25%), and subjective or clinical mental impairment (56%) were found to be related to each other and to poor performance on cognitive tests, especially to verbal impairments in patients with left lateral infarctions and to memory deficits and cognitive inflexibility in patients with frontal medial infarctions. Furthermore, cognitive deficits and poor outcome were associated with diffuse brain damage. Depression and anxiety were unrelated to test performances, but were frequently reported by patients with right lateral infarctions.

Unilateral Acute Closed-Angle Glaucoma After Elective Lumbar Surgery Reveals Multiple Intracranial Aneurysms. A Case Report and Discussion on Workup of Differential Diagnoses.

PubMed

Storey, Christopher; Menger, Richard; Hefner, Matthew; Keating, Patrick; Ahmed, Osama; Guthikonda, Bharat

2015-11-01

The purpose of our paper is to present a case of a rare complication of posterior lumbar surgery. Our patient presented for elective lumbar decompression, which was complicated by durotomy. She then developed sudden headache and right eye pain once upright on postoperative day 2. Then on postoperative day 3, she developed a dilated nonreactive pupil with extraocular movements intact. A computed tomography scan of the head was negative for subarachnoid hemorrhage. Magnetic resonance angiography showed a possible right posterior communicating artery aneurysm. She was transferred to a tertiary center with a severe headache and a nonreactive pupil, raising concern for evolving third nerve palsy due to aneurysm. A cerebral angiogram was performed and showed multiple aneurysms. Aneurysm location did not explain the patient's symptoms, and ophthalmology was consulted. Elevated intraocular pressure was noted, and the patient was diagnosed with acute angle-closure glaucoma (AACG). Our patient was medically treated and subsequently underwent laser peripheral iridotomy. She has had improved vision and pupillary function at 1 month follow-up. The diagnosis is complicated by a durotomy, which led to cascade in the differential diagnosis to rule out intracranial pathology. Her age and home medications, which had sympathomimetic effects, placed her at increased risk, but lying prone in the dark under the drapes was likely the lead causative factor. In conclusion, a postoperative posterior spine patient with eye pain and changes in vision and pupils should be evaluated with AACG in mind due to the devastating consequences if left untreated or treatment is delayed. Copyright © 2015 Elsevier Inc. All rights reserved.

High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance.

PubMed

Ono, Hideaki; Inoue, Tomohiro; Tanishima, Takeo; Tamura, Akira; Saito, Isamu; Saito, Nobuhito

2018-04-01

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Abdominal Aortic Aneurysm: Evolving Controversies and Uncertainties.

PubMed

Carino, Davide; Sarac, Timur P; Ziganshin, Bulat A; Elefteriades, John A

2018-06-01

Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?

Heparin surface stent-graft for the treatment of a carotid pseudoaneurysm.

PubMed

Tsolaki, Elpiniki; Elpiniki, Tsolaki; Salviato, Elisabetta; Rocca, Tiberio; Braccini, Lucia; Galeotti, Roberto; Mascoli, Francesco

2010-10-01

Carotid pseudoaneurysms are a rare consequence of carotid surgery, trauma, and infection. Historically, carotid aneurysms and pseudoaneurysms were treated surgically. However, endovascular techniques have recently become a valid alternative for the treatment of carotid pseudoaneurysms. The case of a 57-year-old male patient with a pseudoaneurysm of the right internal carotid artery is described. The patient came to our unit with a painless and pulsatile mass in the neck, which was growing slowly. Five years earlier, he had undergone surgery on a saccular aneurysm located on the distal extracranial segment of the right internal carotid artery. The pseudoaneurysm was successfully treated with a heparin surface Viabahn stent-graft system (Gore AL, Flagstaff, AZ). Heparin surface stent-grafts can be used for the treatment of carotid lesions and may offer protection against intimal hyperplasia and thrombosis. Further studies are needed to evaluate the long-term results. Copyright © 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases.

PubMed

Lüders, Jürgen C; Steinmetz, Michael P; Mayberg, Marc R

2005-01-01

Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.

Endovascular Repair of Descending Thoracic Aortic Aneurysm

PubMed Central

2005-01-01

Executive Summary Objective To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA). Clinical Need Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition. The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases. The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia. The Technology Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs. The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall. The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration. Review Strategy Objectives To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs Measures of Effectiveness Primary Outcome Mortality rates (30-day and longer term) Secondary Outcomes Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation Rate of reintervention (through surgical or endovascular approach) Measures of Safety Complications were categorized into 2 classes: Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia. Inclusion Criteria Studies comparing the clinical outcomes of ESG treatment with surgical approaches Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs Exclusion Criteria Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta Studies investigating the aneurysms of the ascending and the arch of the aorta Studies using custom-made grafts Literature Search The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies. One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria. Summary of Findings Mortality The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery). Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA. Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula. Technical Success Rate Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases). Surgical Reintervention In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding. Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case). Endovascular Revision In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak. Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak. Graft Migration Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%. Aortic Rupture In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%. Postprocedural Complications In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery. Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%). Time-Related Outcomes The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days). The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively. Ontario-Based Economic Analysis In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure. Hospitalization Costs The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative). Professional (Ontario Health Insurance Plan) Costs Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations. The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes. The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes. Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured. Conclusions Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair. There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention. However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay. PMID:23074469

Evaluating of small intracranial aneurysms by 64-detector CT Angiography: a comparison with 3-dimensional rotation DSA or surgical findings.

PubMed

Zhang, He; Hou, Chang; Zhou, Zhi; Zhang, Hao; Zhou, Gen; Zhang, Gui

2014-01-01

The diagnostic performance of 64-detector computed tomographic angiography (CTA) for detection of small intracranial aneurysms (SIAs) was evaluated. In this prospective study, 112 consecutive patients underwent 64-detector CTA before volume-rendering rotation digital subtraction angiography (VR-RDSA) or surgery. VR-RDSA or intraoperative findings or both were used as the gold standards. The accuracy, sensitivity, specificity, and positive predictive values (PPV) and negative predictive values (NPV), as measures to detect or rule out SIAs, were determined by patient-based and aneurysm size-based evaluations. The reference standard methods revealed 84 small aneurysms in 71 patients. The results of patient-based 64-detector CTA evaluation for SIAs were: accuracy, 98.2%; sensitivity, 98.6%; specificity, 97.6%; PPV, 98.6%; and NPV, 97.6%. The aneurysm-based evaluation results were: accuracy, 96.8%; sensitivity, 97.6%; specificity, 95.1%; PPV, 97.6%; and NPV, 95.1%. Two false-positive and two false-negative findings for aneurysms <3 mm in size occurred in the 64-detector CTA analysis. The diagnostic performance of 64-detector CTA did not improve much compared with 16-detector CTA for detecting SIAs, especially for very small aneurysms. VR-RDSA is still necessary for patients with a history of subarachnoid hemorrhage if the CTA findings are negative. Copyright © 2012 by the American Society of Neuroimaging.

[A Case of Gastric Cancer with Splenic Artery Aneurysm, Intraoperative ICG Fluorography Is Useful in Evaluating the Blood Flow of Stomach and Spleen].

PubMed

Usui, Kenji; Sakamoto, Kaoru; Akabane, Kentaro; Hayasaka, Kazuki; Mizuki, Toru; Yagi, Yutaka; Shirahata, Yasuhiro; Ichikawa, Hiroshi; Hanyu, Takaaki; Ishikawa, Takashi; Kameyama, Hitoshi; Suzuki, Satoshi; Saito, Kiyohiro; Wakai, Toshifumi

2017-11-01

An 81-year-oldwoman with advancedgastric cancer was referredto our hospital. Preoperative contrast-enhancedCT revealeda roundcalcification of the splenic hilum with 15mm in diameter as a splenic artery aneurysm. She underwent transcatheter arterial embolization(TAE)for the splenic artery aneurysm. Celiac artery angiography showedcollateral arterial network of the spleen from left gastric artery. Surgery for the gastric cancer was performed1 4 days after TAE. We cut the right gastric andbilateral epigastric arteries. After the left gastric artery clamping, we performedintraoperative indocyanine green(ICG)fluorography. ICG fluorography confirmedthat the bloodflow of the upper thirdof the stomach andspleen were maintained. We safely performed distal gastrectomy, and the postoperative course was uneventful.

Mortality After Elective and Ruptured Abdominal Aortic Aneurysm Surgical Repair: 12-Year Single-Center Experience of Estonia.

PubMed

Lieberg, J; Pruks, L-L; Kals, M; Paapstel, K; Aavik, A; Kals, J

2018-06-01

Abdominal aortic aneurysm is a degenerative vascular pathology with high mortality due to its rupture, which is why timely treatment is crucial. The current single-center retrospective study was undertaken to analyze short- and long-term all-cause mortality after operative treatment of abdominal aortic aneurysm and to examine the factors that influence outcome. The data of all abdominal aortic aneurysm patients treated with open repair or endovascular aneurysm repair in 2004-2015 were retrospectively retrieved from the clinical database of Tartu University Hospital. The primary endpoint was 30-day, 90-day, and 5-year all-cause mortality. The secondary endpoint was determination of the risk factors for mortality. Elective abdominal aortic aneurysm repair was performed on 228 patients (mean age 71.8 years), of whom 178 (78%) were treated with open repair and 50 (22%) with endovascular aneurysm repair. A total of 48 patients with ruptured abdominal aortic aneurysm were treated with open repair (mean age 73.8 years) at the Department of Vascular Surgery, Tartu University Hospital, Estonia. Mean follow-up period was 4.2 ± 3.3 years. In patients with elective abdominal aortic aneurysm, 30-day, 90-day, and 5-year all-cause mortality rates were 0.9%, 2.6%, and 32%, respectively. In multivariate analysis, the main predictors for 5-year mortality were preoperative creatinine value and age (p < 0.05). In patients with ruptured abdominal aortic aneurysm, 30-day, 90-day, and 5-year all-cause mortality rates were 22.9%, 33.3%, and 55.1%, respectively. In multivariate analysis, the risk factors for 30-day mortality in ruptured abdominal aortic aneurysm were perioperative hemoglobin and lactate levels (p < 0.05). According to this study, the all-cause mortality rates of elective abdominal aortic aneurysm and ruptured abdominal aortic aneurysm at our hospital were comparable to those at other centers worldwide. Even though some variables were identified as potential predictors of survival, the mortality rates after ruptured abdominal aortic aneurysm remain high. Early diagnosis, timely treatment, and detection of the risk factors for abdominal aortic aneurysm progression would improve survival in patients with abdominal aortic aneurysm.

Aneurysm in the brain

MedlinePlus

... ruptured: Clipping is done during open brain surgery (craniotomy) . Endovascular repair is most often done. It usually ... unit (ICU) Complete bed rest and activity restrictions Drainage of blood from the brain area (cerebral ventricular ...

Swallowing problems

MedlinePlus

... Read More Brain aneurysm repair Brain surgery Laryngectomy Multiple sclerosis Oral cancer Parkinson disease Stroke Throat or larynx ... Jejunostomy feeding tube Mouth and neck radiation - discharge Multiple sclerosis - discharge Stroke - discharge Review Date 5/11/2016 ...

Effect of statin therapy on serum activity of proteinases and cytokines in patients with abdominal aortic aneurysm

PubMed Central

Muehling, Bernd; Oberhuber, Alexander; Schelzig, Hubert; Bischoff, Gisela; Marx, Nikolaus; Sunder-Plassmann, Ludger; Orend, Karl H

2008-01-01

Background and aims: Metalloproteinases (MMPs) are considered to be key enzymes in the pathogenesis of abdominal aortic aneurysms (AAA), with elevated levels in diseased aorta and in patient sera. Statins seem to exert an inhibitory effect on MMP activity in the aortic wall. No data exist on the effect of statins on serum activity of MMPs and inflammatory cytokines (interleukins, IL). Methods: The serum activities of MMP2 and MMP9, osteoprotegerin (OPG), and IL6 and IL10 in 63 patients undergoing elective infrarenal aneurysm repair were measured on the day before surgery. Levels were correlated to statin therapy and aneurysm diameter. Results: There was no significant difference between the two groups in the activity of circulating levels of MMP2/9, OPG, and IL6/10 in patients with infrarenal aortic aneurysm. IL6 levels in patients with AAA larger than 6 cm were significantly elevated; differences in serum activities of MMP2/9, OPG, and IL10 were not related to AAA diameter. Conclusion: Serum activities of MMP2/9, OPG, and IL6/10 are not correlated to statin therapy; IL6 levels are higher in patients with large aneurysms. Hence the effect of statin therapy in the treatment of aneurismal disease remains to be elucidated. PMID:19337556

Ruptured persistent sciatic artery aneurysm managed by endovascular embolization.

PubMed

Rezayat, Combiz; Sambol, Elliot; Goldstein, Lee; Broderick, Stephen R; Karwowski, John K; McKinsey, James F; Vouyouka, Ageliki G

2010-01-01

Persistent sciatic artery (PSA) is a rare vascular anomaly present in 0.025% to 0.05% of the population. They are particularly prone to aneurysmal degeneration, potentially leading to distal ischemia, sciatic neuropathy, or rarely rupture. Here, we describe a case of a ruptured PSA aneurysm managed by endovascular embolization. A 70-year-old man initially presented with acute left lower extremity ischemia. He was found to have a popliteal embolus originating from a complete persistent sciatic artery aneurysm. He underwent thrombolysis followed by a femoropopliteal bypass and ligation of the proximal popliteal artery to exclude the PSA. Four weeks later he re-presented with severe pain, a pulsatile buttock mass, and anemia in the setting of hemodynamic instability. A ruptured PSA aneurysm was confirmed by computed tomography angiography (CTA). This was managed emergently by endovascular exclusion of the inflow and outflow vessels using Amplatzer vascular plugs. His postoperative course was complicated by both a foot drop, likely secondary to sciatic nerve ischemia, and a buttock abscess. To our knowledge, this is the first report detailing the endovascular management of a ruptured PSA aneurysm. The etiology, management, and complications associated with the treatment of this rare vascular entity are discussed. Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Effect of exercise on patient specific abdominal aortic aneurysm flow topology and mixing

PubMed Central

Arzani, Amirhossein; Les, Andrea S.; Dalman, Ronald L.; Shadden, Shawn C.

2014-01-01

SUMMARY Computational fluid dynamics modeling was used to investigate changes in blood transport topology between rest and exercise conditions in five patient-specific abdominal aortic aneurysm models. Magnetic resonance imaging was used to provide the vascular anatomy and necessary boundary conditions for simulating blood velocity and pressure fields inside each model. Finite-time Lyapunov exponent fields, and associated Lagrangian coherent structures, were computed from blood velocity data, and used to compare features of the transport topology between rest and exercise both mechanistically and qualitatively. A mix-norm and mix-variance measure based on fresh blood distribution throughout the aneurysm over time were implemented to quantitatively compare mixing between rest and exercise. Exercise conditions resulted in higher and more uniform mixing, and reduced the overall residence time in all aneurysms. Separated regions of recirculating flow were commonly observed in rest, and these regions were either reduced or removed by attached and unidirectional flow during exercise, or replaced with regional chaotic and transiently turbulent mixing, or persisted and even extended during exercise. The main factor that dictated the change in flow topology from rest to exercise was the behavior of the jet of blood penetrating into the aneurysm during systole. PMID:24493404

False traumatic aneurysms and arteriovenous fistulas: retrospective analysis.

PubMed

Davidovic, Lazar B; Banzić, Igor; Rich, Norman; Dragaš, Marko; Cvetkovic, Slobodan D; Dimic, Andrija

2011-06-01

The purpose of this study was to analyze the incidence, clinical presentation, diagnosis, and treatment of false traumatic aneurysms and arteriovenous fistulas as well as the outcomes of the patients. A retrospective, 16-year survey has been conducted regarding the cases of patients who underwent surgery for false traumatic aneurysms (FTA) of arteries and traumatic arteriovenous fistulas (TAVF). Patients with iatrogenic AV fistulas and iatrogenic false aneurysms were excluded from the study. There were 36 patients with TAVF and 47 with FTA. In all, 73 (87.95%) were male, and 10 (12.05%) were female, with an average age of 36.93 years (13-82 years). In 25 (29.76%) cases TAVF and FTA appeared combat-related, and 59 (70.24%) were in noncombatants. The average of all intervals between the injury and surgery was 919. 8 days (1 day to 41 years) for FTA and 396.6 days (1 day to 9 years) for TAVF. Most of the patients in both groups were surgically treated during the first 30 days after injury. One patient died on the fourth postoperative day. There were two early complications. The early patency rate was 83.34%, and limb salvage was 100%. There were no recurrent AV fistulas that required additional operations. Because of their history of severe complications, FTA and TAV fistulas require prompt treatment. The treatment is simpler if there is only a short interval between the injury and the operation. Surgical endovascular repair is mostly indicated.

Cognition and adjustment after late and early operation for ruptured aneurysm.

PubMed

Sonesson, B; Ljunggren, B; Säveland, H; Brandt, L

1987-09-01

Does early aneurysm operation, while lowering the overall management mortality, result in an unacceptable morbidity in terms of increased cognitive disturbances and psychosocial maladjustment? The present study evaluates quality of life, degree of cognitive dysfunction, and adjustment of 93 patients with satisfactory neurological recoveries after operations for ruptured supratentorial aneurysms. All patients had been in neurological Grades I to III (Hunt and Hess) after subarachnoid hemorrhage (SAH). Fifty-five patients were operated upon during the acute state, i.e., within 72 hours after bleeding (early surgery = ES), and 38 patients had been subjected to late surgery (LS), i.e., were operated on 9 days or more after SAH. Each patient was subjected to a clinical interview and a comprehensive neuropsychological investigation. The time interval between SAH and assessment varied between 12 and 103 months (mean, 56 months). The results confirm that there are indication of cognitive malfunctioning and psychosocial disturbances of varying severity and distribution in patients who have undergone LS. The pattern and distribution of sequelae after LS did not differ substantially from that in patients subjected to ES. The results offer strong support to the concept that remaining disturbances in cognition are mainly related to the impact of the initial hemorrhage per se. In patients with anterior communicating artery aneurysms, a larger decrease in tempo and perceptual vigilance was noted, suggesting that the subfrontal midline structures are particularly involved in processes demanding flexibility, attention, and capacity to adapt to novel demands in a perceptual situation.

[Microsurgical anatomy importance of A1-anterior communicating artery complex].

PubMed

Monroy-Sosa, Alejandro; Pérez-Cruz, Julio César; Reyes-Soto, Gervith; Delgado-Hernández, Carlos; Macías-Duvignau, Mario Alberto; Delgado-Reyes, Luis

2013-01-01

The anterior cerebral artery originates from the bifurcation of the internal carotid artery lateral to the optic chiasm, then joins with its contralateral counterpart via the anterior communicating artery. A1-anterior communicating artery complex is the most frequent anatomical variants and is the major site of aneurysms between 30 to 37%. Know the anatomy microsurgical, variants anatomical and importance of complex precommunicating segment-artery anterior communicating in surgery neurological of the pathology vascular, mainly aneurysms, in Mexican population. The study was performed in 30 brains injected. Microanatomy was studied (length and diameter) of A1-anterior communicating artery complex and its variants. 60 segments A1, the average length of left side was 11.35 mm and 11.84 mm was right. The average diameter of left was 1.67 mm and the right was 1.64 mm. The average number of perforators on the left side was 7.9 and the right side was 7.5. Anterior communicating artery was found in 29 brains of the optic chiasm, its course depended on the length of the A1 segment. The average length of the segment was 2.84 mm, the average diameter was 1.41 mm and the average number of perforators was 3.27. A1-anterior communicating artery complex variants were found in 18 (60%) and the presence of two blister-like aneurysms. It is necessary to understand the A1-anterior communicating artery complex microanatomy of its variants to have a three-dimensional vision during aneurysm surgery.

Improved Visualization of Intracranial Vessels with Intraoperative Coregistration of Rotational Digital Subtraction Angiography and Intraoperative 3D Ultrasound

PubMed Central

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Introduction Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. Methods We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Results Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Conclusions Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography. PMID:25803318

Combination Superficial Temporal Artery-Middle Cerebral Artery Bypass and M2-M2 Reanastomosis With Trapping of a Stented Distal Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

PubMed

Burkhardt, Jan-Karl; Yousef, Sonia; Tabani, Halima; Benet, Arnau; Rubio, Roberto Rodriguez; Lawton, Michael T

2018-05-12

Distal middle cerebral artery (MCA) aneurysms often have non-saccular morphology and cannot be clipped, requiring revascularization and trapping instead. Combination bypasses are needed when 2 arteries exit the aneurysm, and extracranial-intracranial and intracranial-intracranial bypasses can be used. This video demonstrates a combination bypass used to treat a previously stented distal MCA aneurysm with both a superficial temporal artery (STA)-to-MCA bypass and an M2-to-M2 reanastomosis. This 56-yr-old man presented with distal left-sided MCA aneurysm 2 years earlier and attempted stent-assisted coiling was aborted after the aneurysm was perforated with stenting alone. Follow-up angiography demonstrated progressive aneurysm enlargement, and he was referred for surgery. The patient consented for the procedure and a pterional craniotomy extended posteriorly exposed the distal Sylvian fissure and efferent M4-cortical arteries. After splitting the Sylvian fissure, the "flash fluorescence" technique with indocyanine green (ICG) videoangiography identified an M4 recipient artery from the deeper of 2 exiting branches for STA-MCA bypass.1 The aneurysm was then trapped, and inflow and the more superficial outflow arteries were anastomosed end to end (M2-M2 in-situ bypass). A platelet plug that developed at the reanastomosis site was broken apart with mechanical manipulation, and ICG videoangiography demonstrated patency of both bypasses. The patient recovered without any neurological deficits, and postoperative computed tomography angiography confirmed bypass patency. Combination bypasses are needed when unclippable bifurcation aneurysms require revascularization. Careful intraoperative evaluation of patency of the bypass is imperative and helps identifying and addressing any potential early bypass occlusion.

New method for obliterative treatment of an anterior wall aneurysm in the internal carotid artery: encircling silicone sheet clip procedure--technical case report.

PubMed

Kurokawa, Y; Wanibuchi, M; Ishiguro, M; Inaba, K

2001-08-01

Aneurysms on the anterior surface of the internal carotid artery (ICA) have been shown to be somewhat different from ordinary berry aneurysms because they are rather small, grow rapidly in a short time, and easily lead to rupture, especially during surgery. The most difficult problem is that this type of aneurysm cannot be eliminated easily by an ordinary clipping procedure without causing apparent arterial stenosis or occlusion. A 52-year-old man experienced a subarachnoid hemorrhage because of a ruptured aneurysm located on the anterior surface of the ICA. The tiny aneurysmal body, which was covered with a layer of brain tissue, was successfully exposed. The ICA seemed to be atherosclerotic, and the aneurysmal portion was solitary and had a reddish color. A large silicone sheet encircling clip (Vascwrap; Mizuho Ikakogyo Co., Ltd., Tokyo, Japan) was selected for this patient. The proximal margin of the silicone sheet was incised with a V-shaped cut, and the middle part of the sheet, which covered the diagonal part of the ICA, was trimmed to make it shorter. The blade of the fenestrated clip was applied to obliterate the aneurysm and was attached to the normal arterial wall together with this modified Vascwrap sheet to create a small space between the normal arterial wall and the surrounding Vascwrap sheet. Then tiny pieces of Teflon fiber (E.I. duPont de Nemours and Co., Wilmington, DE) was inserted from both margins, and the whole Vascwrap sheet was sealed with fibrin glue to ensure good adhesion. This method seemed adequate in treating this difficult aneurysm without causing postoperative regrowth or occlusion of the patient's ICA.

Improved visualization of intracranial vessels with intraoperative coregistration of rotational digital subtraction angiography and intraoperative 3D ultrasound.

PubMed

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography.

Dual-Image Videoangiography During Intracranial Microvascular Surgery.

PubMed

Feletti, Alberto; Wang, Xiangdong; Tanaka, Riki; Yamada, Yasuhiro; Suyama, Daisuke; Kawase, Tsukasa; Sano, Hirotoshi; Kato, Yoko

2017-03-01

Indocyanine green videoangiography (ICG-VA) is a valuable tool to assess vessel and aneurysm patency during neurovascular surgical procedures. However, ICG-VA highlights vascular structures, which appear white over a black background. Anatomic relationships are sometimes difficult to understand at first glance. Dual-image videoangiography (DIVA) enables simultaneous visualization of light and near-infrared fluorescence images of ICG-VA. The DIVA system was mounted on an OPMI Pentero Flow 800 intraoperative microscope. DIVA was used during microsurgical procedures on 5 patients who were operated for aneurysm clipping and superficial temporal artery-middle cerebral artery bypass. DIVA provides real-time simultaneous visualization of aneurysm and vessels and surrounding structures including brain, nerves, and surgical clips. Although visual contrast between vessels and background is higher with standard black-and-white imaging, DIVA makes it easier to understand anatomic relationships between intracranial structures. DIVA also provides better vision of the depth of field. DIVA has the potential to become a widely used intraoperative tool to check patency of intracranial vessels. It should be considered as an adjunct to standard ICG-VA for better understanding of vascular anatomy in relation to surrounding structures and can have an impact on decision making during surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement.

PubMed

Svensson, Lars G; Pillai, Saila T; Rajeswaran, Jeevanantham; Desai, Milind Y; Griffin, Brian; Grimm, Richard; Hammer, Donald F; Thamilarasan, Maran; Roselli, Eric E; Pettersson, Gösta B; Gillinov, A Marc; Navia, Jose L; Smedira, Nicholas G; Sabik, Joseph F; Lytle, Bruce W; Blackstone, Eugene H

2016-03-01

To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P < .05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities (P < .0001). These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

An Analysis of the Surgery Scheduling Process at Madigan Army Medical Center, Tacoma, Washington

DTIC Science & Technology

1986-07-29

CODE Incision and Drainage (I&D) 10060 of Abscess I&D of Abscess Complicated 10061 I&D of Pilonidal Cyst 10080 Debridement 11044 Skin Biopsy 11100...Unilateral 60220 Parathyroidectomy 60500 Craniotomy , Supratentorial 61310 Intracranial Aneurysm, Carotid 61700 Circulation Lumbar Laminectomy 62297...SURGICAL PRE/POST-OP SURGERY PRE/POST-OP TOTAL CASE CODE NURSING PREP ANESTHESIA SURGERY TIME Incision and 10060 23 13 22 33 91 Drainage (I&D) of Abscess I

Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.

PubMed

Dua, Anahita; Koprowski, Steven; Upchurch, Gilbert; Lee, Cheong J; Desai, Sapan S

2017-01-01

In 2014, we published a series of articles in the Journal of Vascular Surgery that detailed the decrease in volume of open aneurysm repair (OAR) completed for abdominal aortic aneurysm (AAA) by vascular surgery trainees. At that time, only data points from 2000 through 2011 were available, and reliable predictions could only be made through 2015. Lack of data on endovascular aneurysm repair (EVAR) using fenestrated (FEVAR) and branched (BrEVAR) endografts also affected our findings. Despite these limitations, our predictions for OAR completed by vascular trainees were accurate for 2012 to 2014. This report uses updated data points through 2014 in conjunction with data on FEVAR and BrEVAR obtained from industry to predict trends in OAR and how it will affect vascular surgery training through 2020. An S-curve modified logistic function was used to model the effect of introducing new technologies (EVAR, FEVAR, BrEVAR) on the standard management of AAA with OAR starting in the year 2000, similar to the technique that we have previously described. Weighted samples and data from the United States Census Bureau were used in conjunction with volume estimates derived from the National Inpatient Sample, State Inpatient Databases, and industry sources to determine trends in OAR and EVAR. The number of cases completed at teaching hospitals was calculated using the National Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees through 2020. Sensitivity analysis and trend analysis were completed. Approximately 45,000 AAA repairs are completed annually in the United States, but only 15% of these are now completed using OAR compared with >50% just a decade ago. Further, with the accelerating adoption of FEVAR and BrEVAR, and expanding indications for standard EVAR, our model predicts that <3000 OARs will be completed annually by 2020. Because only a subset of these cases are completed at teaching institutions, our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs. Our initial prediction in the 2014 report was that vascular trainees would complete approximately five OARs by 2020. After incorporating new data on BrEVAR, FEVAR, and the accelerating pace of EVAR use between 2012 and 2014, it now appears that vascular trainees will complete one to three OARs during their training. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Posterior inferior cerebellar artery aneurysms: Anatomical variations and surgical strategies

PubMed Central

Singh, Rohit K.; Behari, Sanjay; Kumar, Vijendra; Jaiswal, Awadhesh K.; Jain, Vijendra K.

2012-01-01

Context: Posterior inferior cerebellar artery (PICA) aneurysms are associated with multiple anatomical variations of the parent vessel. Complexities in their surgical clipping relate to narrow corridors limited by brain-stem, petrous-occipital bones, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns. Aims: The present study focuses on surgical considerations during clipping of saccular PICA aneurysms. Setting and Design: Tertiary care, retrospective study. Materials and Methods: In 20 patients with PICA aneurysms, CT angiogram/digital substraction angiogram was used to correlate the site and anatomical variations of aneurysms located on different segments of PICA with the approach selected, the difficulties encountered and the final outcome. Statistical Analysis: Comparison of means and percentages. Results: Aneurysms were located on PICA at: vertebral artery/basilar artery (VA/BA)-PICA (n=5); anterior medullary (n=4); lateral medullary (n=3); tonsillomedullary (n=4); and, telovelotonsillar (n=4) segments. The Hunt and Hess grade distribution was I in 15; II in 2; and, III in 3 patients (mean ictus-surgery interval: 23.5 days; range: 3-150 days). Eight patients had hydrocephalus. Anatomical variations included giant, thrombosed aneurysms; 2 PICA aneurysms proximal to an arteriovenous malformation; bilobed or multiple aneurysms; low PICA situated at the foramen magnum with a hypoplastic VA; and fenestrated PICA. The approaches included a retromastoid suboccipital craniectomy (n=9); midline suboccipital craniectomy (n=6); and far-lateral approach (n=5). At a follow-up (range 6 months-2.5 years), 13 patients had no deficits (modified Rankin score (mRS) 0); 2 were symptomatic with no significant disability (mRS1); 1 had mild disability (mRS2); 1 had moderately severe disability (mRS4); and 3 died (mRS6). Three mortalities were caused by vasospasm (2) and, rupture of unclipped second VA-BA junctional aneurysm (1). Conclusions: PICA aneurysms may present with only IVth ventricular blood without subarachnoid hemorrhage. PICA may have multiple anomalies and its aneurysms may be missed on CT angiograms. Surgical approach is influenced by VA-BA tortuosity and variations in anatomy, location of the VA-BA junction and the PICA aneurysm relative to the brain-stem, and the pattern of collateral supply. The special category of VA-PICA junctional aneurysms and its management; and, the multiple anatomical variations of PICA aneurysms, merit special surgical considerations and have been highlighted in this study. PMID:22639684

Biodegradable Magnesium Stent Treatment of Saccular Aneurysms in a Rat Model - Introduction of the Surgical Technique.

PubMed

Nevzati, Edin; Rey, Jeannine; Coluccia, Daniel; D'Alonzo, Donato; Grüter, Basil; Remonda, Luca; Fandino, Javier; Marbacher, Serge

2017-10-01

The steady progess in the armamentarium of techniques available for endovascular treatment of intracranial aneurysms requires affordable and reproducable experimental animal models to test novel embolization materials such as stents and flow diverters. The aim of the present project was to design a safe, fast, and standardized surgical technique for stent assisted embolization of saccular aneurysms in a rat animal model. Saccular aneurysms were created from an arterial graft from the descending aorta.The aneurysms were microsurgically transplanted through end-to-side anastomosis to the infrarenal abdominal aorta of a syngenic male Wistar rat weighing >500 g. Following aneurysm anastomosis, aneurysm embolization was performed using balloon expandable magnesium stents (2.5 mm x 6 mm). The stent system was retrograde introduced from the lower abdominal aorta using a modified Seldinger technique. Following a pilot series of 6 animals, a total of 67 rats were operated according to established standard operating procedures. Mean surgery time, mean anastomosis time, and mean suturing time of the artery puncture site were 167 ± 22 min, 26 ± 6 min and 11 ± 5 min, respectively. The mortality rate was 6% (n=4). The morbidity rate was 7.5% (n=5), and in-stent thrombosis was found in 4 cases (n=2 early, n=2 late in stent thrombosis). The results demonstrate the feasibility of standardized stent occlusion of saccular sidewall aneurysms in rats - with low rates of morbidity and mortality. This stent embolization procedure combines the opportunity to study novel concepts of stent or flow diverter based devices as well as the molecular aspects of healing.

Transient ischaemic attacks due to a pulsating mass in the neck produced after incision and drainage of parapharyngeal abscess.

PubMed

Khan, Mohammad Iqbal; Tariq, Mohammad; Rashid, Danyal

2008-01-01

Carotid endarterectomy is the most commonly performed vascular surgical procedure. One of the complications of carotid endarterectomy is Pseudoaneurysm of the carotid artery frequently managed by endo-vascular technique. Pseudoaneurysm caused by other aetiological factors is rare entity. Penetrating trauma and neck surgery are known but very rare causes of pseudo aneurysm of the carotid artery. We have successfully managed a case of carotid artery pseudoaneurysm caused by incision and drainage of parapharyngeal abscess. This surgery also leads to the palsy of right vagus nerve causing complete hoarseness of voice. The patient presented with Transit Ischaemic Attacks (TIA) and amurosis fugos. Resection of aneurysm and reconstruction of right carotid artery lead to complete recovery. Vocal cord palsy was managed by Vox implant injection leading to full recovery.

Surgical management of third nerve palsy

PubMed Central

Singh, Anupam; Bahuguna, Chirag; Nagpal, Ritu; Kumar, Barun

2016-01-01

Third nerve paralysis has been known to be associated with a wide spectrum of presentation and other associated factors such as the presence of ptosis, pupillary involvement, amblyopia, aberrant regeneration, poor bell's phenomenon, superior oblique (SO) overaction, and lateral rectus (LR) contracture. Correction of strabismus due to third nerve palsy can be complex as four out of the six extraocular muscles are involved and therefore should be approached differently. Third nerve palsy can be congenital or acquired. The common causes of isolated third nerve palsy in children are congenital (43%), trauma (20%), inflammation (13%), aneurysm (7%), and ophthalmoplegic migraine. Whereas, in adult population, common etiologies are vasculopathic disorders (diabetes mellitus, hypertension), aneurysm, and trauma. Treatment can be both nonsurgical and surgical. As nonsurgical modalities are not of much help, surgery remains the main-stay of treatment. Surgical strategies are different for complete and partial third nerve palsy. Surgery for complete third nerve palsy may involve supra-maximal recession - resection of the recti. This may be combined with SO transposition and augmented by surgery on the other eye. For partial third nerve, palsy surgery is determined according to nature and extent of involvement of extraocular muscles. PMID:27433033

MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting.

PubMed

Clarke, M G; Thomas, H G; Chester, J F

2005-01-01

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.

MRSA-Infected External Iliac Artery Pseudoaneurysm Treated with Endovascular Stenting

DOE Office of Scientific and Technical Information (OSTI.GOV)

Clarke, M.G.; Thomas, H.G.; Chester, J.F.

2005-04-15

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered,more » balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.« less

How do elderly patients decide where to go for major surgery? Telephone interview survey

PubMed Central

Schwartz, Lisa M; Woloshin, Steven; Birkmeyer, John D

2005-01-01

Objective To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions. Design National telephone interview study. Setting United States. Participants 510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier—abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate. Results Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice “a lot”), followed by the hospital having “nationally recognised” surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%). Conclusion Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians. PMID:16192286

Wall stress on ascending thoracic aortic aneurysms with bicuspid compared with tricuspid aortic valve.

PubMed

Xuan, Yue; Wang, Zhongjie; Liu, Raymond; Haraldsson, Henrik; Hope, Michael D; Saloner, David A; Guccione, Julius M; Ge, Liang; Tseng, Elaine

2018-03-08

Guidelines for repair of bicuspid aortic valve-associated ascending thoracic aortic aneurysms have been changing, most recently to the same criteria as tricuspid aortic valve-ascending thoracic aortic aneurysms. Rupture/dissection occurs when wall stress exceeds wall strength. Recent studies suggest similar strength of bicuspid aortic valve versus tricuspid aortic valve-ascending thoracic aortic aneurysms; thus, comparative wall stress may better predict dissection in bicuspid aortic valve versus tricuspid aortic valve-ascending thoracic aortic aneurysms. Our aim was to determine whether bicuspid aortic valve-ascending thoracic aortic aneurysms had higher wall stresses than their tricuspid aortic valve counterparts. Patients with bicuspid aortic valve- and tricuspid aortic valve-ascending thoracic aortic aneurysms (bicuspid aortic valve = 17, tricuspid aortic valve = 19) greater than 4.5 cm underwent electrocardiogram-gated computed tomography angiography. Patient-specific 3-dimensional geometry was reconstructed and loaded to systemic pressure after accounting for prestress geometry. Finite element analyses were performed using the LS-DYNA solver (LSTC Inc, Livermore, Calif) with user-defined fiber-embedded material model to determine ascending thoracic aortic aneurysm wall stress. Bicuspid aortic valve-ascending thoracic aortic aneurysms 99th-percentile longitudinal stresses were 280 kPa versus 242 kPa (P = .028) for tricuspid aortic valve-ascending thoracic aortic aneurysms in systole. These stresses did not correlate to diameter for bicuspid aortic valve-ascending thoracic aortic aneurysms (r = -0.004) but had better correlation to tricuspid aortic valve-ascending thoracic aortic aneurysms diameter (r = 0.677). Longitudinal stresses on sinotubular junction were significantly higher in bicuspid aortic valve-ascending thoracic aortic aneurysms than in tricuspid aortic valve-ascending thoracic aortic aneurysms (405 vs 329 kPa, P = .023). Bicuspid aortic valve-ascending thoracic aortic aneurysm 99th-percentile circumferential stresses were 548 kPa versus 462 kPa (P = .033) for tricuspid aortic valve-ascending thoracic aortic aneurysms, which also did not correlate to bicuspid aortic valve-ascending thoracic aortic aneurysm diameter (r = 0.007). Circumferential and longitudinal stresses were greater in bicuspid aortic valve- than tricuspid aortic valve-ascending thoracic aortic aneurysms and were more pronounced in the sinotubular junction. Peak wall stress did not correlate with bicuspid aortic valve-ascending thoracic aortic aneurysm diameter, suggesting diameter alone in this population may be a poor predictor of dissection risk. Our results highlight the need for patient-specific aneurysm wall stress analysis for accurate dissection risk prediction. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Ultra Low Density Shape Memory Polymer Foams With Tunable Physicochemical Properties for Treatment of intracranial Aneurysms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Singhal, Pooja

Shape memory polymers (SMPs) are a rapidly emerging class of smart materials that can be stored in a deformed temporary shape, and can actively return to their original shape upon application of an external stimulus such as heat, pH or light. This behavior is particularly advantageous for minimally invasive biomedical applications comprising embolic/regenerative scaffolds, as it enables a transcatheter delivery of the device to the target site. The focus of this work was to exploit this shape memory behavior of polyurethanes, and develop an efficient embolic SMP foam device for the treatment of intracranial aneurysms.In summary, this work reports amore » novel family of ultra low density polymer foams which can be delivered via a minimally invasive surgery to the aneurysm site, actuated in a controlled manner to efficiently embolize the aneurysm while promoting physiological fluid/blood flow through the reticulated/open porous structure, and eventually biodegrade leading to complete healing of the vasculature.« less

French Women From Multiplex Abdominal Aortic Aneurysm Families Should Be Screened

PubMed Central

Le Hello, Claire; Koskas, Fabien; Cluzel, Philippe; Tazi, Zoubida; Gallos, Corina; Piette, Jean Charles; Lasserve, Elisabeth Tournier; Kieffer, Edouard; Cacoub, Patrice

2005-01-01

Background: Multiplex abdominal aortic aneurysm families (MAAAFs) (≥1 subject plus the proband) represent 1% to 34% of abdominal aortic aneurysm (AAA), but the percentage in France is unknown. Method: The MAAAF rate was retrospectively defined by analysis of 3 groups: 72 of 104 consecutive individuals undergoing AAA surgery during 1994, 24 of 53 women and 35 of 76 men with giant (≥9 cm) AAA operated on during 1986 to 1994. MAAAF characteristics were determined based on 10 families issued from these 3 groups and 34 others identified nationwide. Data were obtained from a standardized questionnaire for probands and relatives, detailed pedigrees of each family, and computed tomography (CT) scans without contrast medium of the aorta and lower limb arteries for first-degree relatives ≥40-year-of age. Results: The MAAAF rate was 4.2% for the consecutive-surgery patients (proband M/F ratio, 17:1; mean age at surgery, 68.5 ± 8.5 years). CT detected no additional AAA among them (screened individuals M/F ratio, 0.63; mean age, 54.0 ± 11.2 years). MAAAF rates were 8.3% and 14.3% for the women's and giant-AAA groups with CT screening, respectively. Characteristics were investigated in 104 affected subjects from 44 MAAAFs: female relatives were more often affected than probands (P < 0.025). Compared with men, affected female relatives were significantly older at diagnosis and surgery (P < 0.05 and P < 0.02, respectively), as were affected women (P < 0.02 and P < 0.01, respectively). CT scan screening identified significantly more AAA and abdominal aortic dilatations among the 44 MAAAFs than the consecutive-surgery group (5 and 4, respectively; P < 0.001). Conclusion: Although the MAAAF rate seems low in France, women from MAAAF were affected more often and later, suggesting that they should be screened. PMID:16244549

Aortic Root Replacement for Children With Loeys-Dietz Syndrome.

PubMed

Patel, Nishant D; Alejo, Diane; Crawford, Todd; Hibino, Narutoshi; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A

2017-05-01

Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality. Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1 (3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Battle of the Bulge: Aortic Aneurysm Management From Early Modernity to the Present.

PubMed

Barr, Justin

2017-02-21

For centuries, physicians have recognized aortic aneurysms as an acute threat to life. Therapeutic approaches to the disease began in the 18th century when leading physicians, such as René Laennec and Antonio Valsalva, applied research on circulation and blood coagulation to devise whole-body fasting and bleeding regimens to prevent rupture. After John Hunter's success in ligating arteries to treat peripheral aneurysms, surgeons attempted analogous operations on the aorta, but even the renowned Sir Astley Cooper and William Halsted met with disastrous results. Other clinicians tried various methods of creating intraluminal clots, including the application of such new technologies as electricity and plastic. Vessel repair techniques, pioneered by Alexis Carrel and others in the 20th century, eventually provided a reliably effective treatment. In the past few decades, minimally invasive methods that approach aneurysms endovascularly through small groin incisions have been adopted. A successful 2005 congressional campaign to fund screening for aortic aneurysms brought the disease to national attention and symbolizes current confidence in curing it. Drawing on various published and unpublished sources, this paper elucidates the development of specific treatments for aortic aneurysms over time and more broadly addresses how medicine and surgery apply the knowledge and technology available in particular eras to treat a specific, identifiable, and lethal disease. Examining the evolution of these therapeutic efforts unveils broader trends in the history of medicine. This allows aortic aneurysms to serve as a case study for exploring shifting philosophies in medical history.

Endovascular repair of abdominal aortic aneurysms: vascular anatomy, device selection, procedure, and procedure-specific complications.

PubMed

Bryce, Yolanda; Rogoff, Philip; Romanelli, Donald; Reichle, Ralph

2015-01-01

Abdominal aortic aneurysm (AAA) is abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. Open repair of AAA involves lengthy surgery time, anesthesia, and substantial recovery time. Endovascular aneurysm repair (EVAR) provides a safer option for patients with advanced age and pulmonary, cardiac, and renal dysfunction. Successful endovascular repair of AAA depends on correct selection of patients (on the basis of their vascular anatomy), choice of the correct endoprosthesis, and familiarity with the technique and procedure-specific complications. The type of aneurysm is defined by its location with respect to the renal arteries, whether it is a true or false aneurysm, and whether the common iliac arteries are involved. Vascular anatomy can be divided more technically into aortic neck, aortic aneurysm, pelvic perfusion, and iliac morphology, with grades of difficulty with respect to EVAR, aortic neck morphology being the most common factor to affect EVAR appropriateness. When choosing among the devices available on the market, one must consider the patient's vascular anatomy and choose between devices that provide suprarenal fixation versus those that provide infrarenal fixation. A successful technique can be divided into preprocedural imaging, ancillary procedures before AAA stent-graft placement, the procedure itself, postprocedural medical therapy, and postprocedural imaging surveillance. Imaging surveillance is important in assessing complications such as limb thrombosis, endoleaks, graft migration, enlargement of the aneurysm sac, and rupture. Last, one must consider the issue of radiation safety with regard to EVAR. (©)RSNA, 2015.

[Arterial involvements in hereditary dysplasia of the connective tissue].

PubMed

Beylot, C; Doutre, M S; Beylot-Barry, M; Busquet, M

1994-03-01

Arterial involvement is an important feature of the diagnosis and, above all, prognosis of heritable disorders of connective tissue. In pseudoxanthoma elasticum, a progressive occlusive syndrome is associated with hemorrhage and especially with gastrointestinal bleeding. Aneurysms are uncommon. Hypertension occurs frequently. Cutaneous signs (yellowish pseudo xanthomatous papules of the large folds) the ocular changes (angioid streaks) and pathology showing numerous, thickened, fragmented, disorganized, calcified elastic fibers in the deep dermis and arterial walls, allow the diagnosis to be made. In the heterogeneous group of Ehlers-Danlos syndromes, type IV is characterized by sudden spontaneous rupture of the large arteries. Aneurysms and carotido-cavernous fistulae are rather frequent. Owing to friability of the arterial walls, arteriograms and other procedure requiring arterial puncture may prove hazardous and surgery difficult. Such patients have an acrogeric morphotype, and thin, fragile skin, but cutaneous hyperelasticity and joint hyperlaxity are usually minimal. Pathology evidences collagen hypoplasia in the skin and arterial walls. The severity of Marfan syndrome is due to aortic involvement. A fusiform aneurysm of the ascending aorta represents a vital risk of rupture. Aortic root dilatation is associated and responsible of severe aortic regurgitation. Aortic dissection is also a serious threat. Improved surgical techniques for repairing a dilated or dissected aortic root with simultaneous replacement of the aortic valve increases the life expectancy of such patients. Dolichomorphism is the characteristic skeletal abnormality, particularly with arachnodactyly and upward ectopia lentis, which is almost bilateral, is a very frequent feature of Marfan syndrome. The most typical histological finding is aortic cystic median necrosis. The basic defect in Marfan syndrome concerns the fibrillin, whose gene is located on chromosome 15. The three diseases detailed in this paper constitute the main areas of this subject, but arterial involvement may occur in other inheritable disorders of connective tissue (osteogenesis imperfecta, cutis laxa, Werner syndrome, Menkes syndrome, etc).

Delayed recovery of adipsic diabetes insipidus (ADI) caused by elective clipping of anterior communicating artery and left middle cerebral artery aneurysms.

PubMed

Tan, Jeffrey; Ndoro, Samuel; Okafo, Uchenna; Garrahy, Aoife; Agha, Amar; Rawluk, Danny

2016-12-16

Adipsic diabetes insipidus (ADI) is an extremely rare complication following microsurgical clipping of anterior communicating artery aneurysm (ACoA) and left middle cerebral artery (MCA) aneurysm. It poses a significant challenge to manage due to an absent thirst response and the co-existence of cognitive impairment in our patient. Recovery from adipsic DI has hitherto been reported only once. A 52-year-old man with previous history of clipping of left posterior communicating artery aneurysm 20 years prior underwent microsurgical clipping of ACoA and left MCA aneurysms without any intraoperative complications. Shortly after surgery, he developed clear features of ADI with adipsic severe hypernatraemia and hypotonic polyuria, which was associated with cognitive impairment that was confirmed with biochemical investigations and cognitive assessments. He was treated with DDAVP along with a strict intake of oral fluids at scheduled times to maintain eunatremia. Repeat assessment at six months showed recovery of thirst and a normal water deprivation test. Management of ADI with cognitive impairment is complex and requires a multidisciplinary approach. Recovery from ADI is very rare, and this is only the second report of recovery in this particular clinical setting.

Use of cardiovascular magnetic resonance in the evaluation of a giant right atrial appendage aneurysm: a case report and review of the literature.

PubMed

Sivakumaran, Lojan; Sayegh, Karl; Mehanna, Emile; Sanchez, Frank W; Fields, Jonathan; Cury, Ricardo

2017-12-04

Right atrial appendage aneurysms are rare entities that may have significant clinical consequences. When co-existing with atrial fibrillation, patients are at risk of developing pulmonary or paradoxical systemic emboli. An elderly patient presented to medical attention with symptoms of acute diverticulitis. On abdominal computed tomography, a massively enlarged right atrial appendage aneurysm was discovered incidentally. The aneurysm caused marked compression of the right ventricle and contained an area of hypoenhancement concerning for an intraluminal thrombus. Gadolinium-enhanced cardiovascular magnetic resonance was performed and first-pass perfusion images demonstrated that the area of hypoenhancement was in fact poorly mixing blood. The patient was therefore managed medically. Right atrial appendage aneurysms are infrequently encountered cardiac abnormalities. In the literature, surgery has been offered to patients who are young, symptomatic, or have evidence of thrombotic disease, although whether this practice pattern is associated with superior clinical outcomes is unclear. In the present case, gadolinium-enhanced cardiovascular magnetic resonance imaging was used to exclude the presence of intraluminal thrombus in an elderly patient, which helped orient the patient's treating team towards medical-rather than surgical-therapy.

Durability of aneurysm treatments in patients with active Behcet's disease.

PubMed

Elsharawy, Mohamed A; Elsaid, Aymen; Al-Dhafery, Bander; Alghnimi, Ibrahim; Almabyouq, Fatimah

2016-10-01

Aneurysms in Behcet's disease are rare, serious, and recurrent. To achieve durable treatment, patients should receive immunosuppressive therapy before intervention to induce remission. We present early and long-term results of emergency cases of active Behcet's disease, which did not permit waiting for suppressive treatment. The study was undertaken on all cases admitted to the vascular unit, King Fahd Hospital of University for aneurysm treatment in patients with active Behcet's disease over about 10 years. All patients had exclusion of the aneurysm either by open surgery or endovascular intervention. Morbidities and mortality were recorded within the hospital admission and on the follow-up. During the study period, three cases were included. All interventions were successful and lifesaving. However, two cases, treated with surgical interposition grafts, were blocked in the intermediate term follow-up (2-12 months) and one case, treated with endovascular treatment, complicated with pseudoaneurysm at femoral puncture site after six months. Although early results were good, intermediate ones were not satisfactory because of progressive graft thrombosis and formation of new aneurysms. Awareness of these rare cases help for early identification and proper immunosuppressive before emergency vascular intervention is warranted. © The Author(s) 2015.

Right hepatic artery aneurysm.

PubMed

Bernal, Astrid Del Pilar Ardila; Loures, Paulo; Calle, Juan Cristóbal Ospina; Cunha, Beatriz; Córdoba, Juan Camilo

2016-01-01

We report a case of an aneurysm of the right hepatic artery and its multidisciplinary management by general surgery, endoscopy and radiology services. Being a case of extremely low incidence, it is important to show its diagnostic and therapeutic approach. RESUMO Relatamos um caso de aneurisma da artéria hepática direita conduzido de forma multidisciplinar pelos Serviços de Cirurgia Geral, Endoscopia e Radiologia. Em se tratando de caso de incidência baixíssima, é importante mostrar o enfoque diagnóstico e terapêutico usado em seu manejo.

Left Ventricular Assist Device Implantation with Concomitant Aortic Valve and Ascending Aortic Replacement

PubMed Central

Panholzer, Bernd; Cremer, Jochen; Haneya, Assad

2018-01-01

Left ventricular assist device (LVAD) is nowadays a routine therapy for patients with advanced heart failure. We present the case of a 74-year-old male patient who was admitted to our center with terminal heart failure in dilated cardiomyopathy and ascending aortic aneurysm with aortic valve regurgitation. The LVAD implantation with simultaneous aortic valve and supracoronary ascending aortic replacement was successfully performed. PMID:29552039

Left Ventricular Assist Device Implantation with Concomitant Aortic Valve and Ascending Aortic Replacement.

PubMed

Huenges, Katharina; Panholzer, Bernd; Cremer, Jochen; Haneya, Assad

2018-01-01

Left ventricular assist device (LVAD) is nowadays a routine therapy for patients with advanced heart failure. We present the case of a 74-year-old male patient who was admitted to our center with terminal heart failure in dilated cardiomyopathy and ascending aortic aneurysm with aortic valve regurgitation. The LVAD implantation with simultaneous aortic valve and supracoronary ascending aortic replacement was successfully performed.

Late post-AVR progression of bicuspid aortopathy: link to hemodynamics.

PubMed

Naito, Shiho; Gross, Tatiana; Disha, Kushtrim; von Kodolitsch, Yskert; Reichenspurner, Hermann; Girdauskas, Evaldas

2017-05-01

The ascending aortic dilatation may progress after aortic valve replacement (AVR) in bicuspid aortic valve (BAV) patients. Our aim was to evaluate rheological flow patterns and histological characteristics of the aneurysmal aorta in BAV patients at the time of reoperative aortic surgery. 13 patients (mean age: 42 ± 9 years, 10 (77%) male) with significant progression of proximal aortopathy after isolated AVR surgery for BAV disease (i.e., 16.7 ± 8.1 years post-AVR) were identified by cardiac phase-contrast cine magnetic resonance imaging (MRI) in our hospital. A total of nine patients (69%) underwent redo aortic surgery. Based on the MRI data, the aortic area of the maximal flow-induced stress (jet sample) and the opposite site (control sample) were identified and corresponding samples were collected intraoperatively. Histological sum-score values [i.e. aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3)] were compared between these samples. Mean proximal aortic diameter at MRI follow-up was 55 ± 6 mm (range 47-66mm). Preoperative cardiac MRI demonstrated eccentric systolic flow pattern directed towards right-lateral/right posterior wall of the proximal aorta in 9/13 (69%) patients. Histological sum-score values were significantly higher in the jet sample vs control sample (i.e., 8.3 ± 3.8 vs 5.6 ± 2.4, respectively, p = 0.04). Hemodynamic factors may still be involved in the late progression of bicuspid aortopathy even after isolated AVR surgery for BAV disease.

Evaluation of the levels of metalloproteinsase-2 in patients with abdominal aneurysm and abdominal hernias.

PubMed

Antoszewska, Magdalena

2013-05-01

Abdominal aortic aneurysms and abdominal hernias become an important health problems of our times. Abdominal aortic aneurysm and its rupture is one of the most dangerous fact in vascular surgery. There are some theories pointing to a multifactoral genesis of these kinds of diseases, all of them assume the attenuation of abdominal fascia and abdominal aortic wall. The density and continuity of these structures depend on collagen and elastic fibers structure. Reducing the strength of the fibers may be due to changes in the extracellular matrix (ECM) by the proteolytic enzymes-matrix metalloproteinases (MMPs) that degrade extracellular matrix proteins. These enzymes play an important role in the development of many disease: malignant tumors (colon, breast, lung, pancreas), cardiovascular disease (myocardial infarction, ischemia-reperfusion injury), connective tissue diseases (Ehler-Danlos Syndrome, Marfan's Syndrome), complications of diabetes (retinopathy, nephropathy). One of the most important is matrix metalloproteinase-2 (MMP-2). The aim of the study was an estimation of the MMP-2 blood levels in patients with abdominal aortic aneurysm and primary abdominal hernia, and in patients with only abdominal aortic aneurysm. The study involved 88 patients aged 42 to 89 years, including 75 men and 13 women. Patients were divided into two groups: patients with abdominal aortic aneurysm and primary abdominal hernia (45 persons, representing 51.1% of all group) and patients with only abdominal aortic aneurysm (43 persons, representing 48,9% of all group). It was a statistically significant increase in MMP-2 blood levels in patients with abdominal aortic aneurysm and primary abdominal hernia compared to patients with only abdominal aortic aneurysm. It was a statistically significant increase in the prevalence of POCHP in patients with only abdominal aortic aneurysm compared to patients with abdominal aortic aneurysm and primary abdominal hernia. Statistically significant higher MMP-2 blood levels in patients with abdominal aortic aneurysm and primary abdominal hernia seems shows that this enzyme plays a role in the pathogenesis of primary abdominal hernias. The observed distribution of MMP-2 blood levels in patients with abdominal aortic aneurysm and primary abdominal hernia may raise the conclusion that this enzyme determines the presence of multi-organ failure of the connective tissue--the patients with only abdominal aortic aneurysm had significantly lower MMP-2 blood levels.

A Comparative Study of Different Hypothermic Circulatory Arrest Strategies on Aortic Surgery.

ClinicalTrials.gov

2018-03-22

Morality; Hypothermic Circulatory Arrest Time; Aortic-cross Clamping Time; Cardiopulmonary Bypass Time; Operation Time; Re-Thoracotomy; ICU Stay; Mechanical Ventilation Time; Blood Transfusion; Neurological Disorder; Dialysis; Aneurysm; Endoleak; Hospital Stay

Thoracic aortic aneurysm clinically pertinent controversies and uncertainties.

PubMed

Elefteriades, John A; Farkas, Emily A

2010-03-02

This paper addresses clinical controversies and uncertainties regarding thoracic aortic aneurysm and its treatment. 1) Estimating true aortic size is confounded by obliquity, asymmetry, and noncorresponding sites: both echocardiography and computed tomography/magnetic resonance imaging are necessary for complete assessment. 2) Epidemiology of thoracic aortic aneurysm. There has been a bona fide increase in incidence of aortic aneurysm making aneurysm disease the 18th most common cause of death. 3) Aortic growth rate. Although a virulent disease, thoracic aortic aneurysm is an indolent process. The thoracic aorta grows slowly-0.1 cm/year. 4) Evidence-based intervention criteria. It is imperative to extirpate the thoracic aorta before rupture or dissection occurs; surgery at 5.0- to 5.5-cm diameter will prevent most adverse natural events. Symptomatic (painful) aneurysms must be resected regardless of size. 5) Development of nonsize criteria. Mechanical properties of the aorta deteriorate at the same 6 cm at which dissection occurs; elastic properties of the aorta may soon become useful intervention criteria. 6) Medical treatment of aortic aneurysm. Medical treatment is of unproven value, even beta-blockers and angiotensin-receptor blockers. 7) A genetic disease. Even non-Marfan aneurysms have a strong genetic basis. 8) Need for biomarkers. Virulent but silent, TAA cries out for a biomarker that can predict the onset of adverse events. Pathophysiologic understanding has led to identification of promising biomarkers, especially metalloproteinases. 9) Endovascular therapy for aneurysms. Endovascular therapy has burgeoned, despite the fact that the EVAR-2, DREAM, and INSTEAD trials showed no benefit at mid-term over medical or conventional surgical therapy. We must avoid "irrational exuberance." 10) Inciting events for acute aortic dissection. Recent evidence shows that dissections are preceded by a specific severe exertional or emotional event. 11) "Silver lining" of aortic disease. Proximal aortic root disease seems to protect against arteriosclerosis. Copyright 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Treatment strategy for ruptured abdominal aortic aneurysms.

PubMed

Davidovic, L

2014-07-01

Rupture is the most serious and lethal complication of the abdominal aortic aneurysm. Despite all improvements during the past 50 years, ruptured abdominal aortic aneurysms are still associated with very high mortality. Namely, including patients who die before reaching the hospital, the mortality rate due to abdominal aortic aneurysm rupture is 90%. On the other hand, during the last twenty years, the number of abdominal aortic aneurysms significantly increased. One of the reasons is the fact that in majority of countries the general population is older nowadays. Due to this, the number of degenerative AAA is increasing. This is also the case for patients with abdominal aortic aneurysm rupture. Age must not be the reason of a treatment refusal. Optimal therapeutic option ought to be found. The following article is based on literature analysis including current guidelines but also on my Clinics significant experience. Furthermore, this article show cases options for vascular medicine in undeveloped countries that can not apply endovascular procedures at a sufficient level and to a sufficient extent. At this moment the following is evident. Thirty-day-mortality after repair of ruptured abdominal aortic aneurysms is significantly lower in high-volume hospitals. Due to different reasons all ruptured abdominal aortic aneurysms are not suitable for EVAR. Open repair of ruptured abdominal aortic aneurysm should be performed by experienced open vascular surgeons. This could also be said for the treatment of endovascular complications that require open surgical conversion. There is no ideal procedure for the treatment of AAA. Each has its own advantages and disadvantages, its own limits and complications, as well as indications and contraindications. Future reductions in mortality of ruptured abdominal aortic aneurysms will depend on implementation of population-based screening; on strategies to prevent postoperative organ injury and also on new medical technology improvements. Taking this into consideration, education of young vascular surgeons in endovascular but also in open aortic surgery, is of vast importance.

[Peroperative risks in cerebral aneurysm surgery].

PubMed

Mustaki, J P; Bissonnette, B; Archer, D; Boulard, G; Ravussin, P

1996-01-01

The perioperative complications associated with cerebral aneurysm surgery require a specific anaesthetic management. Four major perioperative accidents are discussed in this review. The anaesthetic and surgical management in case of rebleeding subsequent to the re-rupture of the aneurysm is mainly prophylactic. It includes haemodynamic stability assurance, maintenance of mean arterial pressure (MAP) between 80-90 mmHg during stimulation of the patient such as endotracheal intubation, application of the skull-pin head-holder, incision, and craniotomy. The aneurysmal transmural pressure should be adequately maintained by avoiding an aggressive decrease of intracranial pressure. Once the skull is open, the brain must be kept slack in order to decrease pressure under the retractors and avoid the risks of stretching and tearing of the adjacent vessels. If, despite these precautions, the aneurysm ruptures again. MAP should be decreased to 60 mmHg and the brain rendered more slack, in order to allow direct clipping of the aneurysm, or temporary clipping of the adjacent vessels. The optimal agents in this situation are isoflurane (which decreases CMRO2), intravenous anaesthetic agents (inspite their negative inotropic effect, they may potentially protect the brain) and sodium nitroprusside. Vasospasm occurs usually between the 3rd and the 7th day after subarachnoid haemorrhage. It may be seen peroperatively. The optimal treatment, as well as prophylaxis, is moderate controlled hypertension (MAP > 100 mmHg), associated with hypervolaemia and haemodilution, the so-called triple H therapy, with strict control of the filling pressures. Other beneficial therapies are calcium antagonists (nimodipine and nicardipine), the removal of the blood accumulated around the brain and in the cisternae, and possibly local administration of papaverine. Abrupt MAP increases are controlled in order to maintain adequate aneurysmal transmural pressure. Beta-blockers, local anaesthetics administered locally or intravenously, a carefully titrated level of anaesthesia, a maintained volaemia play a protective role. Cerebral oedema is sometimes already present at the opening of the skull or may arise later, due to a high pressure under the retractors, to the surgical manipulations of the brain or to brain ischaemia subsequent to temporary clipping. Its treatment is aggressive, with intravenous agents, mannitol, deep hypocapnia and/or lumbar drainage. Prophylaxis, according to the "brain homeostasis concept", is the preferred method to avoid these four peroperative accidents. It includes normal blood volume, normoglycaemia, moderate hypocapnia, normotension, soft manipulation of the brain and optimal brain relaxation.

The Quantitative and Functional Changes of Postoperative Peripheral Blood Immune Cell Subsets Relate to Prognosis of Patients with Subarachnoid Hemorrhage: A Preliminary Study.

PubMed

Zhou, Yu; Jiang, Yugang; Peng, Yong; Zhang, Mingming

2017-12-01

It has been suggested that the preoperative (PRE) and postoperative (POST) immune system alteration triggered by aneurysmal subarachnoid hemorrhage (SAH) and surgical treatment itself may affect patients' prognosis and contribute to POST complications. The mechanisms may be attributed to immune suppression-triggered infection or immune overreaction-triggered aseptic inflammation. In this study, we investigated the dynamic changes in peripheral immune cell subsets as well as the alterations of inflammatory cytokines in patients with aneurysmal SAH who received craniotomy and clipping surgery. In addition, we studied the association of those changes with POST complications and clinical prognosis. We investigated 27 patients who received craniotomy and clipping surgery for aneurysmal SAH. The operations were all performed within 24 hours after the occurrence of aneurysm rupture. Detailed immune monitoring (peripheral blood leukocytes and lymphocyte subsets and inflammatory cytokines) was performed on PRE (on admission), day 1, day 3, and day 6 after operation. Our data showed that the percentage of CD3+, CD8+, natural killer T (NKT), CD4+, and regulatory T (Treg) cells significantly decreased and the level of interleukin 4 (IL-4), interferon γ, and IL-2 significantly increased 1 day after surgery compared with the data in PRE. On the contrary, natural killer (NK), NK group 2 (NKG2D), and B cells increased and the level of IL-10 in plasma decreased. In study of the relationship between POST fever and the change in immune cell subgroups, the fever group had a lower percentage of CD3+, CD4+, NKT, Tregs, and B cells on day 1, day 3, and day 6 after surgery compared with the patients who did not have fever, whereas the CD8+, NK, and NKG2D subsets showed the opposite trend. Furthermore, we analyzed the association between immune profile changes and the prognosis of those patients. The patients were divided into those with an unfavorable prognosis (n = 6) and those with a favorable prognosis (n = 21) according to Glasgow Outcome Scale score and postoperation (POST) coma. Our results showed that except for B cells, patients with a favorable prognosis had a relatively higher percentage of CD3+, CD4+, CD8+, NK, NKT, NKG2D, and Treg cells compared with the unfavorable prognosis group from PRE to day 6 POST. Our results indicated that patients with aneurysmal SAH undergoing craniotomy and clipping surgery had a profound transient deterioration in immune function. In addition, the changes in immune cell subgroups had a strong association with POST fever. The changes in immune cell subgroups were also directly associated with clinical prognosis of the patients. These association findings might be attributable to a better biomarker to predict patient diagnosis. Copyright © 2017 Elsevier Inc. All rights reserved.

"True" posterior communicating aneurysms: Three cases, three strategies.

PubMed

Nery, Breno; Araujo, Ricardo; Burjaili, Bruno; Smith, Timothy R; Rodrigues, Jose Carlos; Silva, Marcelo Nery

2016-01-01

The authors provide a review of true aneurysms of the posterior communicating artery (PCoA). Three cases admitted in our hospital are presented and discussed as follows. First patient is a 51-year-old female presenting with a Fisher II, Hunt-Hess III (headache and confusion) subarachnoid hemorrhage (SAH) from a ruptured true aneurysm of the right PCoA. She underwent a successful ipsilateral pterional craniotomy for aneurysm clipping and was discharged on postoperative day 4 without neurological deficit. Second patient is a 53-year-old female with a Fisher I, Hunt-Hess III (headache, mild hemiparesis) SAH and multiple aneurisms, one from left ophthalmic carotid artery and one (true) from right PCoA. These lesions were approached and successfully treated by a single pterional craniotomy on the left side. The patient was discharged 4 days after surgery, with complete recovery of muscle strength during follow-up. Third patient is a 69-year-old male with a Fisher III, Hunt-Hess III (headache and confusion) SAH, from a true PCoA on the right. He had a left subclavian artery occlusion with flow theft from the right vertebral artery to the left vertebral artery. The patient underwent endovascular treatment with angioplasty and stent placement on the left subclavian artery that resulted in aneurysm occlusion. In conclusion, despite their seldom occurrence, true PCoA aneurysms can be successfully treated with different strategies.

Endovascular Stenting of Peripheral Infected Aneurysms: A Temporary Measure or a Definitive Solution in High-Risk Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Riga, Celia, E-mail: c.riga@imperial.ac.u; Bicknell, Colin; Jindal, Ravul

The purpose of this study was to demonstrate the use of endovascular technology in the management of peripheral infected aneurysms in high-risk patients as a temporary measure or definitive solution. Five cases underwent successful endovascular stenting of infected aneurysms of the subclavian, femoral, and carotid arteries. All these patients were at high risk for open surgery. Covered stents were placed by percutaneous approach under local anesthesia in all patients. Postoperatively, antibiotics were continued for 3 months. A literature review using the Medline database was also undertaken, and all the relevant papers on endovascular management of peripheral infected aneurysms were takenmore » into account. Stent deployment was successful in all patients. One patient died of mediastinal sepsis and another from type A aortic dissection 5 weeks later. Two patients required drainage of the infected hematoma. Three patients did well at a median follow-up of 1 year, with no evidence of sepsis. A review of the literature shows promising early and midterm results. Most early reports were of single cases, reflecting the low incidence of peripheral infected aneurysms. We conclude that further development of endoluminal techniques and long-term follow-up to establish the durability of stenting could potentially lead to a decrease in the high morbidity and mortality rates associated with infected aneurysmal disease in this high-risk group of patients.« less

Endovascular stenting of peripheral infected aneurysms: a temporary measure or a definitive solution in high-risk patients.

PubMed

Riga, Celia; Bicknell, Colin; Jindal, Ravul; Cheshire, Nicholas; Hamady, Mohamad

2008-01-01

The purpose of this study was to demonstrate the use of endovascular technology in the management of peripheral infected aneurysms in high-risk patients as a temporary measure or definitive solution. Five cases underwent successful endovascular stenting of infected aneurysms of the subclavian, femoral, and carotid arteries. All these patients were at high risk for open surgery. Covered stents were placed by percutaneous approach under local anesthesia in all patients. Postoperatively, antibiotics were continued for 3 months. A literature review using the Medline database was also undertaken, and all the relevant papers on endovascular management of peripheral infected aneurysms were taken into account. Stent deployment was successful in all patients. One patient died of mediastinal sepsis and another from type A aortic dissection 5 weeks later. Two patients required drainage of the infected hematoma. Three patients did well at a median follow-up of 1 year, with no evidence of sepsis. A review of the literature shows promising early and midterm results. Most early reports were of single cases, reflecting the low incidence of peripheral infected aneurysms. We conclude that further development of endoluminal techniques and long-term follow-up to establish the durability of stenting could potentially lead to a decrease in the high morbidity and mortality rates associated with infected aneurysmal disease in this high-risk group of patients.

Totally normothermic aortic arch replacement without circulatory arrest.

PubMed

Touati, Gilles D; Marticho, Paul; Farag, Moataz; Carmi, Doron; Szymanski, Catherine; Barry, Misbaou; Trojette, Faouzi; Caus, Thierry

2007-08-01

Various techniques have been proposed for cerebral protection during the surgical treatment of complex aortic disease. The authors propose a revisited strategy of normothermic replacement of the aortic arch to avoid limitations and complications of profound hypothermic circulatory arrest. From April 2000 to May 2006, 19 patients with an aneurysm of the aortic arch and 10 patients with an acute (7) or a chronic (3) aortic dissection underwent a totally normothermic, complete replacement of the aortic arch using three pumps: One pump ensured antegrade cerebral perfusion, at a flow rate adapted to obtain a pressure of 70 mmHg in the right radial artery, and required a selective cannulation of the supra-aortic vessels. A second pump ensured body perfusion at a flow rate adapted to obtain a pressure of 55 mmHg in the left femoral artery and was situated between the right femoral artery and the right atrium. A special balloon aortic occlusion catheter was placed in the descending thoracic aorta. A third pump ensured intermittent normothermic myocardial perfusion via the coronary venous sinus. The arch reconstruction was performed with no time limit. There were two operative, in-hospital (6.8%) mortalities. All others patients were rapidly extubated, except one, with no neurological sequelae, and postoperative course was uneventful, without coagulopathy or hepato-renal impairment. In the light of these results, a normothermic procedure is possible for arch surgery and may ensure a more physiological autoregulation of cerebral blood flow while maintaining body perfusion without high vascular resistances.

Clipping Versus Coiling in the Management of Posterior Communicating Artery Aneurysms with Third Nerve Palsy: A Systematic Review and Meta-Analysis.

PubMed

Gaberel, Thomas; Borha, Alin; di Palma, Camille; Emery, Evelyne

2016-03-01

To compare surgical clipping with endovascular coiling in terms of recovery from oculomotor nerve palsy (ONP) in the management of posterior communicating artery (PCoA) aneurysms causing third nerve palsy. We conducted a systematic review of the literature and meta-analysis. The meta-analysis included 11 relevant studies involving 384 patients with third nerve palsy caused by PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 were treated by coiling (33.0%). Pooled odds ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery, and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared with 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenszel odds ratio of 4.44 (95% confidence interval = 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in patients with unruptured aneurysms. No procedure-related deaths were reported by any of the 11 studies. Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling; this could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would better address the therapeutic dilemma, but pending the results of such a trial, we recommend treating PCoA aneurysms causing ONP with surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Obliteration of a giant fusiform carotid terminus-M1 aneurysm after distal clip application and extracranial-intracranial bypass. Case report.

PubMed

Ferroli, P; Ciceri, E; Parati, E; Minati, L; Broggi, G

2007-06-01

Giant intracranial aneurysms may not be amenable to direct surgical clipping or endovascular coiling because of three critical factors: 1) lack of clear aneurysmal neck; 2) giant size; 3) involvement with critical perforating or branch vessels. Techniques of flow redirection, however, may offer an alternative treatment strategy for these difficult lesions. In this paper, we report on the use of this alternative strategy in the successful treatment of a left giant fusiform carotid terminus-M1 aneurysm in a 16 year-old boy suffering from Ehler-Danlos disease. This patient was admitted to our Institution because his aneurysm was continuing to be increasing in size, despite a previous ligation of his left cervical ICA which was performed at another institution 2 years earlier after the patient had experienced a hemorrhagic stroke. Upon admission, a neurological examination revealed a slight motor aphasia with mild right hemiparesis, remnant of the ancient stroke. Because of its size and the involvement with M1 perforating arteries, a direct aneurysm attack was deemed inadvisable. After an initial ECA-ICA high flow bypass which spontaneously thrombosed, we performed a repeated high flow bypass with the application of a single clip on M1, right distal to the fusiform dilatation. After an uneventful postoperative course, we were unable to observe any new neurological deficits after surgery. A CT scan on postoperative day 1 revealed that the aneurysm had undergone a spontaneous thrombosis which was completely obliterated at the time of a 6-month follow-up angiogram. At that time, the ECA-ICA bypass was found to be patent. In conclusion the alternative of flow alteration strategies can be successfully used in the treatment of aneurysms that cannot be safely trapped or occluded by traditional neurosurgical methods.

Submitral aneurysm in children.

PubMed

Manuel, Valdano; Sousa-Uva, Miguel; Miguel, Gade; Magalhães, Manuel Pedro; Pedro, Albino; Júnior, António Pedro Filipe; Morais, Humberto

2016-08-01

We report a surgical series of submitral aneurysm in children. Between March 2011 and December 2015, eight consecutive patients less than 18 years old with submitral aneurysm underwent surgical correction. Six patients were female, the mean age was 7 ± 3.8 years old, and mean weight was 21.4 kg. Six patients were in NYHA functional class III or IV. Six patients underwent repair via a transatrial approach, another with a transatrial combined with transaneurysmal approach, and another with a transventricular approach. There were no in-hospital deaths but one 30-day mortality. One patient required reoperation. Two patients required mitral valve replacement. At discharge, one patient had severe and another had moderate mitral regurgitation. The mean follow-up time was 26.4 months and five patients were alive. No reintervention was required. Submitral aneurysm is not restricted to adults. Heart failure is the commonest clinical presentation in the pediatric age. The transatrial approach is feasible, safe, and associated with good short-term results. The mitral valve can be preserved in the majority of cases. © 2016 Wiley Periodicals, Inc.

Open and endovascular aneurysm repair in the Society for Vascular Surgery Vascular Quality Initiative.

PubMed

Spangler, Emily L; Beck, Adam W

2017-12-01

The Society for Vascular Surgery Vascular Quality Initiative is a patient safety organization and a collection of procedure-based registries that can be utilized for quality improvement initiatives and clinical outcomes research. The Vascular Quality Initiative consists of voluntary participation by centers to collect data prospectively on all consecutive cases within specific registries which physicians and centers elect to participate. The data capture extends from preoperative demographics and risk factors (including indications for operation), through the perioperative period, to outcomes data at up to 1-year of follow-up. Additionally, longer-term follow-up can be achieved by matching with Medicare claims data, providing long-term longitudinal follow-up for a majority of patients within the Vascular Quality Initiative registries. We present the unique characteristics of the Vascular Quality Initiative registries and highlight important insights gained specific to open and endovascular abdominal aortic aneurysm repair. Copyright © 2017 Elsevier Inc. All rights reserved.

Renal compensatory adaptation for water handling in a patient with adipsic diabetes insipidus after clipping of a ruptured aneurysm of the anterior communicating artery
.

PubMed

Imai, Eri; Kaneko, Shuzo; Tsukamoto, Yusuke

2017-08-01

A 38-year-old Japanese man who had undergone clipping surgery for a ruptured aneurysm of the anterior communicating artery 2 days prior, suddenly developed refractory hypernatremia (serum sodium (Na) 156 - 162 mmol/L). Symptoms included low plasma vasopressin, fluctuating urine osmolality (120 - 710 mOsm/kg) and lack of thirst, all suggesting adipsic diabetes insipidus (ADI). Hypernatremia was corrected by scheduled water intake with desmopressin administration. During 1-year follow-up after the surgery, his serum Na level normalized despite the suspension of desmopressin, but neither thirst nor osmolality-dependent vasopressin release recovered. Meanwhile, his urine osmolality shifted to a constant high level. The present case suggests that renal compensatory adaptation, apparently independent of the circulating vasopressin level, plays a major role in water handling in longitudinal ADI.
.

Outcome after open surgery repair in endovascular-suitable patients with ruptured abdominal aortic aneurysms.

PubMed

Krenzien, Felix; Matia, Ivan; Wiltberger, Georg; Hau, Hans-Michael; Freitas, Bruno; Moche, Michael; Schmelzle, Moritz; Jonas, Sven; Fellmer, Peter T

2013-11-01

Endovascular aneurysm repair (EVAR) has been suggested in several studies to be superior to open surgery repair (OSR) for the treatment of ruptured abdominal aortic aneurysms (rAAAs), but this finding might be affected by selection bias based on aneurysm morphology and patient characteristics. We tested rAAA anatomy according to EVAR suitability in patients undergoing OSR to assess the impact on mortality. This retrospective analysis reports on 83 patients with rAAAs treated between November 2002 and July 2013. Pre-operative computed tomography (CT) scans were evaluated based on EVAR suitability and were determined by blinded independent reviewers. CT scans were lacking due to acquisition in an external institution with no availability (n = 9) or solely ultrasound evaluations (n = 8). In addition patient characteristics and outcomes were assessed. All patients who underwent OSR and who had available preoperative CT scans were included in the study (n = 66). In summary, 42 % of the patients (28/66; 95 % confidence interval [CI], 30.5 - 54.4) were considered eligible for EVAR according to pre-operative CT scans and 58 % of the patients (38/66; 95 % CI, 45.6 - 69.5) were categorized as unsuitable for endovascular repair. Patients suitable for EVAR had a significantly lower prevalence of in-hospital deaths (25 % [7/28]; 95 % CI, 9 - 41) in contrast to patients unsuitable for EVAR (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02). EVAR-suitable patients had a highly significant mortality reduction undergoing OSR. Thus, the present study proposes that EVAR suitability is a positive predictor for survival after open repair of rAAA.

A cadaveric study of the endoscopic endonasal transclival approach to the basilar artery.

PubMed

Lai, Leon T; Morgan, Michael K; Chin, David C W; Snidvongs, Kornkiat; Huang, June X Z; Malek, Joanne; Lam, Matthew; McLachlan, Rohan; Harvey, Richard J

2013-04-01

The anterior transclival route to basilar artery aneurysms is not widely performed. The objective of this study was to carry out a feasibility assessment of the transclival approach to basilar aneurysms with advanced endonasal techniques on 11 cadaver heads. Clival dura was exposed from the sella to the foramen magnum between the paraclival segments of the internal carotid arteries (ICA) laterally. An inverted dural "U" flap was reflected inferiorly to expose the basilar artery. The maximal dimensions from operative measurements were recorded. Surgical manoeuvrability of multiple instruments and the proficiency to place proximal and distal vascular clips were evaluated. The mean operative depth (± standard deviation), measured from the anterior choanae to the basilar artery, was 110±6mm. The lateral corridors were limited distally by the medial pterygoids (mean width 21±2mm) and paraclival ICA (mean width 20±2mm). The mean transclival craniectomy dimensions were 19±2mm (width) and 23±4mm (height). Exposure of the basilar-anterior inferior cerebellar artery junction, superior cerebellar artery, and the basilar caput were possible in 100%, 91%, and 64% of instances, respectively. Placements of proximal and distal aneurysm clips were achieved in all instances. Based on our findings, the transclival endoscopic endonasal surgery approach provides excellent visualisation of the basilar artery. Clip application and manoeuvrability of instruments was considered adequate for basilar aneurysm surgery. Surgical skills and instrumentation to control significant haemorrhage can potentially limit the clinical applicability of this technique. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.

The Weekend Effect in AAA Repair.

PubMed

O'Donnell, Thomas F X; Li, Chun; Swerdlow, Nicholas J; Liang, Patric; Pothof, Alexander B; Patel, Virendra I; Giles, Kristina A; Malas, Mahmoud B; Schermerhorn, Marc L

2018-04-18

Conflicting reports exist regarding whether patients undergoing surgery on the weekend or later in the week experience worse outcomes. We identified patients undergoing abdominal aortic aneurysm (AAA) repair in the Vascular Quality Initiative between 2009 and 2017 [n = 38,498; 30,537 endovascular aneurysm repair (EVAR) and 7961 open repair]. We utilized mixed effects logistic regression to compare adjusted rates of perioperative mortality based on the day of repair. Tuesday was the most common day for elective repair (22%), Friday for symptomatic repairs (20%), and ruptured aneurysms were evenly distributed. Patients with ruptured aneurysms experienced similar adjusted mortality whether they underwent repair during the week or on weekends. Transfers of ruptured AAA were more common over the weekend. However, patients transferred on the weekend experienced higher adjusted mortality than those transferred during the week (28% vs 21%, P = 0.02), despite the fact that during the week, transferred patients actually experienced lower adjusted mortality than patients treated at the index hospital (21% vs 31%, P < 0.01). Among symptomatic patients, adjusted mortality was higher for those undergoing repair over the weekend than those whose surgeries were delayed until a weekday (7.9% vs 3.1%, P = 0.02). Adjusted mortality in elective cases did not vary across the days of the week. Results were consistent between open and EVAR patients. We found no evidence of a weekend effect for ruptured or symptomatic AAA repair. However, patients with ruptured AAA transferred on the weekend experienced higher mortality than those transferred during the week, suggesting a need for improvement in weekend transfer processes.

Effect of exercise on patient specific abdominal aortic aneurysm flow topology and mixing.

PubMed

Arzani, Amirhossein; Les, Andrea S; Dalman, Ronald L; Shadden, Shawn C

2014-02-01

Computational fluid dynamics modeling was used to investigate changes in blood transport topology between rest and exercise conditions in five patient-specific abdominal aortic aneurysm models. MRI was used to provide the vascular anatomy and necessary boundary conditions for simulating blood velocity and pressure fields inside each model. Finite-time Lyapunov exponent fields and associated Lagrangian coherent structures were computed from blood velocity data and were used to compare features of the transport topology between rest and exercise both mechanistically and qualitatively. A mix-norm and mix-variance measure based on fresh blood distribution throughout the aneurysm over time were implemented to quantitatively compare mixing between rest and exercise. Exercise conditions resulted in higher and more uniform mixing and reduced the overall residence time in all aneurysms. Separated regions of recirculating flow were commonly observed in rest, and these regions were either reduced or removed by attached and unidirectional flow during exercise, or replaced with regional chaotic and transiently turbulent mixing, or persisted and even extended during exercise. The main factor that dictated the change in flow topology from rest to exercise was the behavior of the jet of blood penetrating into the aneurysm during systole. Copyright © 2013 John Wiley & Sons, Ltd.

Natural history of aneurysmal aortic arch branch vessels in a single tertiary referral center.

PubMed

Brownstein, Adam J; Rajaee, Sareh; Erben, Young; Li, Yupeng; Rizzo, John A; Lyall, Vikram; Mojibian, Hamid; Ziganshin, Bulat A; Elefteriades, John A

2018-05-23

Little is known about the natural history and management of aneurysmal aortic arch branch vessels (AABVs). The objectives of this study were to assess the natural history of aneurysmal AABVs and to examine the outcomes of operative intervention. A retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with an aneurysmal AABV and a computed tomography scan were selected for review. Patients' demographics, aneurysm characteristics, management, and follow-up information were collected. There were 105 patients with 147 aneurysmal AABVs; 76 were male (72%), with a mean age of 70 years (range, 17-93 years). We identified 63 innominate, 50 left subclavian, 30 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 65 (62%) had aortic aneurysms and six (6%) had suffered an aortic dissection. Most were asymptomatic (104 [99%]); one had chest pain and an enlarging swollen mass. Twelve (11%) patients underwent operative repair (OR) for 12 aneurysmal AABVs because of symptoms, growth, or concomitant aortic operations; 93 (89%) were observed in the no operative repair (NOR) group with cross-sectional imaging. The overall mean vessel diameter was 2.08 ± 0.68 cm. The mean diameters in the OR and NOR groups were 3.32 ± 1.24 cm and 1.97 ± 0.46 cm, respectively (P = .002). OR included nine bypasses with resection, two stent grafts, and one resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration, one patient developed stent thrombosis, and one patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for the NOR group, with no ruptures or emboli. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, a descending aortic aneurysm (P = .041) and a left subclavian artery aneurysm (P = .016) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .001). Aneurysmal AABVs tend to have a benign natural history with slow growth rates and low rates of complications, including rupture and embolization. We recommend expectant observational management for small, incidentally detected aneurysms. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Randomized clinical trial of remote ischaemic preconditioning versus no preconditioning in the prevention of perioperative myocardial infarction during open surgery for ruptured abdominal aortic aneurysm.

PubMed

Pedersen, T F; Budtz-Lilly, J; Petersen, C N; Hyldgaard, J; Schmidt, J-O; Kroijer, R; Grønholdt, M-L; Eldrup, N

2018-06-01

Remote ischaemic preconditioning (RIPC) has been suggested as a means of protecting vital organs from reperfusion injury during major vascular surgery. This study was designed to determine whether RIPC could reduce the incidence of perioperative myocardial infarction (MI) during open surgery for ruptured abdominal aortic aneurysm (AAA). Secondary aims were to see if RIPC could reduce 30-day mortality, multiple organ failure, acute intestinal ischaemia, acute kidney injury and ischaemic stroke. This randomized, non-blinded clinical trial was undertaken at three vascular surgery centres in Denmark. Patients who had open surgery for ruptured AAA were randomized to intervention with RIPC or control in a 1 : 1 ratio. Postoperative complications and deaths were registered, and ECG and blood samples were obtained daily during the hospital stay. Of 200 patients randomized, 142 (72 RIPC, 70 controls) were included. There was no difference in rates of perioperative MI between the RIPC and control groups (36 versus 43 per cent respectively), or in rates of organ failure. However, in the per-protocol analysis 30-day mortality was significantly reduced in the RIPC group (odds ratio 0·46, 95 per cent c.i. 0·22 to 0·99; P = 0·048). RIPC did not reduce the incidence of perioperative MI in patients undergoing open surgery for ruptured AAA. Registration number: NCT00883363 ( http://www.clinicaltrials.gov).

[Review of pre- and post-treatment multidetector computed tomography findings in abdominal aortic aneurysms].

PubMed

Casula, E; Lonjedo, E; Cerverón, M J; Ruiz, A; Gómez, J

2014-01-01

The increase in the frequency of abdominal aortic aneurysms (AAA) and the widely accepted use of endovascular aneurysm repair (EVAR) as a first-line treatment or as an alternative to conventional surgery make it necessary for radiologists to have thorough knowledge of the pre- and post-treatment findings. The high image quality provided by multidetector computed tomography (MDCT) enables CT angiography to play a fundamental role in the study of AAA and in planning treatment. The objective of this article is to review the cases of AAA in which CT angiography was the main imaging technique, so that radiologists will be able to detect the signs related to this disease, to diagnose it, to plan treatment, and to detect complications in the postoperative period. Copyright © 2012 SERAM. Published by Elsevier Espana. All rights reserved.

A novel sax-stent method in treatment of ascending aorta and aortic arch aneurysms evaluated by finite element simulations.

PubMed

Arokiaraj, M C; De Beule, M; De Santis, G

2017-02-01

A novel stent method to simplify treatment of proximal ascending aorta and aortic arch aneurysms was developed and investigated by finite element analysis. Therapy of ascending aortic and aortic arch aneurysms is difficult and challenging and is associated with various complications. A 55mm wide×120mm long stent was designed without the stent graft and the stent was deployed by an endovascular method in a virtual patient-specific aneurysm model. The stress-strain analysis and deployment characteristics were performed in a finite element analysis using the Abaqus software. The stent, when embedded in the aortic wall, significantly reduced aortic wall stresses, while preserving the side coronary ostia and side branches in the aortic arch. When tissue growth was modeled computationally over the stent struts the wall stresses in aorta was reduced. This effect became more pronounced when increasing the thickness of the tissue growth. There were no abnormal stresses in the aorta, coronary ostium and at the origin of aortic branches. The stent reduced aneurysm expansion cause by hypertensive condition from 2mm without stenting to 1.3mm after stenting and embedding. In summary, we uncovered a simple treatment method using a bare nitinol stent without stent graft in the treatment of the proximal aorta and aortic arch aneurysms, which could eventually replace the complex treatment methods for this disease. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Open surgery versus endovascular approach in treatment of extracranial carotid artery aneurysms.

PubMed

Ni, Leng; Weng, Huiling; Pu, Zuo; Zheng, Yuehong; Liu, Bao; Ye, Wei; Zeng, Rong; Liu, Changwei

2018-05-01

The objective of this study was to investigate and to compare the early and long-term results of open surgery with endovascular intervention in the treatment of extracranial carotid artery aneurysms (ECCAs). A retrospective review of patients diagnosed with ECCAs who underwent open surgical or endovascular treatment from 1997 to 2017 was performed. Clinical characteristics, aneurysm profile, and treatment outcomes were recorded. Early results (<30 days) were evaluated in terms of mortality, perioperative stroke or transient ischemic attack, and cranial nerve injury. Late results were analyzed in terms of both overall and stroke-free survival and freedom from reinterventions. A total of 48 patients with ECCAs including 34 (70.8%) true aneurysms and 14 (29.2%) pseudoaneurysms were treated. The median age was 51 years, and 19 patients (39.6%) were men; 41 patients (85.4%) had symptoms, whereas 7 (14.6%) were asymptomatic. Among 48 patients, 32 patients (66.7%) underwent open surgery; endovascular repair was performed on 16 patients (33.3%). The 30-day stroke or transient ischemic attack rate was not significantly different between the open group (6.3% [2/32]) and the endovascular group (0% [0/16]; P = .307). Cranial nerve injuries occurred in eight patients in the open group (25%) and in no patient in the endovascular group (0%; P = .029). Median length of stay was significantly longer in the open group than in the endovascular group (20 vs 14 days, respectively; P = .013). Median follow-up was 46 months (range, 0-20 years), and no aneurysm-related death occurred during this period. Overall survival rates at 5 years were 88.7% (standard error [SE], 0.08) in the open group and 91.7% (SE, 0.08) in the endovascular group (P = .319; log-rank, .992). For the same time interval, stroke-free survival rates were 85.2% (SE, 0.10) in the open group and 92.2% (SE, 0.07) in the endovascular group (P = .653; log-rank, .201). One patient (1/28 [3.6%]) in the open group and two patients (2/16 [12.5%]) in the endovascular group underwent endovascular reinterventions because of restenosis during the follow-up period. Reintervention-free survival rates were 90.9% in the open group (SE, 0.09) and 69.2% in the endovascular group (SE, 0.21; P = .082; log-rank, 3.016). In this single-institutional experience, both operative and endovascular interventions for ECCAs provided acceptable early and 5-year results. The endovascular approach had significantly less cranial nerve injury and shorter length of hospital stay. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Combined Laser-Doppler Flowmetry and Spectrophotometry: Feasibility Study of a Novel Device for Monitoring Local Cortical Microcirculation during Aneurysm Surgery.

PubMed

Sommer, Björn; Kreuzer, Maximilian; Bischoff, Barbara; Wolf, Dennis; Schmitt, Hubert; Eyupoglu, Ilker Y; Rössler, Karl; Buchfelder, Michael; Ganslandt, Oliver; Wiendieck, Kurt

2017-01-01

Background  Monitoring of cortical cerebral perfusion is essential, especially in neurovascular surgery. Study Aims  To test a novel noninvasive laser-Doppler flowmetry and spectrophotometry device for feasibility during elective cerebral aneurysm surgery. Material and Methods  In this prospective single-institution nonrandomized trial, we studied local cerebral microcirculation using the noninvasive laser-Doppler spectrophotometer "Oxygen-to-see" (O2C) in 20 consecutive patients (15 female, 5 male; median age: 60.5 ± 11.7 years) who were operated on for incidental cerebral aneurysms. Capillary-venous oxygenation (oxygen saturation ["SO 2 "]), postcapillary venous filling pressures (relative hemoglobin content ["rHb"]), blood cell velocity ("velo"), and blood flow ("flow") were measured in 7-mm tissue depth using a subdural fiberoptic probe. Results  Representative recordings were acquired immediately after dural opening over a median time span of 88 ± 21.8 seconds (range: 60-128 seconds) before surgical manipulation. Baseline values (median ± 2 standard deviations) of brain perfusion as measured with the O2C device were SO 2 , 39 ± 16.6%; rHb, 53 ± 18.6 arbitrary units (AU); velo, 60 ± 20.4 AU; and flow, 311 ± 72.8 AU. Placement of the self-retaining retractor led to a decrease in SO 2 of 17% ± 29% ( p  < .05) and flow of 10% ± 11% ( p  < .01); rHb increased by 18% ± 20% ( p  < .01), and velo remained unchanged. Retractor removal caused the opposite with an increased flow of 10% ± 7% ( p  < 0.001) and velo (3% ± 6%, p  = 0.11), but a decrease in SO 2 of 24% ± 33% ( p  = 0.09) and rHb of 12% ± 20% ( p =0.18). No neurologic or surgical complications occurred. Conclusion  Using this novel noninvasive system, we were able to measure local cerebral microcirculation during aneurysm surgery. Our data indicate that this device is able to detect changes during routine neurosurgical maneuvers. Thus it may be useful for early detection of cerebral microcirculatory disturbances. Georg Thieme Verlag KG Stuttgart · New York.

Beneficial Effects of Pre-operative Exercise Therapy in Patients with an Abdominal Aortic Aneurysm: A Systematic Review.

PubMed

Pouwels, S; Willigendael, E M; van Sambeek, M R H M; Nienhuijs, S W; Cuypers, P W M; Teijink, J A W

2015-01-01

The impact of post-operative complications in abdominal aortic aneurysm (AAA) surgery is substantial, and increases with age and concomitant co-morbidities. This systematic review focuses on the possible effects of pre-operative exercise therapy (PET) in patients with AAA on post-operative complications,aerobic capacity, physical fitness, and recovery. A systematic search on PET prior to AAA surgery was conducted. The methodological quality of the included studies was rated using the Physiotherapy Evidence Database scale. The agreement between the reviewers was assessed with Cohen's kappa. Five studies were included, with a methodological quality ranging from moderate to good. Cohen's kappa was 0.79. Three studies focused on patients with an AAA (without indication for surgical repair) with physical fitness as the outcome measure. One study focused on PET in patients awaiting AAA surgery and one study focused on the effects of PET on post-operative complications, length of stay, and recovery. PET has beneficial effects on various physical fitness variables of patients with an AAA. Whether this leads to less complications or faster recovery remains unclear. In view of the large impact of post-operative complications, it is valuable to explore the possible benefits of a PET program in AAA surgery.

Intravenously injected human multilineage-differentiating stress-enduring cells selectively engraft into mouse aortic aneurysms and attenuate dilatation by differentiating into multiple cell types.

PubMed

Hosoyama, Katsuhiro; Wakao, Shohei; Kushida, Yoshihiro; Ogura, Fumitaka; Maeda, Kay; Adachi, Osamu; Kawamoto, Shunsuke; Dezawa, Mari; Saiki, Yoshikatsu

2018-06-01

Aortic aneurysms result from the degradation of multiple components represented by endothelial cells, vascular smooth muscle cells, and elastic fibers. Cells that can replenish these components are desirable for cell-based therapy. Intravenously injected multilineage-differentiating stress-enduring (Muse) cells, endogenous nontumorigenic pluripotent-like stem cells, reportedly integrate into the damaged site and repair the tissue through spontaneous differentiation into tissue-compatible cells. We evaluated the therapeutic efficacy of Muse cells in a murine aortic aneurysm model. Human bone marrow Muse cells, isolated as stage-specific embryonic antigen-3 + from bone marrow mesenchymal stem cells, or non-Muse cells (stage-specific embryonic antigen-3 - cells in mesenchymal stem cells), bone marrow mesenchymal stem cells, or vehicle was intravenously injected at day 0, day 7, and 2 weeks (20,000 cells/injection) after inducing aortic aneurysms by periaortic incubation of CaCl 2 and elastase in severe combined immunodeficient mice. At 8 weeks, infusion of human Muse cells attenuated aneurysm dilation, and the aneurysmal size in the Muse group corresponded to approximately 62.5%, 55.6%, and 45.6% in the non-Muse, mesenchymal stem cell, and vehicle groups, respectively. Multiphoton laser confocal microscopy revealed that infused Muse cells migrated into aneurysmal tissue from the adventitial side and penetrated toward the luminal side. Histologic analysis demonstrated robust preservation of elastic fibers and spontaneous differentiation into endothelial cells and vascular smooth muscle cells. After intravenous injection, Muse cells homed and expanded to the aneurysm from the adventitial side. Subsequently, Muse cells differentiated spontaneously into vascular smooth muscle cells and endothelial cells, and elastic fibers were preserved. These Muse cell features together led to substantial attenuation of aneurysmal dilation. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Multiple sites of vascular dilation or aneurysmal disease and matrix metalloproteinase genetic variants in patients with abdominal aortic aneurysm.

PubMed

Fiotti, Nicola; Calvagna, Cristiano; Sgorlon, Giada; Altamura, Nicola; Pitacco, Paola; Zamolo, Francesca; Di Girolamo, Filippo Giorgio; Chiarandini, Stefano; Biolo, Gianni; Adovasio, Roberto

2018-06-01

The objective of this study was to assess whether functional genetic polymorphisms of matrix metalloproteinases (MMPs) 1, 3, 9, and 12 are associated with arterial enlargements or aneurysms of the thoracic aorta or popliteal arteries in patients with abdominal aortic aneurysm (AAA). The associations between MMP1 (-1607 G in/del, rs1799750), MMP3 (-1171 A in/del rs35068180), MMP9 (13-26 CA repeats around -90, rs2234681, rs917576, rs917577), and MMP12 (G/T missense variation, rs652438) polymorphisms and enlargements or aneurysms of the thoracic aorta and popliteal arteries were tested in 169 consecutive AAA patients. Thoracic aorta enlargement or aneurysm (TE/A; maximum diameter, >35 mm) was detected in 34 patients (20.1% prevalence). MMP9 rs2234681 microsatellite was the only genetic determinant of TE/A in AAA patients (P = .003), followed by hypercholesterolemia and antiplatelet use. Carriers of both alleles with ≥22 CA repeats had a 5.9 (95% confidence interval, 1.9-18.6; P < .0001) increased odds of TE/A, and a score considering all three variables showed 98% negative predictive value and 30% positive predictive value for thoracic aortic aneurysm detection. Eighty-two popliteal artery enlargements or aneurysms (diameter >10 mm) occurred in 55 patients (33.1% prevalence). Carriers of MMP12 rs652438 C allele showed an 18% (P = .006) increased diameter in popliteal arteries and a 2.8 (95% confidence interval, 1.3-6; P = .008) increased odds of popliteal artery enlargement or aneurysm compared with TT genotype. Among patients with AAA, carriers of homozygous ≥22 CA repeats in MMP9 rs12234681 and of C allele in MMP12 rs652438 have a substantial risk of carrying thoracic and popliteal enlargements, respectively. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Aortic Arch Morphology and Aortic Length in Patients with Dissection, Traumatic, and Aneurysmal Disease.

PubMed

Alberta, H B; Takayama, T; Smits, T C; Wendorff, B B; Cambria, R P; Farber, M A; Jordan, W D; Patel, V; Azizzadeh, A; Rovin, J D; Matsumura, J S

2015-12-01

To assess aortic arch morphology and aortic length in patients with dissection, traumatic injury, and aneurysm undergoing TEVAR, and to identify characteristics specific to different pathologies. This was a retrospective analysis of the aortic arch morphology and aortic length of dissection, traumatic injury, and aneurysmal patients. Computed tomography imaging was evaluated of 210 patients (49 dissection, 99 traumatic injury, 62 aneurysm) enrolled in three trials that received the conformable GORE TAG thoracic endoprosthesis. The mean age of trauma patients was 43 ± 19.6 years, 57 ± 11.7 years for dissection and 72 ± 9.6 years for aneurysm patients. A standardized protocol was used to measure aortic arch diameter, length, and take-off angle and clockface orientation of branch vessels. Differences in arch anatomy and length were assessed using ANOVA and independent t tests. Of the 210 arches evaluated, 22% had arch vessel common trunk configurations. The aortic diameter and the distance from the left main coronary (LMC) to the left common carotid (LCC) were greater in dissection patients than in trauma or aneurysm patients (p < .001). Aortic diameter in aneurysm patients was greater compared with trauma patients (p < .05). The distances from the branch vessels to the celiac artery (CA) were greater in dissection and aneurysm patients than in trauma patients (p < .001). The take-off angle of the innominate (I), LCCA, and left subclavian (LS) were greater, between 19% and 36%, in trauma patients than in dissection and aneurysm patients (p < .001). Clockface orientation of the arch vessels varies between pathologies. Arch anatomy has significant morphologic differences when comparing aortic pathologies. Describing these differences in a large sample of patients is beneficial for device designs and patient selection. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

A rare case of large isolated internal iliac artery aneurysm with ureteral obstruction and hydronephrosis: Compression symptoms are limitation for endovascular procedures.

PubMed

Nenezic, Dragoslav; Tanaskovic, Slobodan; Gajin, Predrag; Ilijevski, Nenad; Novakovic, Aleksandra; Radak, Djordje

2015-04-01

In this report, we aim to present a rare case of isolated internal iliac artery aneurysm with associated left ureteric obstruction and consequent hydronephrosis. A 66-year-old male patient was admitted for occasional pain in the lower back that appeared one month earlier. CT arteriography revealed isolated internal iliac artery (diameter 99 mm) with ureteral obstruction, hydroureter and left kidney hydronephrosis occurrence. Aneurysm was resected, after six months the patient was doing well. Bearing in mind that 77% of the patients with isolated internal iliac artery have symptoms caused by aneurysmal compression on adjacent organs, we wanted to highlight that despite the amazing expansion of endovascular procedures in the last decades, its therapeutic effect in isolated internal iliac artery's treatment is to a great extent limited since compression symptoms cannot be solved. Open surgery remains the gold standard for isolated internal iliac artery's treatment considering significant limitations of endovascular procedures due to the inability to eliminate problems caused by compression. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage: The Helsinki experience.

PubMed

Randell, Tarja; Niemelä, Mika; Kyttä, Juha; Tanskanen, Päivi; Määttänen, Markku; Karatas, Ayse; Ishii, Keisuke; Dashti, Reza; Shen, Hu; Hernesniemi, Juha

2006-10-01

Aneurysmal subarachnoid hemorrhage is a devastating disease that is followed by a marked stress response affecting other organs besides the brain. The aim in the management of patients with aSAH is not only to prevent rebleedings by treating the aneurysm by either microneurosurgery or endovascular surgery, but also to evacuate acute space-occupying hematomas and to treat hydrocephalus. This review is based on the experience of the authors in the management of more than 7500 patients with aSAH treated in the Department of Neurosurgery at Helsinki University Central Hospital, Finland. The role of the neuroanesthesiologist together with the neurosurgeon may begin in the emergency department to assess and stabilize the general medical and neurologic status of the patients. Early preoperative management of patients in the NICU, prevention of rebleeding, and providing a slack brain during microneurosurgical procedures are further steps. Postoperative management, prevention, and treatment of possible medical complications and cerebrovascular spasm are as necessary as high-quality microsurgery. Multidisciplinary and professional teamwork is essential in the management of patients with cerebral aneurysms.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm - A Case Report and Literature Review.

PubMed

Bacalbasa, Nicolae; Brezean, Iulian; Anghel, Claudiu; Barbu, Ion; Pautov, Mihai; Balescu, Irina; Brasoveanu, Vladislav

2017-01-01

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary. Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm – A Case Report and Literature Review

PubMed Central

BACALBASA, NICOLAE; BREZEAN, IULIAN; ANGHEL, CLAUDIU; BARBU, ION; PAUTOV, MIHAI; BALESCU, IRINA; BRASOVEANU, VLADISLAV

2017-01-01

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary. PMID:28882969

Re-do aortic root replacement after an allograft aortic root replacement.

PubMed

Vrtik, Marian; Tesar, Peter J

2009-10-01

Structural degeneration of allograft aortic root is a global process. In addition to valvular degeneration, the allograft wall calcification poses a risk of systemic calcific embolization and late phase anastomotic aneurysm formation and rupture (anecdotal). Furthermore, the valve annulus is often small, and the tissues are rigid making the implantation of an adequately sized prosthesis within the allograft wall difficult. To avoid these issues, we routinely perform re-do aortic root replacement with either a mechanical valve conduit or bio-root composite graft. The technique has been successfully used in 22 consecutive patients with no operative mortality and minimal morbidity.

Cerebral Aneurysm Clipping Surgery Simulation Using Patient-Specific 3D Printing and Silicone Casting.

PubMed

Ryan, Justin R; Almefty, Kaith K; Nakaji, Peter; Frakes, David H

2016-04-01

Neurosurgery simulator development is growing as practitioners recognize the need for improved instructional and rehearsal platforms to improve procedural skills and patient care. In addition, changes in practice patterns have decreased the volume of specific cases, such as aneurysm clippings, which reduces the opportunity for operating room experience. The authors developed a hands-on, dimensionally accurate model for aneurysm clipping using patient-derived anatomic data and three-dimensional (3D) printing. Design of the model focused on reproducibility as well as adaptability to new patient geometry. A modular, reproducible, and patient-derived medical simulacrum was developed for medical learners to practice aneurysmal clipping procedures. Various forms of 3D printing were used to develop a geometrically accurate cranium and vascular tree featuring 9 patient-derived aneurysms. 3D printing in conjunction with elastomeric casting was leveraged to achieve a patient-derived brain model with tactile properties not yet available from commercial 3D printing technology. An educational pilot study was performed to gauge simulation efficacy. Through the novel manufacturing process, a patient-derived simulacrum was developed for neurovascular surgical simulation. A follow-up qualitative study suggests potential to enhance current educational programs; assessments support the efficacy of the simulacrum. The proposed aneurysm clipping simulator has the potential to improve learning experiences in surgical environment. 3D printing and elastomeric casting can produce patient-derived models for a dynamic learning environment that add value to surgical training and preparation. Copyright © 2016 Elsevier Inc. All rights reserved.

Surgical management of vascular access related aneurysms to salvage dialysis access: case report and a systematic review of the literature.

PubMed

Furukawa, Hiroshi

2015-01-01

We retrospectively evaluated the surgical outcome of revising vascular access related aneurysms (VARAs) to salvage dialysis access. Twenty-six consecutive hemodialysis patients (mean age 67.6 years, range: 32-89 years) who presented with true or false VARA and underwent surgery between January 2006 and February 2011 were enrolled in this study, and comprised 11 women and 15 men. Aneurysms were true in 21 patients and false in five; native arteriovenous fistulas (AVFs) were reported in 23, including one infected native pseudoaneurysm, and arteriovenous prosthetic grafts (AVGs) in three. The mean aneurysm diameter was 29.8 ± 8.0 mm, ranging from 18 to 50 mm. Indications of surgical intervention were local pain, rapid enlargement of the aneurysm, and AVF failure due to stenosis. Surgical revision was performed by resection of VARA and concomitant creation of a new proximal arteriovenous anastomosis in 18 patients. Two aneurysms were ruptured by blunt dissection; however, bleeding did not occur due to prior clamping of the inflow artery without hemodynamic compromise. VARA plication was performed in one case in which severe calcified VARA could not be incised. No significant complications were reported, except for delayed wound healing in three patients and minor peripheral neuropathy in five. The postoperative course was uneventful without hospital mortality in all patients with VARA. Aggressive surgical management of VARAs is likely to become an acceptable procedure to salvage dialysis access and consistently maintain AVF or AVG function.

The natural history of splanchnic artery aneurysms and outcomes after operative intervention.

PubMed

Corey, Michael R; Ergul, Emel A; Cambria, Richard P; English, Sean J; Patel, Virendra I; Lancaster, R Todd; Kwolek, Christopher J; Conrad, Mark F

2016-04-01

Splanchnic artery aneurysms (SAAs) are uncommon, and standards for surveillance and intervention are lacking. The goal of this study was to review our 20-year experience with managing SAAs. The Research Patient Data Registry at the Massachusetts General Hospital was queried, and all patients with SAAs identified by axial imaging from 1994 to 2014 were included. Aneurysms were stratified into two cohorts: those that underwent early intervention (<6 months after lesion discovery) and those that received surveillance. Primary study end points included aneurysm growth or rupture during surveillance and patient 30-day morbidity or mortality after aneurysm repair. There were 264 SAAs identified in 250 patients. In 166 patients, 176 SAAs (66.6%) were placed into the surveillance cohort; 38 SAAs (21.6%) did not have subsequent axial imaging and were considered lost to follow-up. Mean aneurysm size in the surveillance cohort at first imaging study was 16.28 mm (8-41 mm), and mean surveillance time was 36.1 months (2-155 months); 126 SAAs (91.3%) remained stable in size over time, and 8 SAAs (5.8%) required intervention for aneurysm growth after a mean of 24 months. There were no ruptures in the surveillance cohort. There were 88 SAAs (33.3%) repaired early. Mean size of SAAs that were repaired early was 31.1 mm (10-140 mm). For intact SAAs, 30-day morbidity and mortality rates after repair were 13% and 3%, respectively. In the early repair cohort, 13 SAAs (14.7%) were ruptured at presentation. The 30-day morbidity and mortality rates after rupture were 54% and 8%, respectively. Five ruptured SAAs (38%) were anatomically located in the pancreaticoduodenal arcade. On univariate analysis, pancreaticoduodenal aneurysms were strongly associated with rupture (P = .0002). Small SAAs (≤25 mm) are not prone to significant expansion and do not require frequent surveillance imaging. Imaging every 3 years for small SAAs is adequate. Aneurysms of the pancreaticoduodenal arcade and gastroduodenal aneurysms are more likely to rupture and therefore warrant a more aggressive interventional approach. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

A deleterious gene-by-environment interaction imposed by calcium channel blockers in Marfan syndrome.

PubMed

Doyle, Jefferson J; Doyle, Alexander J; Wilson, Nicole K; Habashi, Jennifer P; Bedja, Djahida; Whitworth, Ryan E; Lindsay, Mark E; Schoenhoff, Florian; Myers, Loretha; Huso, Nick; Bachir, Suha; Squires, Oliver; Rusholme, Benjamin; Ehsan, Hamid; Huso, David; Thomas, Craig J; Caulfield, Mark J; Van Eyk, Jennifer E; Judge, Daniel P; Dietz, Harry C

2015-10-27

Calcium channel blockers (CCBs) are prescribed to patients with Marfan syndrome for prophylaxis against aortic aneurysm progression, despite limited evidence for their efficacy and safety in the disorder. Unexpectedly, Marfan mice treated with CCBs show accelerated aneurysm expansion, rupture, and premature lethality. This effect is both extracellular signal-regulated kinase (ERK1/2) dependent and angiotensin-II type 1 receptor (AT1R) dependent. We have identified protein kinase C beta (PKCβ) as a critical mediator of this pathway and demonstrate that the PKCβ inhibitor enzastaurin, and the clinically available anti-hypertensive agent hydralazine, both normalize aortic growth in Marfan mice, in association with reduced PKCβ and ERK1/2 activation. Furthermore, patients with Marfan syndrome and other forms of inherited thoracic aortic aneurysm taking CCBs display increased risk of aortic dissection and need for aortic surgery, compared to patients on other antihypertensive agents.

Prosthetic valve sparing aortic root replacement: an improved technique.

PubMed

Leacche, Marzia; Balaguer, Jorge M; Umakanthan, Ramanan; Byrne, John G

2008-10-01

We describe a modified surgical technique to treat patients with a previous history of isolated aortic valve replacement who now require aortic root replacement for an aneurysmal or dissected aorta. This technique consists of replacing the aortic root with a Dacron conduit, leaving intact the previously implanted prosthesis, and re-implanting the coronary arteries in the Dacron graft. Our technique differs from other techniques in that we do not leave behind any aortic tissue remnant and also in that we use a felt strip to obliterate any gap between the old sewing ring and the newly implanted graft. In our opinion, this promotes better hemostasis. We demonstrate that this technique is safe, feasible, and results in acceptable outcomes.

Analysis of Surgical Freedom Variation Across the Basilar Artery Bifurcation: Towards a Deeper Insight Into Approach Selection for Basilar Apex Aneurysms.

PubMed

Tayebi Meybodi, Ali; Benet, Arnau; Rodriguez Rubio, Roberto; Yousef, Sonia; Lawton, Michael T

2018-03-03

The orbitozygomatic approach is generally advocated over the pterional approach for basilar apex aneurysms. However, the impact of the extensions of the pterional approach on the obtained maneuverability over multiple vascular targets (relevant to basilar apex surgery) has not been studied before. To analyze the patterns of surgical freedom change across the basilar bifurcation between the pterional, orbitopterional, and orbitozygomatic approaches. Surgical freedom was assessed for 3 vascular targets important in basilar apex aneurysm surgery (ipsilateral and contralateral P1-P2 junctions, and basilar apex), and compared between the pterional, orbitopterional, and orbitozygomatic approaches in 10 cadaveric specimens. Transitioning from the pterional to orbitopterional approach, the surgical freedom increased significantly at all 3 targets (P < .05). However, the gain in surgical freedom declined progressively from the most superficial target (60% for ipsilateral P1-P2 junction) to the deepest target (35% for contralateral P1-P2 junction). Conversely, transitioning from the orbitopterional to the orbitozygomatic approach, the gain in surgical freedom was minimal for the ipsilateral P1-P2 and basilar apex (<4%), but increased dramatically to 19% at the contralateral P1-P2 junction. The orbitopterional approach provides a remarkable increase in surgical maneuverability compared to the pterional approach for the basilar apex target and the relevant adjacent arterial targets. However, compared to the orbitopterional, the orbitozygomatic approach adds little maneuverability except for the deepest target (ie, contralateral P1-P2 junction). Therefore, the orbitozygomatic approach may be most efficacious with larger basilar apex aneurysms limiting the control over of the contralateral P1 PCA.

Percutaneous trans-hepatic gelfoam-cyanoacrylate glue embolization for ruptured post-traumatic hepatic artery pseudo-aneurysm in a limited-resource scenario.

PubMed

Kumar, Manoj; Goel, Prabudh; Rawat, J D; Kumari, Shweta; Shankhwar, S N; Kureel, S N

2013-05-01

We present our experience with an indigenously designed percutaneous trans-hepatic ultrasound-guided Gelfoam sponge cum cyanoacrylate glue-based embolization technique for the treatment of a ruptured post-traumatic aneurysm of a branch of the right hepatic artery (RHA) as a 'life-saving emergent' procedure in a patient unfit for surgery or endovascular intervention and in a 'limited-resource' scenario (non-availability of Digital Subtraction Angiography Suite). An 8-year-old boy sustained crush-injury to the right lobe of the liver in a road-traffic accident and presented in shock. After resuscitation, a laparotomy and repair of the right lobe of liver were undertaken. Bleeding restarted 1 week after the surgery; the patient bled from drain site and went into shock. Exploration was not advisable in view of poor general condition, and sepsis, deranged coagulation and parental reluctance in view of guarded prognosis. Multi-detector Computed Tomography Angiography was performed after resuscitation which revealed active bleed from a ruptured pseudo-aneurysm of a branch of RHA. The bleeding artery was identified with duplex sonography and was embolized by the percutaneous trans-hepatic route proximal to the site of pseudo-aneurysm and rupture by a two-step process. Initially, a thin paste/'slurry' made of powdered gelfoam dissolved in sterile saline was injected into the bleeding vessel. Subsequently, the area was sealed by injecting 1.0 ml of N-butyl-2-cyanoacrylate glue. Hemostasis was confirmed by Color and Power Doppler Ultrasonography both post-procedure and after 48 h. With supportive management, the patient showed a rapid recovery and was discharged after 2 weeks. He continues to be well at 3-month follow-up. The technique was effective in controlling hemostasis and life-saving in our set-up.

Hereditary hemochromatosis as a risk factor for joint replacement surgery.

PubMed

Sahinbegovic, Enijad; Dallos, Tomás; Aigner, Elmar; Axmann, Roland; Engelbrecht, Matthias; Schöniger-Hekele, Maximilian; Karonitsch, Thomas; Farkas, Martin; Karger, Thomas; Willeit, Johann; Stölzel, Ulrich; Keysser, Gernot; Datz, Christian; Kiechl, Stefan; Schett, Georg; Zwerina, Jochen

2010-07-01

Hemochromatosis is an inherited disease with iron overload and joint involvement resembling osteoarthritis. To determine the rate of joint replacement surgery in patients with hemochromatosis, we performed a cross-sectional cohort study. A total of 199 individuals with hereditary hemochromatosis were included. The prevalence of joint replacement surgery in hip, knee, and ankle joints because of secondary osteoarthritis was assessed. Data were compared with 917 healthy subjects from the population-based Bruneck study. A total of 32 of 199 individuals with hemochromatosis received joint replacement surgery with a total number of 52 joints replaced. Compared with expected rates in healthy individuals, patients with hemochromatosis had a significantly higher risk for joint replacement surgery (odds ratio 9.0; confidence interval, 4.6-17.4). Joint replacement occurred significantly earlier in life in patients with hemochromatosis; 21.9% of the patients with hemochromatosis and 1.7% of healthy individuals required joint replacement before the age of 50 years (P=.0027). Moreover, patients with hemochromatosis were more likely to require multiple joint replacements (8.5%) than the control group (expected rate 0.3%; P=.0001). Hemochromatosis is a risk factor for joint replacement surgery because of severe secondary osteoarthritis. Copyright 2010 Elsevier Inc. All rights reserved.

Mixed reality for robotic treatment of a splenic artery aneurysm.

PubMed

Pietrabissa, Andrea; Morelli, Luca; Ferrari, Mauro; Peri, Andrea; Ferrari, Vincenzo; Moglia, Andrea; Pugliese, Luigi; Guarracino, Fabio; Mosca, Franco

2010-05-01

Techniques of mixed reality can successfully be used in preoperative planning of laparoscopic and robotic procedures and to guide surgical dissection and enhance its accuracy. A computer-generated three-dimensional (3D) model of the vascular anatomy of the spleen was obtained from the computed tomography (CT) dataset of a patient with a 3-cm splenic artery aneurysm. Using an environmental infrared localizer and a stereoscopic helmet, the surgeon can see the patient's anatomy in transparency (augmented or mixed reality). This arrangement simplifies correct positioning of trocars and locates surgical dissection directly on top of the aneurysm. In this way the surgeon limits unnecessary dissection, leaving intact the blood supply from the short gastric vessels and other collaterals. Based on preoperative planning, we were able to anticipate that the vascular exclusion of the aneurysm would result in partial splenic ischemia. To re-establish the flow to the spleen, end-to-end robotic anastomosis of the splenic artery with the Da Vinci surgical system was then performed. Finally, the aneurysm was fenestrated to exclude arterial refilling. The postoperative course was uneventful. A control CT scan 4 weeks after surgery showed a well-perfused and homogeneous splenic parenchyma. The final 3D model showed the fenestrated calcified aneurysm and patency of the re-anastomosed splenic artery. The described technique of robotic vascular exclusion of a splenic artery aneurysm, followed by re-anastomosis of the vessel, clearly demonstrates how this technology can reduce the invasiveness of the procedure, obviating an otherwise necessary splenectomy. Also, the use of intraoperative mixed-reality technology proved very useful in this case and is expected to play an increasing role in the operating room of the future.

Tissue factor levels and the fibrinolytic system in thin and thick intraluminal thrombus and underlying walls of abdominal aortic aneurysms.

PubMed

Siennicka, Aldona; Zuchowski, Marta; Kaczmarczyk, Mariusz; Cnotliwy, Miłosław; Clark, Jeremy Simon; Jastrzębska, Maria

2018-03-20

The hemostatic system cooperates with proteolytic degradation in processes allowing abdominal aortic aneurysm (AAA) formation. In previous studies, it has been suggested that aneurysm rupture depends on intraluminal thrombus (ILT) thickness, which varies across each individual aneurysm. We hypothesized that hemostatic components differentially accumulate in AAA tissue in relation to ILT thickness. Thick (A1) and thin (B1) segments of ILTs and aneurysm wall sections A (adjacent to A1) and B (adjacent to B1) from one aneurysm sac were taken from 35 patients undergoing elective repair. Factor levels were measured using enzyme-linked immunosorbent assay of protein extract. Tissue factor (TF) activities were significantly higher in thinner segments of AAA (B1 vs A1, P = .003; B vs A, P < .001; B vs A1, P < .001; B vs B1, P = .001). Significantly higher tissue plasminogen activator was found in thick thrombus-covered wall segments (A) than in B, A1, and B1 (P = .015, P < .001, and P < .001, respectively). Plasminogen concentrations were highest in ILT. Concentrations of α 2 -antiplasmin in thin ILT adjacent walls (B) were higher compared with wall (A) adjacent to thick ILT (P = .021) and thick ILT (A1; P < .001). Significant correlations between levels of different factors were mostly found in thick ILT (A1). However, no correlations were found at B sites, except for a correlation between plasmin and TF activities (r = 0.55; P = .004). These results suggest that higher TF activities are present in thinner AAA regions. These parameters and local fibrinolysis may be part of the processes leading to destruction of the aneurysm wall. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Modelling and numerical simulation of the in vivo mechanical response of the ascending aortic aneurysm in Marfan syndrome.

PubMed

García-Herrera, Claudio M; Celentano, Diego J; Herrera, Emilio A

2017-03-01

Marfan syndrome (MFS) is a genetic disorder that affects connective tissue, impairing cardiovascular structures and function, such as heart valves and aorta. Thus, patients with Marfan disease have a higher risk of developing circulatory problems associated with mitral and aortic valves prolapse, manifested as dilated aorta and aortic aneurysm. However, little is known about the biomechanical characteristics of these structures affected with MFS. This study presents the modelling and simulation of the mechanical response of human ascending aortic aneurysms in MFS under in vivo conditions with intraluminal pressures within normotensive and hypertensive ranges. We obtained ascending aortic segments from five adults with MFS subjected to a vascular prosthesis implantation replacing an aortic aneurysm. We characterised the arterial samples via ex vivo tensile test measurements that enable fitting the material parameters of a hyperelastic isotropic constitutive model. Then, these material parameters were used in a numerical simulation of an ascending aortic aneurysm subjected to in vivo normotensive and hypertensive conditions. In addition, we assessed different constraints related to the movement of the aortic root. Overall, our results provide not only a realistic description of the mechanical behaviour of the vessel, but also useful data about stress/stretch-based criteria to predict vascular rupture. This knowledge may be included in the clinical assessment to determine risk and indicate surgical intervention.

Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.

PubMed

Barillà, D; Sobocinski, J; Stilo, F; Maurel, B; Spinelli, F; Haulon, S

2014-10-01

The aim of this study was to compare the results of complex aneurysm (hostile neck anatomies) repair in high-risk patients with two minimally invasive techniques, fenestrated endografting (f-EVAR where EVAR stands for endovascular aneurysm repair) and minilaparotomy. All high-risk patients (N.=50, group 1) with hostile neck abdominal aortic aneurysms (AAAs) operated in the vascular surgery department of the "Policlinico Universitario G. Martino" of Messina (Italy) during a 5-year period (January 2006-December 2010) were cross-matched with 50 similar patients (group 2) treated in the Vascular Surgery Department of the "Hopital Cardiologique" University of Lille (France) with similar anatomies, comorbidities and risk factors. The patients in group 1 underwent open minilaparotomy surgery, and the patients in group 2 were treated with f-EVAR. The aim of our study was to compare perioperative complications, survival and reintervention rates. Perioperative cardiac complications occurred in 5 patients (10%) in group 1, and 1 patient (2%) in group 2 (P<0.092). Renal impairment not requiring permanent hemodialysis was significantly higher in group 1 (14% vs. 2% P<0.027), as well as respiratory complications (32% vs. 2% P<0.0001). Five patients (10%) in group 1 underwent reintervention vs. 4 patients in group 2 (P<0.7268). There was no statistically significant difference for survival rates at 30 days (92% in group 1 and 96% in group 2; P=0.399); at six months (90% vs. 96%; P=0.239); at one year (90% vs. 96%; P=0.239); and at two years (84% vs. 94%; P=0.110). However, we observed statistically significant differences in survival rates at three years (74% vs. 94%; P<0.006); at four years (70% vs. 86%; P<0.005); and at five years (65% vs. 68%; P<0.003). Our results showed that both techniques are effective in the treatment of AAA with hostile neck in high-risk patients. Although operative mortality rate was not statistically different, f-EVAR showed better results in terms of early complications and late survival.

Assessment of subclinical acute kidney injury after abdominal aortic aneurysm surgery using novel markers: L-FABP and H-FABP.

PubMed

Kokot, Michał; Biolik, Grzegorz; Ziaja, Damian; Fojt, Tadeusz; Kędzierski, Leszek; Antoniak, Katarzyna; Janowska, Mirosława; Pawlicki, Krzysztof; Ziaja, Krzysztof; Duława, Jan

2014-01-01

One of the most severe complications of repair surgery for abdominal aortic aneurysms (AAA) is acute kidney injury (AKI). Even small rises in serum creatinine are associated with increased mortality. The aim of this study was to assess the dynamics of AKI after elective AAA surgery using novel markers. The study group consisted of 22 patients with AAA. We measured urinary liver- (u-L-FABP) and heart-type fatty acid-binding proteins (u-H-FABP) before, during and within 3 days after surgery. We found an abrupt and significant elevation of both urine FABPs normalized to urinary creatinine; u-L-FABP reached its peak value 2 hours after aortic clamp release {137.79 (38.57-451.79) vs. 9.94 (6.82-12.42) ng/mg baseline value, p<0.05; values are medians (lower-upper quartile)}. The peak value of u-H-FABP was reported 72 hours after aortic clamp release {16.462 (4.182-37.595) vs. 0.141 (0.014-0.927) ng/mg baseline value, p<0.05}. The serum creatinine level did not changed significantly during the investigation period. The significant rise of both u-L-FABP and u-H-FABP after AAA surgery indicates renal proximal and distal tubule injury in this population. Our results suggest that, after AAA surgery, the distal tubules could be more affected than the proximal ones. u-FABPs could serve as sensitive biomarkers of kidney tubular injury and may allow to detect the very early phases of AKI.

Augmented reality in neurovascular surgery: feasibility and first uses in the operating room.

PubMed

Kersten-Oertel, Marta; Gerard, Ian; Drouin, Simon; Mok, Kelvin; Sirhan, Denis; Sinclair, David S; Collins, D Louis

2015-11-01

The aim of this report is to present a prototype augmented reality (AR) intra-operative brain imaging system. We present our experience of using this new neuronavigation system in neurovascular surgery and discuss the feasibility of this technology for aneurysms, arteriovenous malformations (AVMs), and arteriovenous fistulae (AVFs). We developed an augmented reality system that uses an external camera to capture the live view of the patient on the operating room table and to merge this view with pre-operative volume-rendered vessels. We have extensively tested the system in the laboratory and have used the system in four surgical cases: one aneurysm, two AVMs and one AVF case. The developed AR neuronavigation system allows for precise patient-to-image registration and calibration of the camera, resulting in a well-aligned augmented reality view. Initial results suggest that augmented reality is useful for tailoring craniotomies, localizing vessels of interest, and planning resection corridors. Augmented reality is a promising technology for neurovascular surgery. However, for more complex anomalies such as AVMs and AVFs, better visualization techniques that allow one to distinguish between arteries and veins and determine the absolute depth of a vessel of interest are needed.

Effects of variation in cerebral haemodynamics during aneurysm surgery on brain tissue oxygen and metabolism.

PubMed

Kett-White, R; Hutchinson, P J; Czosnyka, M; al-Rawi, P; Gupta, A; Pickard, J D; Kirkpatrick, P J

2002-01-01

This study explores the sensitivities of multiparameter tissue gas sensors and microdialysis to variations in blood pressure, CSF drainage and to well-defined periods of ischaemia accompanying aneurysm surgery, and their predictive value for infarction. A Neurotrend sensor [brain tissue partial pressure of oxygen (PBO2), carbon dioxide (PBCO2), brain pH (pHB) and temperature] and microdialysis catheter were inserted into the appropriate vascular territory prior to craniotomy. Baseline data showed a clear correlation between PBO2 and mean arterial pressure (MAP) below a threshold of 80 mmHg. PBO2 improved with CSF drainage in 20 out of 28 (Wilcoxon: P < 0.05) cases where data was available. In 26 patients the effects of temporary vascular clipping (TC) (mean duration 16 minutes) were assessed. 2 patients subsequently declared infarction in the region of the probes. PBO2 fell from a mean 3.2 (95% CI 2.4-4.1) kPa to a minimum of 1.5 (95% CI 1.0-2.0) kPa in the non-infarct group. There was a lower baseline PBO2 (mean 0.8 kPa) in the patients who infarcted. PBCO2 mirrored PBO2 changes, whereas pHB did not change significantly in either group. Microdialysis changes associated with decreased PBO2 included a delayed increase in lactate, a raised lactate/pyruvate ratio and more rarely an increased glutamate. These changes were seen in 11 patients but were not predictive of infarction. Hypotension during aneurysm surgery is associated with a low PBO2. Multiparameter sensors can be sensitive to acute ischaemia. Microdialysis shows potential in the detection of metabolic changes during tissue hypoxia.

Results of Early High-Flow Bypass and Trapping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery.

PubMed

Kikkawa, Yuichiro; Ikeda, Toshiki; Takeda, Ririko; Nakajima, Hiroyuki; Ogura, Takeshi; Ooigawa, Hidetoshi; Kurita, Hiroki

2017-09-01

The aim of this study is to clarify the efficacy and safety of early surgery using trapping of the affected internal carotid artery (ICA) and high-flow bypass between the second portion of the middle cerebral artery and cervical external carotid artery with radial artery graft for ruptured blood blister-like aneurysms (BBAs) arising from the anterior wall of the ICA. Medical charts of 16 consecutive patients (7 men and 9 women; mean, 59 years) with subarachnoid hemorrhage (World Federation of Neurosurgical Societies grade I, n = 2; grade II, n = 5; grade III, n = 2; grade IV, n = 4; grade V, n = 3) caused by ruptured BBA surgically treated between July 2010 and October 2015 were retrospectively reviewed. Eleven patients underwent acute surgery within 24 hours after the onset, whereas surgery was performed between 3 and 17 days after the onset because of referral delay or associated vasospasm in 5 patients. All patients underwent the same surgical procedure. Elimination of the BBA and patency of the bypass were achieved in all patients. Postoperatively, 2 patients showed small infarction in the Heubner artery area, and 2 others suffered symptomatic vasospasm, but no patient suffered infarction in the posterior communicating/anterior choroidal artery territories. Identically, no patient showed ischemic optic neuropathy. At the last follow-up (mean, 36 months), favorable clinical outcome (good recovery or mild disability in Glasgow Outcome Scale) was achieved in 14 (88%) of the patients without rebleeding or refilling of the aneurysms. Early surgical repair of BBAs by trapping of the affected ICA with high-flow bypass is safe and effective treatment with satisfactory midterm outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

Early outcomes with a single-sided access endovascular stent.

PubMed

Hofmann, Michael; Pecoraro, Felice; Planer, David; Pfammatter, Thomas; Puippe, Gilbert; Bettex, Dominique; Veith, Frank J; Lachat, Mario; Chaykovska, Lyubov

2018-03-27

The objective of this study was to report the 1-year follow-up study results of the new Horizon stent graft (Endospan, Herzliya, Israel) from two different prospective consecutive trials. The Horizon abdominal aortic aneurysm stent graft system is a 14F profile system requiring only a single access site. It consists of three modules, introduced separately: base limb (iliac to iliac limb); distal aortic limb; and proximal aortic limb with a bare suprarenal crown and active fixation. Data from the first in man (FIM) clinical study with 10 patients enrolled and the pivotal study with 30 patients were analyzed. Outcomes measured were freedom from major adverse events (MAEs) including all-cause mortality, myocardial infarction, renal failure, respiratory failure, paraplegia, stroke, bowel ischemia, and procedural blood loss ≥1000 mL. Performance end points included successful delivery and deployment of the device, freedom from aneurysm growth ≥5 mm, type I or type III endoleak, stent graft occlusion, conversion to open surgery, rupture, and stent graft migration. In the FIM study, one conversion to open surgery with >1000 mL of blood loss was registered perioperatively. In the pivotal study, no perioperative MAE was registered. Overall, at 1-year follow-up, two deaths and one aneurysm growth unrelated to endoleak were registered. The results of both the FIM and pivotal studies demonstrated that 39 of 40 procedures were successful for delivery and deployment of the Horizon stent graft. No MAE was registered during the follow-up. The primary safety and performance end points were met in both studies. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis.

PubMed

Kume, Yuta; Fujita, Tomoyuki; Fukushima, Satsuki; Shimahara, Yusuke; Matsumoto, Yorihiko; Yamashita, Kizuku; Kawamoto, Naonori; Kobayashi, Junjiro

2018-04-26

The presence of cerebral haemorrhage (CH) preoperatively is a risk factor of in-hospital cerebrovascular complications post-valve surgery for acute infective endocarditis. However, factors related to cerebrovascular complications in the long term are poorly understood. We reviewed a series of these patients to investigate risk factors of in-hospital and long-term outcomes. An institutional series of 148 patients who underwent valve surgery for active infective endocarditis between 2000 and 2016 were enrolled. Patients were divided into 2 groups based on the presence of preoperative CH:CH group (n = 25) and non-CH group (n = 123). Of them, 14 (10%) patients were preoperatively diagnosed with mycotic aneurysm (MA). The 30-day mortality was 5% with no difference between the 2 groups. The 5-year survival rate was 92% in the CH group and 77% in the non-CH group. Freedom from CH at 5 years was 92% in the CH group and 97% in the non-CH group. There was no difference in the postoperative haemorrhage rate between patients who had surgery within 14 days from the onset of CH and those who had surgery after 14 days. Freedom from CH at 5 years was 99% in patients without MA and 71% in those with MA. The presence of MA preoperatively was the only independent risk factor of postoperative CH (P = 0.002). Valve surgery for acute infective endocarditis is safe, even in patients with CH preoperatively, regardless of the timing of surgery. Patients with intracranial MA are associated with postoperative CH in the hospital and long term.

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair.

PubMed

Liang, Nathan L; Reitz, Katherine M; Makaroun, Michel S; Malas, Mahmoud B; Tzeng, Edith

2018-05-01

Evidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set. We identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years. We identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results. In this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Aortic Center: specialized care improves outcomes and decreases mortality

PubMed Central

Sales, Marcela da Cunha; Frota Filho, José Dario; Aguzzoli, Cristiane; Souza, Leonardo Dornelles; Rösler, Álvaro Machado; Lucio, Eraldo Azevedo; Leães, Paulo Ernesto; Pontes, Mauro Ricardo Nunes; Lucchese, Fernando Antônio

2014-01-01

Objective To compare in-hospital outcomes in aortic surgery in our cardiac surgery unit, before and after foundation of our Center for Aortic Surgery (CTA). Methods Prospective cohort with non-concurrent control. Foundation of CTA required specialized training of surgical, anesthetic and intensive care unit teams, routine neurological monitoring, endovascular and hybrid facilities, training of the support personnel, improvement of the registry and adoption of specific protocols. We included 332 patients operated on between: January/2003 to December/2007 (before-CTA, n=157, 47.3%); and January/2008 to December/2010 (CTA, n=175, 52.7%). Baseline clinical and demographic data, operative variables, complications and in-hospital mortality were compared between both groups. Results Mean age was 58±14 years, with 65% male. Group CTA was older, had higher rate of diabetes, lower rates of COPD and HF, more non-urgent surgeries, endovascular procedures, and aneurysms. In the univariate analysis, CTA had lower mortality (9.7 vs. 23.0%, P=0.008), which occurred consistently across different diseases and procedures. Other outcomes which were reduced in CTA included lower rates of reinterventions (5.7 vs 11%, P=0.046), major complications (20.6 vs. 33.1%, P=0.007), stroke (4.6 vs. 10.9%, P=0.045) and sepsis (1.7 vs. 9.6%, P=0.001), as compared to before-CTA. Multivariable analysis adjusted for potential counfounders revealed that CTA was independently associated with mortality reduction (OR=0.23, IC 95% 0.08 – 0.67, P=0.007). CTA independent mortality reduction was consistent in the multivariable analysis stratified by disease (aneurysm, OR=0.18, CI 95% 0.03 – 0.98, P=0.048; dissection, OR=0.31, CI 95% 0.09 – 0.99, P=0.049) and by procedure (hybrid, OR=0.07, CI 95% 0.007 – 0.72, P=0.026; Bentall, OR=0.18, CI 95% 0.038 – 0.904, P=0.037). Additional multivariable predictors of in-hospital mortality included creatinine (OR=1.7 [1.1-2.6], P=0.008), urgent surgery (OR=5.0 [1.5-16.7], P=0.008) and thoracoabdominal aneurysm (OR=24.6 [3.1-194.1], P=0.002). Conclusion Thoracic aorta surgery in specialized center was associated with lower incidence of complications and all-cause mortality as compared to usual care. PMID:25714201

Open surgery for aneurysms of the splenic artery at the hilum of the spleen: Report of three cases.

PubMed

Illuminati, Giulio; Pizzardi, Giulia; Pasqua, Rocco

2018-05-18

Aneurysms of the splenic artery (SAA) located at the hilum of the spleen are not well fit for endovascular or laparoscopic treatment. Open surgery may still be the best option of treatment. We report the cases of 3 female patients of a mean age of 59 years (range, 45-68 years) with a hilar (n = 2) or parahilar (n = 1) SAA undergoing successful open surgical resection, through a short left subcostal access. Recovery was uneventful and mean, postoperative length of stay was 4 days (range, 3-5 days). Results of this report support surgical resection and splenectomy for the treatment of SAA located at the hilum of the spleen. For this particular location endovascular treatment may not be advised, as coil embolization can be followed by a massive splenic infarction precipitating the need for splenectomy, due to the exclusion of backflow from the left gastroepiploic artery through the short gastric vessels. As well, endovascular exclusion through insertion of an endograft may not be feasible due to the absence of a distal landing zone, as stent grafting requires a normal caliber artery of sufficient length on each side of the aneurysm. Surgical excision and splenectomy, through a short subcostal incision, remains a viable option of treatment for hilar SAA. Copyright © 2018. Published by Elsevier Ltd.

Rapid prototyping in aortic surgery.

PubMed

Bangeas, Petros; Voulalas, Grigorios; Ktenidis, Kiriakos

2016-04-01

3D printing provides the sequential addition of material layers and, thus, the opportunity to print parts and components made of different materials with variable mechanical and physical properties. It helps us create 3D anatomical models for the better planning of surgical procedures when needed, since it can reveal any complex anatomical feature. Images of abdominal aortic aneurysms received by computed tomographic angiography were converted into 3D images using a Google SketchUp free software and saved in stereolithography format. Using a 3D printer (Makerbot), a model made of polylactic acid material (thermoplastic filament) was printed. A 3D model of an abdominal aorta aneurysm was created in 138 min, while the model was a precise copy of the aorta visualized in the computed tomographic images. The total cost (including the initial cost of the printer) reached 1303.00 euros. 3D imaging and modelling using different materials can be very useful in cases when anatomical difficulties are recognized through the computed tomographic images and a tactile approach is demanded preoperatively. In this way, major complications during abdominal aorta aneurysm management can be predicted and prevented. Furthermore, the model can be used as a mould; the development of new, more biocompatible, less antigenic and individualized can become a challenge in the future. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Modality-specific occult intrarenal pseudoaneurysm in a renal allograft and the legacy of catheter angiography.

PubMed

Rastogi, Neeraj; Williams, Gethin; Alencar, Herlen

2013-11-01

A 69-year-old man with history of end-stage-renal disease (ESRD) underwent successful kidney transplantation from a cadaveric donor in November 2011. However, posttransplant recovery was complicated by delayed graft function and recurrent gross hematuria. Serial Doppler ultrasound (US) of the renal allograft demonstrated a pseudoaneurysm with interval increase in size. However, it could not be visualized with other modalities, including an initial angiogram (postoperative day 49) and a second angiogram (postoperative day 68), followed by surgical exploration (postoperative day 71), which demonstrated complete intra-aneurysmal thrombosis on intraoperative Doppler US. Unfortunately, the patient's hematuria continued and a repeat Doppler US 48 hours later demonstrated a persistent pseudoaneurysm. Therefore, on postoperative day 75, we performed targeted percutaneous intra-aneurysmal thrombin injection under dual image guidance, which showed complete intra-aneurysmal thrombosis on intraprocedural Doppler US. Hematuria recurred the next day. A third angiogram (postoperative day 77) finally illuminated the hidden pseudoaneurysm occult on the first and second angiographic studies (sensitivity [index case] 33%) and surgery. This allowed for successful coil embolization of a subsegmental feeding branch with an excellent outcome. We support a more aggressive management with serial angiography and embolization of the intrarenal symptomatic pseudoaneurysm rather than surgery in renal allograft recipients, with the benefits outweighing the risks. Copyright © 2013 Elsevier Inc. All rights reserved.

Selective Heart, Brain and Body Perfusion in Open Aortic Arch Replacement.

PubMed

Maier, Sven; Kari, Fabian; Rylski, Bartosz; Siepe, Matthias; Benk, Christoph; Beyersdorf, Friedhelm

2016-09-01

Open aortic arch replacement is a complex and challenging procedure, especially in post dissection aneurysms and in redo procedures after previous surgery of the ascending aorta or aortic root. We report our experience with the simultaneous selective perfusion of heart, brain, and remaining body to ensure optimal perfusion and to minimize perfusion-related risks during these procedures. We used a specially configured heart-lung machine with a centrifugal pump as arterial pump and an additional roller pump for the selective cerebral perfusion. Initial arterial cannulation is achieved via femoral artery or right axillary artery. After lower body circulatory arrest and selective antegrade cerebral perfusion for the distal arch anastomosis, we started selective lower body perfusion simultaneously to the selective antegrade cerebral perfusion and heart perfusion. Eighteen patients were successfully treated with this perfusion strategy from October 2012 to November 2015. No complications related to the heart-lung machine and the cannulation occurred during the procedures. Mean cardiopulmonary bypass time was 239 ± 33 minutes, the simultaneous selective perfusion of brain, heart, and remaining body lasted 55 ± 23 minutes. One patient suffered temporary neurological deficit that resolved completely during intensive care unit stay. No patient experienced a permanent neurological deficit or end-organ dysfunction. These high-risk procedures require a concept with a special setup of the heart-lung machine. Our perfusion strategy for aortic arch replacement ensures a selective perfusion of heart, brain, and lower body during this complex procedure and we observed excellent outcomes in this small series. This perfusion strategy is also applicable for redo procedures.

Split-brain phenomena in anterior communicating artery aneurysm rupture: A case report.

PubMed

Korsakova, Natalya; Liebson, Elizabeth; Moskovich, Lena

2017-06-01

In 1976, a patient with an anterior communicating artery aneurysm (ACoAA) rupture (diagnosed on angiography) and sub-arachnoid hemorrhage (SAH) underwent serial neuropsychological testing revealing a classical anterior cerebral artery (ACA) spasm picture with severe anterograde amnesia of Korsakoff's type and dysexecutive syndrome. In addition, the patient demonstrated impaired hemispheric interaction with alien hand syndrome, dyscopia-dysgraphia, complete left ear neglect, and other, more complex, split-brain phenomena. He was evaluated by A. R. Luria in 1976. Following surgery the patient demonstrated gradual improvement. © 2017 The Institute of Psychology, Chinese Academy of Sciences and John Wiley & Sons Australia, Ltd.

Jaundice as a Rare Indication for Aortic Aneurysm Repair.

PubMed

Rieß, Henrik C; Tsilimparis, Nikolaos; Behrendt, Christian A; Wipper, Sabine; Debus, Eike S; Larena-Avellaneda, Axel

2015-10-01

Compression of adjacent anatomic structures by an abdominal aortic aneurysm (AAA) can result in a variety of symptoms. We describe the case of an 88-year-old Caucasian woman with jaundice, elevated laboratory parameters for extrahepatic and intrahepatic cholestasis, and concomitant juxtarenal AAA compressing the liver hilum. Following exclusion of other common causes for cholestasis, the patient was considered to have a symptomatic AAA. Open abdominal aortic surgery revealed a contained rupture and was repaired. Obstructive jaundice secondary to a compromising AAA is a rare condition and to the best of our knowledge has not been reported to date. Copyright © 2015 Elsevier Inc. All rights reserved.

[Pathophysiology, prophylaxis and treatment of reperfusion syndrome in the surgery of abdominal aorta aneurysm].

PubMed

Sukharev, I I; Guch, A A; Medvedskyĭ, E B; Kostylev, M V; Kornitskaia, A I; Gindich, L A; Dominiak, A B; Vlaĭkov, G G

1999-01-01

The peroxidal oxidation of the lipids state was studied up, as well as of the whole blood neutrophils functional activity, hemodynamics and microcirculation of lower extremities in surgical treatment of the abdominal aorta aneurysm. The main significance in the reperfusional syndrome pathophysiology, caused by temporary overcompression of aorta, has the neutrophils activation, their interrelationship with the endothelium cells and the activity lowering of the tissue antioxidant system, manifestated by vascular spasm, which is mostly expressed in the patients with stenotic affection of the lower extremities arteries. Positive effect was noted in application of preparation corvitin, which has antioxidant action.

Endovascular Repair of Abdominal Aortic Aneurysms

PubMed Central

Sternbergh, W. Charles; Yoselevitz, Moises; Money, Samuel R.

1999-01-01

Endovascular treatment of abdominal aortic aneurysms (AAAs) is an exciting new minimally invasive treatment option for patients with this disease. Ochsner Clinic has been the only institution in the Gulf South participating in FDA clinical trials of these investigational devices. Early results with endovascular AAA repair demonstrate a trend towards lower mortality and morbidity when compared with traditional open surgery. Length of stay has been reduced by two-thirds with a marked reduction in postoperative pain and at-home convalescence. If the long-term data on efficacy and durability of these devices are good, most AAAs in the future will be treated with this minimally invasive technique. PMID:21845135

Aortic root repair for thoracic aorta false aneurysm following Bentall procedure.

PubMed

Kumar, Sanjay; Jones, Steve; Sivananthan, U M; McGoldrick, J P

2008-08-01

The Bentall procedure for aortic root replacement in Marfan's syndrome is safe and durable. We describe successful repair of periprosthetic valvular leak, 12 years following Bentall repair with composite graft. The aim of this report is to analyse and evaluate technical factors leading to this unusual occurrence.

Surgical Management of Aneurysmal Hematomas: Prognostic Factors and Outcome.

PubMed

Meneghelli, P; Cozzi, F; Hasanbelliu, A; Locatelli, F; Pasqualin, Alberto

2016-01-01

From 1991 until 2013, 304 patients with intracranial hematomas from aneurysmal rupture were managed surgically in our department, constituting 17 % of all patients with aneurysmal rupture. Of them, 242 patents presented with isolated intracerebral hematomas (in 69 cases associated with significant intraventricular hemorrhage), 50 patients presented with combined intracerebral and subdural hematomas (in 11 cases associated with significant intraventricular hemorrhage), and 12 presented with an isolated subdural hematoma. The surgical procedure consisted of simultaneous clipping of the aneurysm and evacuation of the hematoma in all cases. After surgery, 16 patients (5 %) submitted to an additional decompressive hemicraniectomy, and 66 patients (21 %) submitted to a ventriculo-peritoneal shunt. Clinical outcomes were assessed at discharge and at 6 months, using the modified Rankin Scale (mRS); a favorable outcome (mRS 0-2) was observed in 10 % of the cases at discharge, increasing to 31 % at 6 months; 6-month mortality was 40 %. Applying uni- and multivariate analysis, the following risk factors were associated with a significantly worse outcome: age >60; preoperative Hunt-Hess grades IV-V; pupillary mydriasis (only on univariate); midline shift >10 mm; hematoma volume >30 cc; and the presence of hemocephalus (i.e., packed intraventricular hemorrhage). Based on these results, an aggressive surgical treatment should be adopted for most cases with aneurysmal hematomas, excluding patients with bilateral mydriasis persisting after rescue therapy.

Mycotic abdominal aortic aneurysm due to Streptococcus suis: a case report.

PubMed

Laohapensang, Kamphol; Rutherford, Robert B; Arworn, Supapong

2010-04-01

Streptococcus suis is a common infection of pigs. Human infection is often related to accidental inoculation through skin injuries during occupational exposure to pigs and pork. The disease may present as meningitis, bacteremia, and less commonly endocarditis, arthritis, or bronchopneumonia. Case report and review of the literature. We report a case of bacteremia and severe sepsis caused by S. suis serotype 2 complicated by septic arthritis in a 56-year-old male with history of a prior contact with unprocessed pork. The causative agent was isolated from blood cultures and aspirated synovial fluid. The patient's condition improved after treatment with penicillin, but he was found subsequently to have an abdominal aortic aneurysm, confirmed by computed tomography (CT) scan. The mycotic aneurysm was successfully repaired using an in situ graft reconstruction. Tissue samples analyzed using polymerase chain reaction identified S. suis serotype 2 as the causative organism. After completion of two weeks of parenteral antibiotics, an oral form of ciprofloxacin (0.25 g twice a day) was continued for one month. The patient was discharged from our institution after uncomplicated recovery. Clinical review, a CT scan, and inflammatory markers nine months after surgery revealed no evidence of infection. This is the first report of mycotic aneurysm caused by S. suis, which may be an etiologic agent of mycotic aneurysms, especially when complicated by bacteremia in adults with a recent history of contact with pigs or unprocessed pork.

Hip or knee replacement - in the hospital after

MedlinePlus

Hip replacement surgery - after - self-care; Knee replacement surgery - after - self-care ... taking walks in the hallways with help. After knee replacement, some surgeons recommend using a continuous passive ...

Catching a floating thrombus; a case report on the treatment of a large thrombus in the ascending aorta.

PubMed

de Maat, Gijs Eduard; Vigano, Giorgio; Mariani, Massimo Alessandro; Natour, Ehsan

2017-05-19

The ascending aorta is an uncommon site for non-infective thrombus. In non-aneurysmal and non-atherosclerotic vessels this condition becomes extremely rare, while it represents a source of potential cerebral and peripheral embolic events. Currently, there is no consensus in the guidelines on how to treat a free floating thrombus in ascending aorta, therefore we present our decision making process and therapeutic strategy. A healthy 48-year-old man was hospital admitted with acute abdominal pain. CT-scan showed a right renal embolism in presence of a defect in the distal ascending aorta suggestive for thrombus. After heart team discussion the patient was scheduled for surgery and successfully underwent an emergent thrombus removal. Also, owing to multiple aortic wall insertions, the ascending aorta was replaced. The patient's recovery was uneventful and histological examination showed no signs of connective tissue disorders of aortic wall while confirmed the thrombotic nature of the mass. We present a patient with a floating thrombus in the ascending aorta who underwent an ascending aorta replacement. While angio-CT scan led to a prompt diagnosis, intraoperative epi-aortic echocardiography allowed to define precise location of thrombus, minimizing operative risk. This case demonstrates that multi-disciplinary heart team discussion is essential to define a successful strategy, that surgical treatment is feasible with specific tools such as epi-aortic echocardiography.

A dimensionless parameter for classifying hemodynamics in intracranial

NASA Astrophysics Data System (ADS)

Asgharzadeh, Hafez; Borazjani, Iman

2015-11-01

Rupture of an intracranial aneurysm (IA) is a disease with high rates of mortality. Given the risk associated with the aneurysm surgery, quantifying the likelihood of aneurysm rupture is essential. There are many risk factors that could be implicated in the rupture of an aneurysm. However, the most important factors correlated to the IA rupture are hemodynamic factors such as wall shear stress (WSS) and oscillatory shear index (OSI) which are affected by the IA flows. Here, we carry out three-dimensional high resolution simulations on representative IA models with simple geometries to test a dimensionless number (first proposed by Le et al., ASME J Biomech Eng, 2010), denoted as An number, to classify the flow mode. An number is defined as the ratio of the time takes the parent artery flow transports across the IA neck to the time required for vortex ring formation. Based on the definition, the flow mode is vortex if An>1 and it is cavity if An<1. We show that the specific definition of Le et al. works for sidewall but needs to be modified for bifurcation aneurysms. In addition, we show that this classification works on three-dimensional geometries reconstructed from three-dimensional rotational angiography of human subjects. Furthermore, we verify the correlation of IA flow mode and WSS/OSI on the human subject IA. This work was supported partly by the NIH grant R03EB014860, and the computational resources were partly provided by CCR at UB. We thank Prof. Hui Meng and Dr. Jianping Xiang for providing us the database of aneurysms and helpful discussions.

McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology.

PubMed

Longo, S A; Echegaray, A; Acosta, C M; Rinaldi, L I; Cabrera Schulmeyer, M C; Olavide Goya, I

2016-11-01

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Self-efficacy is an independent predictor for postoperative six-minute walk distance after elective open repair of abdominal aortic aneurysm.

PubMed

Hayashi, Kazuhiro; Kobayashi, Kiyonori; Shimizu, Miho; Tsuchikawa, Yohei; Kodama, Akio; Komori, Kimihiro; Nishida, Yoshihiro

2018-05-01

Open surgery is performed to treat abdominal aortic aneurysm (AAA), although the subsequent surgical stress leads to worse physical status. Preoperative self-efficacy has been reported to predict postoperative physical status after orthopedic surgery; however, it has not been sufficiently investigated in patients undergoing abdominal surgery. The purpose of the present study is to investigate the correlation between preoperative self-efficacy and postoperative six-minute walk distance (6MWD) in open AAA surgery. Seventy patients who underwent open AAA surgery were included. Functional exercise capacity was measured using preoperative and 1 week postoperative 6MWD. Self-efficacy was preoperatively measured using self-efficacy for physical activity (SEPA). The correlations of postoperative 6MWD with age, height, BMI, preoperative 6MWD, SEPA, Hospital Anxiety and Depression Scale (HADS) score, operative time, and blood loss were investigated using multivariate analysis. Single regression analysis showed that postoperative 6MWD was significantly correlated with age (r = -0.553, p ≤ 0.001), height (r = 0.292, p = 0.014), Charlson's comorbidity index (r = -0.268, p = 0.025), preoperative 6MWD (r = 0.572, p ≤ 0.001), SEPA (r = 0.586, p ≤ 0.001), and HADS-depression (r = -0.296, p = 0.013). Multiple regression analysis showed that age (p = 0.002), preoperative 6MWD (p = 0.013), and SEPA (p = 0.043) score were significantly correlated with postoperative 6MWD. Self-efficacy was an independent predictor for postoperative 6MWD after elective open AAA surgery. This suggests the importance of assessing not only physical status but also psychological factors such as self-efficacy. Implications for Rehabilitation Preoperative self-efficacy has been limited to reports after orthopedic surgery. We showed that preoperative self-efficacy predicted postoperative 6MWD after AAA surgery. Treatment to improve self-efficacy might be useful in patients receiving AAA surgery in rehabilitation.

Surgical exclusion of postsurgical pseudoaneurysm of the ascending aorta

PubMed Central

Barik, Ramachandra; Patnaik, Amar Narayana; Kumar, Ravintula Venkata; Mohapatra, Rudra Prasad; Medep, Vikas; Nemani, Lalita

2014-01-01

Pseudoaneurysm of ascending aorta after cardiac surgery is rare in children. We report a case of successful surgical exclusion of ascending aortic pseudoaneurysm in a 15-year-old boy. The neck of the aneurysm was in close proximity to the right coronary artery (RCA). PMID:24987261

Medical Treatment of Aortic Aneurysms in Marfan Syndrome and other Heritable Conditions

PubMed Central

Jost, Christine H. Attenhofer; Greutmann, Matthias; Connolly, Heidi M.; Weber, Roland; Rohrbach, Marianne; Oxenius, Angela; Kretschmar, Oliver; Luscher, Thomas F.; Matyas, Gabor

2014-01-01

Thoracic aortic aneurysms can be triggered by genetic disorders such as Marfan syndrome (MFS) and related aortic diseases as well as by inflammatory disorders such as giant cell arteritis or atherosclerosis. In all these conditions, cardiovascular risk factors, such as systemic arterial hypertension, may contribute to faster rate of aneurysm progression. Optimal medical management to prevent progressive aortic dilatation and aortic dissection is unknown. β-blockers have been the mainstay of medical treatment for many years despite limited evidence of beneficial effects. Recently, losartan, an angiotensin II type I receptor antagonist (ARB), has shown promising results in a mouse model of MFS and subsequently in humans with MFS and hence is increasingly used. Several ongoing trials comparing losartan to β-blockers and/or placebo will better define the role of ARBs in the near future. In addition, other medications, such as statins and tetracyclines have demonstrated potential benefit in experimental aortic aneurysm studies. Given the advances in our understanding of molecular mechanisms triggering aortic dilatation and dissection, individualized management tailored to the underlying genetic defect may be on the horizon of individualized medicine. We anticipate that ongoing research will address the question whether such genotype/pathogenesis-driven treatments can replace current phenotype/syndrome-driven strategies and whether other forms of aortopathies should be treated similarly. In this work, we review currently used and promising medical treatment options for patients with heritable aortic aneurysmal disorders. PMID:24527681

Vocal cord paralysis after aortic arch surgery: predictors and clinical outcome.

PubMed

Ohta, Noriyuki; Kuratani, Toru; Hagihira, Satoshi; Kazumi, Ken-Ichiro; Kaneko, Mitsunori; Mori, Takahiko

2006-04-01

This study is retrospective cohort study of data on vocal cord paralysis after aortic arch surgery collected during 14 years at a general hospital. We investigated factors in the development of vocal cord paralysis after aortic arch surgery and the effect of vocal cord paralysis on clinical course and outcome. We reviewed data for 182 patients who underwent aortic arch surgery for aortic arch aneurysm and aortic dissection between 1989 and 2003, of whom 58 patients had proximal aortic repair, 62 had distal arch repair, and 62 had total arch repair. We assessed factors associated with the development of vocal cord paralysis and examined in detail the clinical outcome of patients with vocal cord paralysis. Postoperative vocal cord paralysis occurred in 40 patients. Multiple logistic regression analysis revealed the following risk factors with odds ratios (OR) for vocal cord paralysis: extension of procedures into distal arch (OR, 17.0), chronic dilatation of the aorta at the left subclavian artery (OR, 9.14), and total arch repair (OR, 4.24). Adoption of open-style stent-grafts reduced the incidence of vocal cord paralysis (OR, 0.031). The postoperative occurrence of vocal cord paralysis itself emerges as an independent predictor of pulmonary complications (OR, 4.12) and leads to a longer duration of hospital stay. The risk of vocal cord paralysis after aortic arch surgery depends on surgical factors, such as aneurysmal involvement of the distal arch, or the application of newer, less invasive surgical procedures. Vocal cord paralysis after aortic arch surgery itself, under aggressive postoperative respiratory management, did not increase aspiration pneumonia but was associated with postoperative complications leading to higher hospital mortality and prolonged hospitalization.

Impact of preoperative regular physical activity on postoperative course after open abdominal aortic aneurysm surgery.

PubMed

Hayashi, Kazuhiro; Hirashiki, Akihiro; Kodama, Akio; Kobayashi, Kiyonori; Yasukawa, Yuto; Shimizu, Miho; Kondo, Takahisa; Komori, Kimihiro; Murohara, Toyoaki

2016-04-01

Early ambulation after open abdominal aortic aneurysm (AAA) surgery is assumed to play a key role in preventing postoperative complications and reducing hospital length of stay. However, the factors predicting early ambulation after open AAA surgery have not yet been sufficiently investigated. Here, we investigated which preoperative and intraoperative variables are associated with start time for ambulation in patients after open AAA surgery. A total of 67 consecutive patients undergoing open AAA surgery were included in the study [male, 62 (92 %); mean age, 68 years (range, 47-82 years), mean AAA diameter, 53 mm (range, 28-80 mm)]. Preoperative physical activity was examined by means of 6-min walk distance (6MWD) and a medical interview. Patients were divided into two groups, according to when independence in walking was attained: early group <3 days (n = 36) and late group ≥3 days (n = 31), and the pre-, intra-, and postoperative recovery data were compared. There were no significant differences in patient baseline characteristics or intraoperative data between the two groups. The number of patients engaging in preoperative regular physical activity and 6MWD were significantly greater (p = 0.042 and p = 0.034, respectively) in the early group than in the late group. In addition, time to hospital discharge was significantly shorter in the early group than in the late group (p = 0.031). Binary logistic regression analysis showed that preoperative regular physical activity was the only independent factor for identifying patients in the early group (odds ratio 2.769, 95 % confidence interval 1.024-7.487, p = 0.045). These results suggest that engaging in regular physical activity is an effective predictor of early ambulation after open AAA surgery.

Attitude towards one's illness vs. attitude towards a surgical operation, displayed by patients diagnosed with asymptomatic abdominal aortic aneurysm and asymptomatic internal carotid artery stenosis.

PubMed

Stanisić, M; Rzepa, T

2012-08-01

Two most frequent asymptomatic diseases qualifying for vascular surgery are abdominal aortic aneurysm (AAA) and internal carotid artery stenosis (ICAS). Emotions experienced by the patient activate processes of dealing with the cognitive dissonance of asymptomatic disease. The aim of this paper was to compare the reasons involved in decision making on surgery in two asymptomatic vascular pathologies. Fifty patients were divided into two groups: the ICAS group-27 (CAS or CEA) and the AAA group-23 (EVAR or open surgical operation (OSR). Specific questionnaire regarding: 1) self-image; 2) attitude to one's illness; 3) reasons for decision on surgery was applied for the study. The χ² test was used to for the analysis. The AAA patients reacted emotionally (88.2%) comparing to ICAS patients reacting "rationally" (59.3%) (α=0.05). In AAA patients attitude towards themselves had worsened (α=0.001) AAA patients were less likely to seek support in decision on surgery (α=0.01). ICAS patients are internally motivated (78.7%), whereas AAA patients are externally motivated (63.9%) (α=0.001). Reasons underlying the decision on surgery, were predominantly rational (55.8%). In the process of decision-making on surgery by asymptomatic patients, evolutionary transformation takes place - the emotional attitude to one's illness leads to rationally evaluated decision. Regardless of the causes the process of making a decision on surgical operation tended to run more smoothly in ICAS patients. The ICAS patients tended to display a rational attitude to their illness. AAA patients displayed a distinctly emotional attitude towards their illness.

Sherlock Holmes in the ER (the case of red and the head).

PubMed

Bendo, Edlira; Gilbert, Molly; Chavis, Pamela; Mistr, Susannah

2009-01-01

A 58-year-old woman presented with a problem with her peripheral vision. Computed tomography scan showed an occipital hemorrhagic stroke. She subsequently suffered gastrointestinal bleeding and at surgery biopsy of a portion of the middle colic artery aneurysm revealed changes consistent with polyarteritis nodosa.

Preoperative prediction of intensive care unit stay following cardiac surgery.

PubMed

De Cocker, Jeroen; Messaoudi, Nouredin; Stockman, Bernard A; Bossaert, Leo L; Rodrigus, Inez E R

2011-01-01

Following cardiac surgery, a great variety in intensive care unit (ICU) stay is observed, making it often difficult to adequately predict ICU stay preoperatively. Therefore, a study was conducted to investigate, which preoperative variables are independent risk factors for a prolonged ICU stay and whether a patient's risk of experiencing an extended ICU stay can be estimated from these predictors. The records of 1566 consecutive adult patients who underwent cardiac surgery at our institution were analysed retrospectively over a 2-year period. Procedures included in the analyses were coronary artery bypass grafting, valve replacement or repair, ascending and aortic arch surgery, ventricular rupture and aneurysm repair, septal myectomy and cardiac tumour surgery. For this patient group, ICU stay was registered and 57 preoperative variables were collected for analysis. Descriptives and log-rank tests were calculated and Kaplan-Meier curves drawn for all variables. Significant predictors in the univariate analyses were included in a Cox proportional hazards model. The definitive model was validated on an independent sample of 395 consecutive adult patients who underwent cardiac surgery at our institution over an additional 6-month period. In this patient group, the accuracy and discriminative abilities of the model were evaluated. Twelve independent preoperative predictors of prolonged ICU stay were identified: age at surgery>75 years, female gender, dyspnoea status>New York Heart Association class II (NYHA II), unstable symptoms, impaired kidney function (estimated glomerular filtration rate (eGFR)<60 ml min(-1)), extracardiac arterial disease, presence of arrhythmias, mitral insufficiency>colour flow mapping (CFM) grade II, inotropic support, intra-aortic balloon pumping (IABP), non-elective procedures and aortic surgery. The individual effect of every predictor on ICU stay was quantified and inserted into a mathematical algorithm (called the Morbidity Defining Cardiosurgical (MDC) index), making it possible to calculate a patient's risk of having an extended ICU stay. The model showed very good calibration and very good to excellent discriminative ability in predicting ICU stay >2, >5 and >7 days (C-statistic of 0.78; 0.82 and 0.85, respectively). Twelve independent preoperative risk factors for a prolonged ICU stay following cardiac surgery were identified and constructed into a proportional hazards model. Using this risk model, one can predict whether a patient will have a prolonged ICU stay or not. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

A deleterious gene-by-environment interaction imposed by calcium channel blockers in Marfan syndrome

PubMed Central

Doyle, Jefferson J; Doyle, Alexander J; Wilson, Nicole K; Habashi, Jennifer P; Bedja, Djahida; Whitworth, Ryan E; Lindsay, Mark E; Schoenhoff, Florian; Myers, Loretha; Huso, Nick; Bachir, Suha; Squires, Oliver; Rusholme, Benjamin; Ehsan, Hamid; Huso, David; Thomas, Craig J; Caulfield, Mark J; Van Eyk, Jennifer E; Judge, Daniel P; Dietz, Harry C

2015-01-01

Calcium channel blockers (CCBs) are prescribed to patients with Marfan syndrome for prophylaxis against aortic aneurysm progression, despite limited evidence for their efficacy and safety in the disorder. Unexpectedly, Marfan mice treated with CCBs show accelerated aneurysm expansion, rupture, and premature lethality. This effect is both extracellular signal-regulated kinase (ERK1/2) dependent and angiotensin-II type 1 receptor (AT1R) dependent. We have identified protein kinase C beta (PKCβ) as a critical mediator of this pathway and demonstrate that the PKCβ inhibitor enzastaurin, and the clinically available anti-hypertensive agent hydralazine, both normalize aortic growth in Marfan mice, in association with reduced PKCβ and ERK1/2 activation. Furthermore, patients with Marfan syndrome and other forms of inherited thoracic aortic aneurysm taking CCBs display increased risk of aortic dissection and need for aortic surgery, compared to patients on other antihypertensive agents. DOI: http://dx.doi.org/10.7554/eLife.08648.001 PMID:26506064

Hybrid and endovascular therapy for extensive thoracoabdominal aortic disease.

PubMed

Riga, Celia V; Bicknell, Colin D; Cheshire, Nicholas J W

2010-12-01

The past 4 decades have witnessed tremendous strides in the evolution of endovascular technology with increased operator experience, greater availability of more sophisticated and versatile endovascular devices, and advances in imaging modalities. In an attempt to limit the physiologic derangements associated with aortic crossclamping and extensive tissue dissection during traditional open surgical repair of extensive thoracoabdominal aortic aneurysms, less invasive strategies have been explored using endovascular technology: hybrid approaches and solely endovascular techniques. This article describes these techniques and their advantages, their current role in thoracoabdominal aortic aneurysm repair and potential future developments in this field. Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Pontine infarction caused by medial branch injury of the basilar artery as a rare complication of cisternal drain placement.

PubMed

Horiuchi, Tetsuyoshi; Yamamoto, Yasunaga; Kuroiwa, Masafumi; Rahmah, Nunung Nur; Hongo, Kazuhiro

2012-04-01

We present a rare complication of cisternal drain placement during aneurysm surgery. A ruptured anterior communicating artery aneurysm was clipped through a right pterional approach. A cisternal drain was inserted from the retro-carotid to the prepontine cistern. Postoperatively, a left-sided paresis of the upper extremity had developed. A CT brain scan revealed that the drain was located between the pons and the basilar artery, resulting in a pontine infarction. Vascular neurosurgeons should keep this complication in mind when placing a cisternal drain tube. The drain tube should not be inserted too deep into the prepontine cistern. Copyright © 2011 Elsevier Ltd. All rights reserved.

Initial clinical experience with a sac-anchoring endoprosthesis for aortic aneurysm repair.

PubMed

Donayre, Carlos E; Zarins, Christopher K; Krievins, Dainis K; Holden, Andrew; Hill, Andrew; Calderas, Carlos; Velez, Jaime; White, Rodney A

2011-03-01

All current aortic endografts depend on proximal and distal fixation to prevent migration. However, migration and rupture can occur, particularly in patients with aortic necks that are short or angulated, or both. We present our initial clinical experience with a new sac-anchoring endoprosthesis designed to anchor and seal the device within the aneurysm sac. The initial worldwide experience using a new endoprosthesis for the treatment of aortic aneurysms (Nellix Endovascular, Palo Alto, Calif) was reviewed. The endoprosthesis consists of dual balloon-expandable endoframes surrounded by polymer-filled endobags designed to obliterate the aneurysm sac and maintain endograft position. Clinical results and follow-up contrast computed tomography (CT) scans at 30 days and 6 and 12 months were reviewed. The endograft was successfully deployed in 21 patients with infrarenal aortic aneurysms measuring 5.7 ± 0.7 cm (range, 4.3-7.4 cm). Two patients with common iliac aneurysms were treated with sac-anchoring extenders that maintained patency of the internal iliac artery. Infusion of 71 ± 37 mL of polymer (range, 19-158 mL) into the aortic endobags resulted in complete aneurysm exclusion in all patients. Mean implant time was 76 ± 35 minutes, with 33 ± 17 minutes of fluoroscopy time and 180 ± 81 mL of contrast; estimated blood loss was 174 ± 116 mL. One patient died during the postoperative period (30-day mortality, 4.8%), and one died at 10 months from non-device-related causes. During a mean follow-up of 8.7 ± 3.1 months and a median of 6.3 months, there were no late aneurysm- or device-related adverse events and no secondary procedures. CT imaging studies at 6 months and 1 year revealed no increase in aneurysm size, no device migration, and no new endoleaks. One patient had a limited proximal type I endoleak at 30 days that resolved at 60 days and remained sealed. One patient has an ongoing distal type I endoleak near the iliac bifurcation, with no change in aneurysm size at 12 months. Initial clinical experience with this novel intrasac anchoring prosthesis is promising, with successful aneurysm exclusion and good short-term results. This new device platform has the potential to address the anatomic restrictions and limitations of current endografts. Further studies with a longer follow-up time are needed. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Society of Thoracic Surgeons 2008 cardiac risk models predict in-hospital mortality of heart valve surgery in a Chinese population: a multicenter study.

PubMed

Wang, Lv; Lu, Fang-Lin; Wang, Chong; Tan, Meng-Wei; Xu, Zhi-yun

2014-12-01

The Society of Thoracic Surgeons 2008 cardiac surgery risk models have been developed for heart valve surgery with and without coronary artery bypass grafting. The aim of our study was to evaluate the performance of Society of Thoracic Surgeons 2008 cardiac risk models in Chinese patients undergoing single valve surgery and the predicted mortality rates of those undergoing multiple valve surgery derived from the Society of Thoracic Surgeons 2008 risk models. A total of 12,170 patients underwent heart valve surgery from January 2008 to December 2011. Combined congenital heart surgery and aortal surgery cases were excluded. A relatively small number of valve surgery combinations were excluded. The final research population included the following isolated heart valve surgery types: aortic valve replacement, mitral valve replacement, and mitral valve repair. The following combined valve surgery types were included: mitral valve replacement plus tricuspid valve repair, mitral valve replacement plus aortic valve replacement, and mitral valve replacement plus aortic valve replacement and tricuspid valve repair. Evaluation was performed by using the Hosmer-Lemeshow test and C-statistics. Data from 9846 patients were analyzed. The Society of Thoracic Surgeons 2008 cardiac risk models showed reasonable discrimination and poor calibration (C-statistic, 0.712; P = .00006 in Hosmer-Lemeshow test). Society of Thoracic Surgeons 2008 models had better discrimination (C-statistic, 0.734) and calibration (P = .5805) in patients undergoing isolated valve surgery than in patients undergoing multiple valve surgery (C-statistic, 0.694; P = .00002 in Hosmer-Lemeshow test). Estimates derived from the Society of Thoracic Surgeons 2008 models exceeded the mortality rates of multiple valve surgery (observed/expected ratios of 1.44 for multiple valve surgery and 1.17 for single valve surgery). The Society of Thoracic Surgeons 2008 cardiac surgery risk models performed well when predicting the mortality for Chinese patients undergoing valve surgery. The Society of Thoracic Surgeons 2008 models were suitable for single valve surgery in a Chinese population; estimates of mortality for multiple valve surgery derived from the Society of Thoracic Surgeons 2008 models were less accurate. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Retrograde cerebral perfusion as an adjunct to prolonged hypothermic circulatory arrest.

PubMed

Esmailian, F; Dox, H; Sadeghi, A; Eghbali, K; Laks, H

1999-10-01

This study was designed to evaluate the use of retrograde cerebral perfusion (RCP) combined with deep hypothermic circulatory arrest (DHCA) in the treatment of complex congenital and adult cardiac disease. Retrospective chart review of 52 cardiac surgery patients (34 male and 18 female; age range, 3 weeks to 89 years old; mean age, 60 years old) who received RCP in conjunction with DHCA from July 1991 through August 1998. Surgical procedures consisted of the following: (1) repair of ascending aortic aneurysms (n = 16); (2) repair of type A aortic dissection (n = 16); (3) repair of arch aneurysms (n = 10); (4) renal cell carcinoma with tumor extension to the inferior vena cava (IVC) and right atrium (n = 5); (6) coronary artery bypass grafting and concomitant aortic valve replacement with calcified aorta (n = 2); (7) Norwood procedure and take down of a Pott's shunt (n = 2); and (8) massive air embolism treatment (n = 1). Mean RCP time was 39 min (range, 3 to 88 min). Thirteen patients had RCP times > 60 min. Mean core temperature (rectal or bladder) was 19 degrees C (range, 15 degrees to 28 degrees C). There were six early deaths, four of which were related to persistent low-output cardiac failure, and two resulted from perioperative stroke. All remaining patients recovered fully without neurologic deficits. RCP is a reliable and technically appealing tool that does the following: (1) it improves DHCA safety and is applicable in a variety of clinical settings with relative ease; (2) it potentially provides oxygen and nutritional support to the brain during DHCA; (3) it helps remove air and other debris from the cerebral vessels; and (4) it is useful in dealing with congenital heart disease and tumor extension into the IVC.

Real-time surgery simulation of intracranial aneurysm clipping with patient-specific geometries and haptic feedback

NASA Astrophysics Data System (ADS)

Fenz, Wolfgang; Dirnberger, Johannes

2015-03-01

Providing suitable training for aspiring neurosurgeons is becoming more and more problematic. The increasing popularity of the endovascular treatment of intracranial aneurysms leads to a lack of simple surgical situations for clipping operations, leaving mainly the complex cases, which present even experienced surgeons with a challenge. To alleviate this situation, we have developed a training simulator with haptic interaction allowing trainees to practice virtual clipping surgeries on real patient-specific vessel geometries. By using specialized finite element (FEM) algorithms (fast finite element method, matrix condensation) combined with GPU acceleration, we can achieve the necessary frame rate for smooth real-time interaction with the detailed models needed for a realistic simulation of the vessel wall deformation caused by the clamping with surgical clips. Vessel wall geometries for typical training scenarios were obtained from 3D-reconstructed medical image data, while for the instruments (clipping forceps, various types of clips, suction tubes) we use models provided by manufacturer Aesculap AG. Collisions between vessel and instruments have to be continuously detected and transformed into corresponding boundary conditions and feedback forces, calculated using a contact plane method. After a training, the achieved result can be assessed based on various criteria, including a simulation of the residual blood flow into the aneurysm. Rigid models of the surgical access and surrounding brain tissue, plus coupling a real forceps to the haptic input device further increase the realism of the simulation.

Dutch experience with the fenestrated Anaconda endograft for short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair.

PubMed

Dijkstra, Martijn L; Tielliu, Ignace F J; Meerwaldt, Robbert; Pierie, Maurice; van Brussel, Jerome; Schurink, Geert Willem H; Lardenoye, Jan-Willem; Zeebregts, Clark J

2014-08-01

In the past decennium, the management of short-neck infrarenal and juxtarenal aortic aneurysms with fenestrated endovascular aneurysm repair (FEVAR) has been shown to be successful, with good early and midterm results. Recently, a new fenestrated device, the fenestrated Anaconda (Vascutek, Renfrewshire, Scotland), was introduced. The aim of this study was to present the current Dutch experience with this device. A prospectively held database of patients treated with the fenestrated Anaconda endograft was analyzed. Decision to treat was based on current international guidelines. Indications for FEVAR included an abdominal aortic aneurysm (AAA) with unsuitable neck anatomy for EVAR. Planning was performed on computed tomography angiography images using a three-dimensional workstation. Between May 2011 and September 2013, 25 patients were treated in eight institutions for juxtarenal (n = 23) and short-neck AAA (n = 2). Median AAA size was 61 mm (59-68.5 mm). All procedures except one were performed with bifurcated devices. A total of 56 fenestrations were incorporated, and 53 (94.6%) were successfully cannulated and stented. One patient died of bowel ischemia caused by occlusion of the superior mesenteric artery. On completion angiography, three type I endoleaks and seven type II endoleaks were observed. At 1 month of follow-up, all endoleaks had spontaneously resolved. Median follow-up was 11 months (range, 1-29 months). There were no aneurysm ruptures or aneurysm-related deaths and no reinterventions to date. Primary patency at 1 month of cannulated and stented target vessels was 96%. Initial and short-term results of FEVAR using the fenestrated Anaconda endograft are promising, with acceptable technical success and short-term complication rates. Growing experience and long-term results are needed to support these findings. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

A review of the surgical management of right-sided aortic arch aneurysms

PubMed Central

Barr, James G.; Sepehripour, Amir H.; Jarral, Omar A.; Tsipas, Pantelis; Kokotsakis, John; Kourliouros, Antonios; Athanasiou, Thanos

2016-01-01

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques. PMID:27001673

Bilateral multiple pulmonary artery aneurysms associated with cavitary pulmonary tuberculosis: a case report.

PubMed

Pallangyo, Pedro; Lyimo, Frederick; Bhalia, Smita; Makungu, Hilda; Nyangasa, Bashir; Lwakatare, Flora; Suranyi, Pal; Janabi, Mohamed

2017-07-19

Pulmonary artery aneurysms constitute <1% of aneurysms occurring in the thoracic cavity. Congenital cardiac defects are responsible for the majority (>50%) of cases, however, pulmonary artery aneurysm is a rare sequelae of pulmonary tuberculosis reported in about 5% of patients with chronic cavitary tuberculosis on autopsy. The natural history of this potentially fatal condition remains poorly understood and guidelines for optimal management are controversial. A 24-year-old man, a nursing student of African descent, was referred to us from an up-country regional hospital with a 4-week history of recurrent episodes of breathlessness, awareness of heartbeats and coughing blood 3 weeks after completing a 6-month course of anti-tuberculosis drugs. A physical examination revealed conjuctival and palmar pallor but there were no stigmata of connective tissue disorders, systemic vasculitides or congenital heart disease. An examination of the cardiovascular system revealed accentuated second heart sound (S 2 ) with early diastolic (grade 1/6) and holosystolic (grade 2/6) murmurs at the pulmonic and tricuspid areas respectively. Blood tests showed iron deficiency anemia, prolonged bleeding time, and mild hyponatremia. A chest radiograph revealed bilateral ovoid-shaped perihilar opacities while a computed tomography scan showed bilateral multiple pulmonary artery pseudoaneurysms with surrounding hematoma together with adjacent cystic changes, consolidations, and tree-in-bud appearance. Our patient refused to undergo surgery and died of aneurismal rupture after 9 days of hospitalization. The presence of intractable hemoptysis among patients with tuberculosis even after completion of anti-tuberculosis course should raise an index of suspicion for pulmonary artery aneurysm. Furthermore, despite of its rarity, early recognition and timely surgical intervention of pulmonary artery aneurysm is crucial to reducing morbidity and preventing the attributed mortality.

Assessment of failure to rescue after abdominal aortic aneurysm repair using the National Surgical Quality Improvement Program procedure-targeted data set.

PubMed

Dakour-Aridi, Hanaa; Paracha, Nawar Z; Locham, Satinderjit; Nejim, Besma; Malas, Mahmoud B

2018-05-18

Open aortic repair (OAR) is associated with higher risk of mortality compared with endovascular aneurysm repair (EVAR). The aim of this study was to compare failure to rescue (FTR) after major predischarge complications in patients undergoing OAR and EVAR. Patients who underwent OAR or EVAR in the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2015 were selected. Patients with ruptured aneurysm and those with type IV thoracoabdominal aneurysms were excluded. The primary outcome was FTR, defined as 30-day mortality in patients who developed at least one complication during their hospital stay. Univariable and multivariable statistics were used. A total of 9097 patients underwent abdominal aortic aneurysm repair. Of those, 3291 (36.2%) had at least one major predischarge complication, 82.5% after OAR (95% confidence interval [CI], 80.9%-84.1%) vs 21.3% after EVAR (95% CI, 20.4%-22.3%; P < .001). Increased FTR was seen after aneurysm rupture, cardiac arrest, septic shock, and acute kidney injury. On multivariable analysis, FTR was not significantly different between OAR and EVAR (adjusted odds ratio, 0.87; 95% CI, 0.61-1.24; P = .44). Propensity score matching and coarsened exact matching showed similar results. Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after major predischarge complications does not depend on the type of surgical approach. When an in-hospital major complication occurs after EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to that of OAR. Therefore, there is no safety net with EVAR. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: the Karolinska approach.

PubMed

Sartipy, Ulrik; Albåge, Anders; Insulander, Per; Lindblom, Dan

2007-09-01

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Outcomes of persistent intraoperative type Ia endoleak after standard endovascular aneurysm repair.

PubMed

Millen, Alistair M; Osman, Khabab; Antoniou, George A; McWilliams, Richard G; Brennan, John A; Fisher, Robert K

2015-05-01

This study analyzed outcomes for patients with persistent intraoperative type Ia endoleaks after standard endovascular aneurysm repair (EVAR). The study group was identified from a consecutive cohort of 209 patients undergoing EVAR in a tertiary center in the United Kingdom during a 2-year period. Data prospectively collected on departmental computerized databases were retrospectively analyzed. Primary outcome parameters were defined as freedom from type Ia endoleak, EVAR-related reintervention, aneurysm rupture, and aneurysm-related mortality. A completion angiogram identified 44 patients (21%) as having a type Ia endoleak, and 33 (75%) had a persistent endoleak after intraoperative adjunctive procedures, including repeated balloon moulding, aortic cuff extension, and Palmaz stent (Cordis, Miami Lakes, Fla) deployment. In the 11 patients (25%) whose endoleak was successfully abolished intraoperatively, there was no recurrence of type Ia endoleak or secondary intervention to treat type 1a endoleak during a median follow-up period of 27 months. Of the 33 patients with persistent endoleak, 31 (94%) demonstrated resolution of the endoleak on first surveillance computed tomography angiography. One patient was lost to follow-up. Embolization of the endoleak in another patient was successful using Onyx (Micro Therapeutics, Inc, Irvine, Calif) 8 days after the initial procedure. No type Ia endoleak was identified after this on any surveillance imaging, and the patient was alive 28 months later with a stable aneurysm size. In the rest of the patients, no recurrence of the endoleak in any subsequent imaging was noticed, and no secondary intervention was required during follow-up. No aneurysm-related deaths occurred, and 91% of the patients had a stable or shrinking aneurysm. Despite adjunctive intraoperative maneuvers, persistent type Ia endoleaks can be relatively common. Our study indicates that they may be observed in selected patients. Further research is required to investigate the natural course and management of type Ia endoleaks identified intraoperatively. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Comparison of endovascular repair with branched stent graft and open repair for aortic arch aneurysm.

PubMed

Kawatou, Masahide; Minakata, Kenji; Sakamoto, Kazuhisa; Nakatsu, Taro; Tazaki, Junichi; Higami, Hirooki; Uehara, Kyokun; Yamazaki, Kazuhiro; Inoue, Kanji; Kimura, Takeshi; Sakata, Ryuzo

2017-08-01

Although conventional open repair is our preference for patients with aortic arch aneurysms, we have often chosen thoracic endovascular aneurysm repair (TEVAR) with a handmade branched stent graft (bTEVAR) in high-risk patients. The aim of this study was to compare the midterm clinical outcomes of our bTEVAR technique to those of the open repair. Between January 2007 and December 2014, we treated 129 patients with aortic arch aneurysm by means of either conventional open repair (OPEN, n = 61) or bTEVAR (n = 68) at our institution. The mean ages were 70.5 ± 12.7 years in the OPEN group and 72.7 ± 12.5 years in the bTEVAR group (P = 0.32). The aetiologies included true aneurysm in 101 patients (78.3%) and chronic dissection in 26 (20.1%). There were 2 (3.3%) in-hospital deaths in the OPEN group and 3 (4.4%) in the bTEVAR group. The mean follow-up duration was 3.0 ± 2.1 years (2.4 ± 1.9 years in the OPEN group and 3.6 ± 2.3 years in the bTEVAR group). There was no difference in 5-year aneurysm-related mortality between groups (10.7% in OPEN vs 12.8% in bTEVAR, P = 0.50). In terms of late additional procedures, however, none were required in the OPEN group, whereas 10 (15.4%) additional endovascular repairs and 4 (6.2%) open repairs were required in the bTEVAR group. Our bTEVAR could be performed with low early mortality, and it yielded similar midterm aneurysm-related mortality to that of conventional open repair. However, these patients undergoing this technique required more late additional procedures than those undergoing conventional open repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Comparison of open and endovascular repair of inflammatory aortic aneurysms.

PubMed

Stone, William M; Fankhauser, Grant T; Bower, Thomas C; Oderich, Gustavo S; Oldenburg, W Andrew; Kalra, Manju; Naidu, Sailendra; Money, Samuel R

2012-10-01

Inflammatory abdominal aortic aneurysms (IAAAs) have been traditionally managed with open repair. Endovascular aneurysm repair (EVAR) was approved September of 1999. Some authors have suggested that EVAR is not an acceptable option for management of an IAAA. However, several recent reports have suggested EVAR is a reasonable management option in these patients. The purpose of our study was to review our experience with the contemporary management of IAAA involving both open and endovascular approaches. A retrospective review of all patients undergoing repair of IAAAs from 1999 to 2011 was conducted at three geographically separate institutions. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. Between 1999 and 2011, 69 patients underwent surgical repair of IAAAs, 59 by open repair and 10 by EVAR. Eighty-three percent of patients were men with a mean age of 67. Aneurysm size was similar in both groups (6.3 cm open repair vs 5.9 cm EVAR). Follow-up for the open group was a mean of 42.6 months and 33.6 months for the EVAR group. Periaortic fibrosis decreased from a mean of 5.4 mm to 2.7 mm after EVAR. Hydronephrosis was present preoperatively in one patient and did not change after EVAR. Aneurysm size decreased in seven patients (70%) who underwent EVAR. Two patients had no change with one lost to follow-up. Mean aneurysm size decrease after EVAR was 1.12 cm (17.8%). There were no aneurysm-related deaths or major morbidities in the EVAR group. Twenty-two patients (37%) in the open surgical group suffered major complications, including myocardial infarction, renal failure, lower extremity amputation, sepsis, and prolonged ventilation. Endovascular repair for IAAA results in successful management with improvement of periaortic inflammation. EVAR should be considered as first-line therapy in which anatomic parameters are favorable. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Respiratory distress after surgery of RVOT pathologies: a word of caution on pseudoaneurysm development.

PubMed

Antal, A Donmez; Cikirikcioglu, M; Myers, P O; Didier, D; Kalangos, A

2010-09-01

Pseudoaneurysm of the right ventricle outflow tract (RVOT) is a rare complication in pediatric cardiac surgery. We report a patient who developed a right ventricular pseudoaneurysm 8 months after RVOT enlargement using a pericardial patch for infundibular pulmonary stenosis. Our patient was born with severe pulmonary valvular stenosis and treated with percutaneous balloon valvotomy in the neonatal period. Six months later, she developed infundibular pulmonary stenosis, which required surgical resection of right ventricle infundibular trabeculations and bovine pericardial patch enlargement. The postoperative period was normal. She was readmitted to hospital 5 months later complaining of wheezing, coughing and shortness of breath. Echocardiography showed a huge aneurysmal dilatation of the outflow patch in connection with the right ventricular cavity. The patient underwent resection of the pseudoaneurysm and former patch, followed by interposition of a bovine jugular vein conduit between the RVOT and pulmonary bifurcation. The early postoperative period was uncomplicated. On echocardiography, no significant residual gradient was measured through the conduit and there was no insufficiency of the valve. RVOT reconstruction with patch enlargement, homograft or conduit implantation can be the origin of pseudoaneurysms. Although their incidence is rare, they are often asymptomatic before becoming quite large and causing compression symptoms as in our patient with respiratory complaints due to airway compression. It is important to follow up these patients closely, especially in the first year after surgery since most aneurysms develop within 6 months of surgery. Georg Thieme Verlag KG Stuttgart, New York.

Rupture after Previous Endovascular Aneurysm Repair due to Type IA Endoleak: Complete Endograft Preservation Is Feasible with Proximal Suturing, Aortic Neck Banding, and Sac Plication.

PubMed

Karkos, Christos D; Mitka, Maria; Pliatsios, Ioannis; Xanthopoulou, Efthalia; Giagtzidis, Ioakeim T; Papadimitriou, Christina T; Papazoglou, Konstantinos O

2018-05-01

Rupture of an abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) may require endograft explantation and replacement with a prosthetic surgical graft. Recent reports have suggested that total endograft removal during late surgical conversion in the nonruptured setting may not be necessary and that preserving functional parts of the endograft may improve results. Similar techniques may be used for ruptured cases diminishing the magnitude of an already difficult and complex procedure. We describe the successful treatment of a ruptured AAA after previous EVAR with complete endograft preservation by combining transmural endograft fixation with sutures, proximal aortic neck banding, and sac plication. Copyright © 2018 Elsevier Inc. All rights reserved.

The effect of surgeon specialization on outcomes after ruptured abdominal aortic aneurysm repair.

PubMed

Hawkins, Alexander T; Smith, Ann D; Schaumeier, Maria J; de Vos, Marit S; Hevelone, Nathanael D; Nguyen, Louis L

2014-09-01

Although mortality after elective abdominal aortic aneurysm (AAA) repair has steadily declined, operative mortality for a ruptured AAA (rAAA) remains high. Repair of rAAA at hospitals with a higher elective aneurysm workload has been associated with lower mortality rates irrespective of the mode of treatment. This study sought to determine the association between surgeon specialization and outcomes after rAAA repair. The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2010 was used to examine the 30-day mortality and morbidity outcomes of patients undergoing rAAA repair by vascular and general surgeons. Multivariable logistic regression analysis was performed for each death and morbidity, adjusting for all independently predictive preoperative risk factors. Survival curves were compared using the log-rank test. We identified 1893 repairs of rAAAs, of which 1767 (96.1%) were performed by vascular surgeons and 72 (3.9%) were performed by general surgeons. There were no significant differences between patients operated on by general vs vascular surgeons in preoperative risk factors or method of repair. Overall 30-day mortality was 34.3% (649 of 1893). After risk adjustment, mortality was significantly lower in the vascular surgery group compared with the general surgery group (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.86; P = .011). The risk of returning to the operating room (OR, 0.58; 95% CI, 0.35-0.97; P = .038), renal failure (OR, 0.54; 95% CI, 0.31-0.95; P = .034), and a cardiac complication (OR, 0.53; 95% CI, 0.28-0.99; P = .047) were all significantly less in the vascular surgery group. Despite similar preoperative risk factors profiles, patients who were operated on by vascular surgeons had lower mortality, less frequent returns to the operating room, and decreased incidences of postoperative renal failure and cardiac events. These data add weight to the case for further centralization of vascular services. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Maximal aortic diameter affects outcome after endovascular repair of abdominal aortic aneurysms.

PubMed

Huang, Ying; Gloviczki, Peter; Duncan, Audra A; Kalra, Manju; Oderich, Gustavo S; Fleming, Mark D; Harmsen, William S; Bower, Thomas C

2017-05-01

The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Clinical data of patients undergoing EVAR between 1997 and 2011 for nonruptured asymptomatic AAAs in a tertiary center were reviewed. Patients were classified according to diameter of AAA: group 1, <5.0 cm; group 2, 5.0 to 5.4 cm; group 3, 5.5 to 5.9 cm; and group 4, ≥6.0 cm. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, and ruptures. There were 874 patients studied (female, 108 [12%]; group 1, 119; group 2, 246; group 3, 243; group 4, 266); mean age was 76 ± 7.2 years. The 30-day mortality rate was 1.0%, not significantly different between groups (P = .22); complication and reintervention rates were 13% and 4.1%, respectively, similar between groups (P < .05). Five-year survival was 68%; freedom from complications and reinterventions was 65% and 74%, respectively; rupture rate was 0.5%. Multivariate analysis revealed that factors associated with all-cause mortality included maximal aortic diameter, age, gender, surgical risk, cancer history, and endograft type (P < .05). Group 4 had increased risks of mortality (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.38-2.85; P = .002) and complications (HR, 1.6; 95% CI, 1.2-2.7; P = .009) relative to group 1. Reinterventions were more frequent for aneurysms ≥6.0 cm (HR, 2.0; 95% CI, 1.2-3.3; P = .01). Late rupture rate after EVAR was not different between groups. Maximal aortic diameter is associated with long-term outcomes after elective EVAR. Patients with large AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR than those with smaller aneurysms. We continue to recommend that AAAs be repaired when they reach 5.5 cm as recommended by the guidelines of the Society for Vascular Surgery. On the basis of our data, EVAR should be considered even in high-risk patients with a maximal aortic diameter between 5.5 and 6.0 cm because surgical risk with aneurysm size above 6.0 cm will increase significantly. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Hip Replacement Surgery

MedlinePlus

... Download Download EPUB Download PDF What is it? Points To Remember About Hip Replacement Surgery Hip replacement ... This leaves your hands and arms free for balance or to use crutches. Use a long-handled " ...

Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study.

PubMed

Tam, Greta; Chan, Yiu Che; Chong, Ka Chun; Lee, Kam Pui; Cheung, Grace Chung-Yan; Cheng, Stephen Wing-Keung

2018-03-01

The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3-37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.

Intrasylvian/Intracerebral Hematomas Associated with Ruptured Middle Cerebral Artery Aneurysms: A Single-Center Series and Literature Review.

PubMed

Zhang, Yupeng; Hu, Quan; Xue, Hao; Zhang, Mingran; Shen, Jie; Deng, Lin; Liu, Qinglin; Li, Gang

2017-02-01

Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH. Copyright © 2016 Elsevier Inc. All rights reserved.

Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures.

PubMed

Price, Joel; Magruder, J Trent; Young, Allen; Grimm, Joshua C; Patel, Nishant D; Alejo, Diane; Dietz, Harry C; Vricella, Luca A; Cameron, Duke E

2016-02-01

Prophylactic aortic root replacement improves survival in patients with Marfan syndrome with aortic root aneurysms, but the optimal procedure remains undefined. Adult patients with Marfan syndrome who had Bentall or aortic valve-sparing root replacement (VSRR) procedures between 1997 and 2013 were identified. Comprehensive follow-up information was obtained from hospital charts and telephone contact. One hundred sixty-five adult patients with Marfan syndrome (aged > 20 years) had either VSRR (n = 98; 69 reimplantation, 29 remodeling) or Bentall (n = 67) procedures. Patients undergoing Bentall procedure were older (median, 37 vs 36 years; P = .03), had larger median preoperative sinus diameter (5.5 cm vs 5.0 cm; P = .003), more aortic dissections (25.4% vs 4.1%; P < .001), higher incidence of moderate or severe aortic insufficiency (49.3% vs 14.4%; P < .001) and more urgent or emergent operations (24.6% vs 3.3%; P < .001). There were no hospital deaths and 9 late deaths in more than 17 years of follow-up (median, 7.8 deaths). Ten-year survival was 90.5% in patients undergoing Bentall procedure and 96.3% in patients undergoing VSRR (P = .10). Multivariable analysis revealed that VSRR was associated with fewer thromboembolic or hemorrhagic events (hazard ratio, 0.16; 95% confidence interval, 0.03-0.85; P = .03). There was no independent difference in long-term survival, freedom from reoperation, or freedom from endocarditis between the 2 procedures. After prophylactic root replacement in patients with Marfan syndrome, patients undergoing Bentall and valve-sparing procedures have similar late survival, freedom from root reoperation, and freedom from endocarditis. However, valve-sparing procedures result in significantly fewer thromboembolic and hemorrhagic events. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Glutathione system participation in thoracic aneurysms from patients with Marfan syndrome.

PubMed

Zúñiga-Muñoz, Alejandra María; Pérez-Torres, Israel; Guarner-Lans, Verónica; Núñez-Garrido, Elías; Velázquez Espejel, Rodrigo; Huesca-Gómez, Claudia; Gamboa-Ávila, Ricardo; Soto, María Elena

2017-05-01

Aortic dilatation in Marfan syndrome (MFS) is progressive. It is associated with oxidative stress and endothelial dysfunction that contribute to the early acute dissection of the vessel and can result in rupture of the aorta and sudden death. We evaluated the participation of the glutathione (GSH) system, which could be involved in the mechanisms that promote the formation and progression of the aortic aneurysms in MFS patients. Aortic aneurysm tissue was obtained during chest surgery from eight control subjects and 14 MFS patients. Spectrophotometrical determination of activity of glutathione peroxidase (GPx), glutathione-S-transferase (GST), glutathione reductase (GR), lipid peroxidation (LPO) index, carbonylation, total antioxidant capacity (TAC), and concentration of reduced and oxidized glutathione (GSH and GSSG respectively), was performed in the homogenate from aortic aneurysm tissue. LPO index, carbonylation, TGF-β1, and GR activity were increased in MFS patients (p < 0.04), while TAC, GSH/GSSG ratio, GPx, and GST activity were significantly decreased (p < 0.04). The depletion of GSH, in spite of the elevated activity of GR, not only diminished the activity of GSH-depend GST and GPx, but increased LPO, carbonylation and decreased TAC. These changes could promote the structural and functional alterations in the thoracic aorta of MFS patients.

Long-term results of aortic valve replacement with Edwards Prima Plus stentless bioprosthesis: eleven years' follow up.

PubMed

Auriemma, Stefano; D'Onofrio, Augusto; Brunelli, Massimo; Magagna, Paolo; Paccanaro, Mariemma; Rulfo, Fanny; Fabbri, Alessandro

2006-09-01

The Edwards Lifesciences Prima Plus stentless valve (ELSV) is a bioprosthesis manufactured from a porcine aortic root. The study aim was to evaluate late clinical outcomes after aortic valve replacement (AVR) with ELSV implanted as a miniroot in patients with aortic valve disease. Between 1993 and 2004, 318 patients (232 males, 86 females; mean age 69 +/- 9 years; range: 37-83 years) underwent AVR with the ELSV. Preoperatively, 102 patients (32%), 162 (51%) and 54 (17%) were in NYHA classes I/II, III and IV, respectively. Aortic stenosis, aortic regurgitation and combined lesions were present in 124 patients (39%), 114 (36%) and 41 (13%), respectively. Twenty patients (6%) were referred for an acute aortic dissection, 20 (6%) for an aortic root aneurysm, and 139 (44%) had an associated aneurysmal dilatation of the ascending aorta. The ascending aorta was replaced in 159 patients (50%); aortic arch replacement was required in 10 (3%). Coronary artery bypass graft was performed in 86 patients (27%). The follow up was based on clinical data. Operative mortality was 5% (n = 17). There were 49 late deaths (5.2%/pt-yr). Valve-related mortality occurred in 10 patients (1%/pt-yr). Actuarial survival at five and 10 years was 78% and 33%, respectively. Actuarial freedom from valve reoperation and structural valve deterioration at 10 years were 100% and 64%. Actuarial freedom from embolic events and endocarditis at 10 years were 84% and 81%, respectively. The ELSV, when implanted as a miniroot, provided good early and long-term results in terms of survival and freedom from major complications.

[Acute brain expansion during emergency neck clipping surgery for cerebral aneurysms in a patient with dilated cardiomyopathy].

PubMed

Nakao, M; Kawaguchi, R; Nakatani, K; Niinai, H; Takezaki, T; Hanaki, C

1996-06-01

A 61-year-old male with coma and undiagnosed dilated cardiomyopathy received emergency cerebral aneurysm surgery. Anesthesia was induced with thiamylal, fentanyl and vecuronium and maintained with 66% N2O and 1.0% isoflurane. Five hundred ml of 20% mannitol was infused in 30 min. At the end of the infusion, hypotension occurred. Immediately after the injection of ephedrine, acute brain swelling was observed. The operation was switched to external decompression. Post-operative echocardiography revealed the presence of dilated cardiomyopathy (DCM). The ejection fraction was 34%. Two weeks later, the second operation was scheduled. The anesthesia was induced with fentanyl, midazolam and vecuronium and maintained with N2O and 0.7% isoflurane. Nitroglycerine, lidocaine, PGE1, dopamine and dobutamine were infused throughout the operation. Five hundred ml of 20% mannitol was infused in 60 min. There were no considerable hemodynamic changes and no episode of brain expansion during operation. We conclude that the rapid infusion of mannitol can trigger acute cardiac failure and brain edema in patients with DCM.

Percutaneous Glue Embolization of a Visceral Artery Pseudoaneurysm in a Case of Sickle Cell Anemia

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gulati, Gurpreet S.; Gulati, Manpreet S.; Makharia, Govind

2006-08-15

Although aneurysmal complications of sickle cell anemia have been described in the intracranial circulation, visceral artery pseudoaneurysms in this disease entity have not previously been reported in the literature. Conventional treatment of visceral pseudoaneurysms has been surgical ligation or resection of the aneurysm. Transcatheter embolization has emerged as an attractive, minimally invasive alternative to surgery in the treatment of these lesions. In certain situations, however, due to the unfavorable angiographic anatomy precluding safe transcatheter embolization, direct percutaneous glue injection of the pseudoaneurysm sac may be considered to achieve successful occlusion of the sac. The procedure may be rendered safer bymore » simultaneous balloon protection of the parent artery. We describe this novel treatment modality in a case of inferior pancreaticoduodenal artery pseudoaneurysm in a patient with sickle cell anemia. Although a complication in the form of glue reflux into the parent vessel occurred that necessitated surgery, this treatment modality may be used in very selected cases (where conventional endovascular embolization techniques are not applicable) after careful selection of the balloon diameter and appropriate concentration of the glue-lipiodol mixture.« less

Long-term outcomes after repair of symptomatic abdominal aortic aneurysms.

PubMed

Chandra, Venita; Trang, Karen; Virgin-Downey, Whitt; Dalman, Ronald L; Mell, Matthew W

2018-04-25

Previous studies have reported increased perioperative mortality of nonruptured symptomatic abdominal aortic aneurysms (Sx-AAA) compared with asymptomatic elective AAA (E-AAA) repairs, but no long-term-outcomes have been reported. We sought to compare long-term outcomes of Sx-AAA and E-AAA after repair at a single academic institution. Patients receiving AAA repair for Sx-AAA and E-AAA from 1995 through 2015 were included. Ruptured AAA and suprarenal or thoracoabdominal AAA were excluded. Demographics, comorbidities, and operative approach were collected. Long-term mortality was the primary outcome, determined by chart review or link to Social Security Death Index. Additionally, long-term mortality and reinterventions were compared after groups were matched with nearest neighbor propensity to reduce bias. AAA repair was performed for 1054 E-AAA (383 open repair [36%], 671 endovascular aneurysm repair [EVAR] [64%]), and 139 symptomatic aneurysms (60 open repair [43%], 79 EVAR [57%]). Age (73 years vs 74 years; P = .13) and aneurysm diameter were similar between Sx-AAA and E-AAA (6.0 cm vs 5.8 cm; P = .5). The proportion of women was higher for Sx-AAA (26% vs 16%; P = .003), as was the proportion of non-Caucasians (40% vs 29%; P = .009). After propensity matching, there were no differences between groups for patient characteristics, AAA diameter, treatment modality, or comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, lung disease, diabetes, renal disease, and smoking history. Women were treated for Sx-AAA at significantly smaller aortic diameters; however, compared with men (5.1 cm vs 6.3 cm; P < .001). Perioperative mortality was 5.0% for Sx-AAA and 2.3% for E-AAA (P = .055). By life-table analysis, Sx-AAA had lower 5-year (62% vs 71%) and 10-year (39% vs 51%) survivals (P = .01) compared with E-AAA for the entire cohort. Similar trends were observed for 5-year and 10-year mortality after propensity matching (63% and 40% vs 71% and 52%; P = .05). When stratified by repair type 5-year and 10-year survivals trended lower after open surgery (68% and 42% Sx-AAA vs 84% and 59% E-AAA; P = .08) but not EVAR (59% and 40% Sx-AAA vs 61% and 49% E-AAA; P = .4). Aneurysm-related reinterventions were similar for Sx-AAA and E-AAA (15% vs 14%; P = .8). Reinterventions were more common after EVAR compared with open repair (22% vs 7%, Sx-AAA P = .015; 20% vs 4% E-AAA; P = .007). Patients with Sx-AAA had lower long-term survival and similar aneurysm-related reinterventions compared with patients with E-AAA undergoing repair. Women also underwent repair for Sx-AAA at a significantly smaller size when compared with men, which emphasizes the role of gender in AAA symptomatology. Differences in long-term survival may be only partially explained by measured patient, aneurysm, and operative factors, and may reflect unmeasured social factors or suggest inherent differences in pathophysiology of Sx-AAAs. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

External carotid compression: a novel technique to improve cerebral perfusion during selective antegrade cerebral perfusion for aortic arch surgery.

PubMed

Grocott, Hilary P; Ambrose, Emma; Moon, Mike

2016-10-01

Selective antegrade cerebral perfusion (SACP) involving cannulation of either the axillary or innominate artery is a commonly used technique for maintaining cerebral blood flow (CBF) during the use of hypothermic cardiac arrest (HCA) for operations on the aortic arch. Nevertheless, asymmetrical CBF with hypoperfusion of the left cerebral hemisphere is a common occurrence during SACP. The purpose of this report is to describe an adjunctive maneuver to improve left hemispheric CBF during SACP by applying extrinsic compression to the left carotid artery. A 77-yr-old male patient with a history of aortic valve replacement presented for emergent surgical repair of an acute type A aortic dissection of a previously known ascending aortic aneurysm. His intraoperative course included cannulation of the right axillary artery, which was used as the aortic inflow during cardiopulmonary bypass and also allowed for subsequent SACP during HCA. After the onset of HCA, the innominate artery was clamped at its origin to allow for SACP. Shortly thereafter, however, the left-sided cerebral oxygen saturation (SrO2) began to decrease. Augmenting the PaO2, PaCO2 and both SACP pressure and flow failed to increase left hemispheric SrO2. Following the use of ultrasound guidance to confirm the absence of atherosclerotic disease in the carotid artery, external pressure was applied partially compressing the artery. With the carotid compression, the left cerebral saturation abruptly increased, suggesting pressurization of the left cerebral hemispheric circulation and augmentation of CBF. Direct ultrasound visualization and cautious partial compression of the left carotid artery may address asymmetrical CBF that occurs with SACP during HCA for aortic arch surgery. This strategy may lead to improved symmetry of CBF and corresponding cerebral oximetry measurements during aortic arch surgery.

Getting your home ready - knee or hip surgery

MedlinePlus

... Philadelphia, PA: Elsevier; 2017:chap 55. Read More ACL reconstruction Hip fracture surgery Hip joint replacement Knee ... Knee joint replacement Knee microfracture surgery Patient Instructions ACL reconstruction - discharge Hip fracture - discharge Hip or knee ...

[Local infiltration analgesia in total joint replacement].

PubMed

de Jonge, Tamás; Görgényi, Szabolcs; Szabó, Gabriella; Torkos, Miklós Bulcsú

2017-03-01

Total hip and knee replacment surgeries are characterized by severe postoperative pain. Local infiltration analgesia is proved to be very effective. However this method has not been widely used in Hungary. To evaluate the efficacy of the local infiltration analgesia with modified components in patients underwent total hip or knee replacement surgery. Data of 99 consecutive patients underwent primary total hip or knee replacement surgery were evaluated prospectively. In all the 99 surgeries modified local infiltration analgesia was applied. Postoperative pain reported on a visual analog scale was recorded as well as the need for further analgetics during the first 18 hours after surgery. The cost of the analgetic drugs was calculated. The control group comprised 97 consecutive patients underwent total hip or knee replacement, where local infiltration analgesia was not applied. Statistical analysis was done. Patients received local infiltration analgesia reported significantly less pain (p<0.001). The need for postoperatively given analgetics was almost 50% less, and the cost of all postoperative analgetics was 47% less than in the control group. In total hip and knee replacement surgeries the modified local infiltration analgesia decreases postoperative pain effectively and contribute to the early mobilization of the patients. Orv. Hetil., 2017, 158(9), 352-357.

Efficacy of Early Rehabilitation After Surgical Repair of Acute Aneurysmal Subarachnoid Hemorrhage: Outcomes After Verticalization on Days 2-5 Versus Day 12 Post-Bleeding.

PubMed

Milovanovic, Andjela; Grujicic, Danica; Bogosavljevic, Vojislav; Jokovic, Milos; Mujovic, Natasa; Markovic, Ivana Petronic

2017-01-01

To develop a specific rehabilitation protocol for patients who have undergone surgical repair of acute aneurysmal subarachnoid hemorrhage (aSAH), and to determine the time at which verticalization should be initiated after aSAH. Sixty-five patients who underwent acute-term surgery for aSAH and early rehabilitation were evaluated in groups: Group 1 (n=34) started verticalization on days 2-5 post-bleeding whereas Group 2 (n=31) started verticalization approximately day 12 post-bleeding. All patients were monitored for early complications, vasospasm and ischemia. Assessments of motor status, depression and anxiety (using Zung scales), and cognitive status (using the Mini-Mental State Examination (MMSE)) were conducted at discharge and at 1 and 3 months post-surgery. At discharge, Group 1 had a significantly higher proportion of patients with ischemia than Group 2 (p=0.004). Group 1 had a higher proportion of patients with hemiparesis than Group 2 three months post-surgery (p=0.015). Group 1 patients scored significantly higher on the Zung depression scale than Group 2 patients at 1 month (p=0.005) and 3 months post-surgery (p=0.001; the same applies to the Zung anxiety scale (p=0.006 and p=0.000, respectively). Group 2 patients scored significantly higher on the MMSE than those in Group 1 at discharge (p=0.040) and 1 month post-surgery (p=0.025). Early verticalization had no effect with respect to preventing early postoperative complications in this patient group. Once a patient has undergone acute surgical repair of aSAH, it is safe and preferred that rehabilitation be initiated immediately postsurgery. However, verticalization should not start prior to day 12 post-bleeding.

Accuracy and trending ability of the fourth-generation FloTrac/Vigileo System™ in patients undergoing abdominal aortic aneurysm surgery.

PubMed

Maeda, Takuma; Hattori, Kohshi; Sumiyoshi, Miho; Kanazawa, Hiroko; Ohnishi, Yoshihiko

2018-06-01

The fourth-generation FloTrac/Vigileo™ improved its algorithm to follow changes in systemic vascular resistance index (SVRI). This revision may improve the accuracy and trending ability of CI even in patients who undergo abdominal aortic aneurysm (AAA) surgery which cause drastic change of SVRI by aortic clamping. The purpose of this study is to elucidate the accuracy and trending ability of the fourth-generation FloTrac/Vigileo™ in patients with AAA surgery by comparing the FloTrac/Vigileo™-derived CI (CI FT ) with that measured by three-dimensional echocardiography (CI 3D ). Twenty-six patients undergoing elective AAA surgery were included in this study. CI FT and CI3 D were determined simultaneously in eight points including before and after aortic clamp. We used CI 3D as the reference method. In the Bland-Altman analysis, CI FT had a wide limit of agreement with CI 3D showing a percentage error of 46.7%. Subgroup analysis showed that the percentage error between CO 3D and CO FT was 56.3% in patients with cardiac index < 2.5 L/min/m 2 and 28.4% in patients with cardiac index ≥ 2.5 L/min/m 2 . SVRI was significantly higher in patients with cardiac index < 2.5 L/min/m 2 (1703 ± 330 vs. 2757 ± 798; p < 0.001). The tracking ability of fourth generation of FloTrac/Vigileo™ after aortic clamp was not clinically acceptable (26.9%). The degree of accuracy of the fourth-generation FloTrac/Vigileo™ in patients with AAA surgery was not acceptable. The tracking ability of the fourth-generation FloTrac/Vigileo™ after aortic clamp was below the acceptable limit.

Rare presentation of ruptured syphilitic aortic aneurysm with pseudoaneurysm.

PubMed

de Almeida Feitosa, Israel Nilton; Dantas Leite Figueiredo, Magda; de Sousa Belem, Lucia; Evelin Soares Filho, Antônio Wilon

2015-11-01

We report the interesting case of a rare form of presentation of rupture of the ascending aorta with formation of a pseudoaneurysm, diagnosed following the development of a large mass on the surface of the chest over a period of about eight months. Serological tests were positive for syphilis. Echocardiography and computed tomography angiography were essential to confirm the diagnosis and therapeutic management. Cardiovascular syphilis is a rare entity since the discovery of penicillin. Rupture of an aortic aneurysm with formation of a pseudoaneurysm is a potentially fatal complication. The postoperative period was uneventful and the patient was discharged from hospital within days of surgery. Copyright © 2015 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Pulmonary Artery Pseudoaneurysm Secondary to Lung Inf lammation.

PubMed

Ishimoto, Shinichirou; Sakurai, Hiroyuki; Higure, Ryouta; Kawachi, Riken; Shimamura, Mie

2018-01-15

Pulmonary artery aneurysms (PAA) and pseudoaneurysms (PAP) are caused by infections, vasculitis, trauma, pulmonary hypertension, congenital heart disease, and connective tissue disease. Most cases of such aneurysm occur in the trunk or major branches of the pulmonary artery, while the peripheral type is less common. The treatment modalities are medical therapy, surgery, and percutaneous catheter embolization. The mortality rate associated with rupture is approximately 50%. We encountered a case of a 53-year-old man with a pulmonary artery pseudoaneurysm secondary to pneumonia and cavity formation during chemotherapy for acute myeloid leukemia (AML). In diagnosis, contrast-enhanced chest computed tomography (CT) scan and pulmonary angiography were very useful. He was treated with right middle and lower lobectomy. After 1-month follow-up, he could restart additional chemotherapy.

Cadaveric aorta implantation for aortic graft infection.

PubMed

Ali, Asad; Bahia, Sandeep S S; Ali, Tahir

2016-01-01

This case report describes a 73-year-old gentleman who underwent explantation of an infected prosthetic aorto-iliac graft and replacement with a cryopreserved thoracic and aorto-iliac allograft. The patient has been followed up a for more than a year after surgery and remains well. After elective tube graft repair of his abdominal aortic aneurysm (AAA) in 2003, he presented to our unit in 2012 in cardiac arrest as a result of a rupture of the distal graft suture line due to infection. After resuscitation he underwent aorto-bifemoral grafting using a cuff of the original aortic graft proximally. Distally the new graft was anastomosed to his common femoral arteries, with gentamicin beads left in situ. Post discharge the patient was kept under close surveillance with serial investigations including nuclear scanning, however it became apparent that his new graft was infected and that he would require aortic graft replacement, an operation with a mortality of at least 50%. The patient underwent the operation and findings confirmed a synthetic graft infection. This tube graft was explanted and a cryopreserved aorta was used to the refashion the abdominal aorta and its bifurcation. The operation required a return to theatre day one post operatively for a bleeding side branch, which was repaired. The patient went on to make a full recovery stepping down from the intensive therapy unit day 6 post operatively and went on to be discharged 32 days after his cryopreserved aorta implantation. Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Outcomes for Symptomatic Abdominal Aortic Aneurysms in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)

PubMed Central

Soden, Peter A.; Zettervall, Sara L.; Ultee, Klaas H.J.; Darling, Jeremy D.; Buck, Dominique B.; Hile, Chantel N.; Hamdan, Allen D.; Schermerhorn, Marc L.

2016-01-01

Introduction Historically symptomatic AAAs were found to have intermediate mortality compared to asymptomatic and ruptured AAAs but, with wider EVAR use, a more recent study suggested mortality of symptomatic aneurysms were similar to asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study is to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. Methods All patients undergoing infrarenal AAA repair were identified in the 2011–2013 ACS-NSQIP, Vascular Surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events (MAE) for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. Results 5502 infrarenal AAAs were identified, 4495 asymptomatic (830 open repair, 3665 [82%] EVAR), 455 symptomatic (143 open, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs, when stratified by procedure type, but larger for ruptured aneurysms (EVAR symptomatic 5.8cm ±1.6 vs. ruptured 7.5cm ±2.0, P<.001; open repair symptomatic 6.4cm ±1.9 vs. ruptured 8.0cm ±1.9, P<.001). The proportion of females was similar in symptomatic and ruptured AAA (27% vs. 23%, P=.14, respectively), but lower in asymptomatic AAA (20%, P<.001). Symptomatic AAAs had intermediate 30-day mortality compared to asymptomatic and ruptured aneurysms after both EVAR (asymptomatic 1.4% vs. symptomatic 3.8%, P=.001; symptomatic vs. 22% ruptured, P<.001) and open repair (asymptomatic 4.3% vs. symptomatic 7.7% , P=.08; symptomatic vs. 57% ruptured, P<.001). After adjustment for age, gender, repair type, dialysis dependence, and history of severe COPD, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30-days compared to those with asymptomatic aneurysms (OR 2.1, 95%CI 1.3–3.5). When stratified by repair type the effect size and direction of the odds ratios were similar (EVAR OR 2.4, CI 1.2–4.7; open repair OR 1.8, CI 0.86–3.9), although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared to symptomatic patients (OR 6.5, CI 4.1–10.6). Conclusion Patients with symptomatic AAAs had a two-fold increased risk of perioperative mortality, compared to asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a seven-fold increased risk of mortality compared to symptomatic aneurysms. PMID:27146791

[CBO guideline 'Deep venous thrombosis and pulmonary embolism; revision of the earlier guidelines. Dutch Organization for Quality Assurance in Hospitals].

PubMed

Büller, H R; van der Meer, J; Oudkerk, M

2000-08-05

Diagnosis of clinically suspected deep venous thrombosis is based on a clinical score, serial compression ultrasonography and D-dimer assay. For the diagnosis of pulmonary embolism perfusion scintigraphy, ventilation scintigraphy, echography of the leg veins and pulmonary angiography in that order lead to the lowest mortality, morbidity and costs. Diagnostics with spiral CT followed by pulmonary angiography leads to equal mortality and fewer angiography procedures. Decision rules based on anamnesis, physical examination, blood gas analysis and chest radiograph have proved to be insufficiently reliable. The present D-dimer assays have too little sensitivity and too much variability. Thrombo-prophylaxis with low-molecular-weight heparin is indicated for general surgery, joint replacement of the knee or hip, cranial and spinal surgery, subarachnoid haemorrhage after surgical treatment of an aneurysm, acute myocardial infarction, ischaemic stroke or spinal cord lesion, intensive care patients, patients with acute paralysis due to a neuromuscular disorder, and bedridden patients with a risk factor. Prophylaxis has to be continued as long as the indication exists. In the acute phase of deep venous thrombosis or pulmonary embolism treatment with (low-molecular-weight) heparin in an adequate dose is necessary. When started at the same time as coumarin derivatives the treatment with heparin has to be continued for at least 5 days. The risk of postthrombotic syndrome after deep venous thrombosis will be lowered by carrying compression stockings for at least 2 years after the event.

Stent-Assisted Coil Embolization for Cavernous Carotid Artery Aneurysms

PubMed Central

KONO, Kenichi; SHINTANI, Aki; OKADA, Hideo; TANAKA, Yuko; TERADA, Tomoaki

2014-01-01

Internal carotid artery (ICA) occlusion with or without a bypass surgery is the traditional treatment for cavernous sinus (CS) aneurysms with cranial nerve (CN) dysfunction. Coil embolization without stents frequently requires retreatment because of the large size of CS aneurysms. We report the mid-term results of six unruptured CS aneurysms treated with stent-assisted coil embolization (SACE). The mean age of the patients was 72 years. The mean size of the aneurysms was 19.8 mm (range: 13–26 mm). Before treatment, four patients presented with CN dysfunction and two patients had no symptoms. SACE was performed under local or general anesthesia in three patients each. Mean packing density was 29.1% and tight packing was achieved. There were no neurological complications. CN dysfunction was cured in three patients (75%) and partly resolved in one patient (25%). Transient new CN dysfunction was observed in two patients (33%). Clinical and imaging follow-up ranged from 6 to 26 months (median: 16 months). Recanalization was observed in three patients (50%; neck remnant in two patients and dome filling in one patient), but no retreatment has yet been required. No recurrence of CN dysfunction has occurred yet. In summary, SACE increases packing density and may reduce requirement of retreatment with an acceptable cure rate of CN dysfunction. SACE may be a superior treatment for coiling without stents and be an alternative treatment of ICA occlusion for selected patients, such as older patients and those who require a high-flow bypass surgeryor cannot receive general anesthesia. PMID:24257503

Prevalence of severe subclinical coronary artery disease on cardiac CT and MRI in patients with extra-cardiac arterial disease.

PubMed

den Dekker, M A M; van den Dungen, J J A M; Tielliu, I F J; Tio, R A; Jaspers, M M J J R; Oudkerk, M; Vliegenthart, R

2013-12-01

Patients with extra-cardiac arterial disease (ECAD) are at high risk of coronary artery disease (CAD). Prevalence of silent, significant CAD in patients with stenotic or aneurysmal ECAD was examined. Early detection and treatment may reduce CAD mortality in this high-risk group. ECAD patients without cardiac complaints underwent computed tomography (CT) for calcium scoring, coronary CT angiography (cCTA) if calcium score was 1,000 or under, and adenosine perfusion magnetic resonance imaging (APMR) if there was no left main stenosis. Significant CAD was defined as calcium score over 1,000, cCTA-detected coronary stenosis of at least 50% lumen diameter, and/or APMR-detected inducible myocardial ischemia. In cases of left main stenosis (or equivalent) or myocardial ischemia, patients were referred to a cardiologist. The prevalence of significant CAD was 56.8% (95% CI 47.5 to 66.0). One-hundred and eleven patients were included. Eighty-four patients (76%) had stenotic ECAD, and 27 (24%) had aneurysmal disease. In patients with stenotic ECAD, significant coronary stenosis was present in 32 (38%) and inducible ischemia in eight (12%). Corresponding results in aneurysmal ECAD were eight (30%) and two (11%), respectively (p for difference >.05). Sixteen (19%) patients with stenotic and six (22%) with aneurysmal ECAD were referred to a cardiologist, with subsequent cardiac intervention in seven (44%) and three (50%), respectively (both p >.05). Patients with stenotic or aneurysmal ECAD have a high prevalence of silent, significant CAD. Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

In-situ laser fenestration of endovascular stent-graft in abdominal aortic aneurysm repair (EVAR)

NASA Astrophysics Data System (ADS)

Micheletti, Filippo; Pini, Roberto; Piazza, Roberta; Ferrari, Vincenzo; Condino, Sara; Rossi, Francesca

2017-02-01

Endovascular abdominal aortic aneurysms repair (EVAR) involves the minimally invasive implantation of a stent-graft within the aorta to exclude the aneurysm from the circulation thus preventing its rupture. The feasibility of such operation is highly dependent on the aorta morphology and in general the presence of one/both renal arteries emerging from the aneurysm is the absolute limit for the implantation of a standard stent-graft. Consequently, classical intervention methods involve the implantation of a custom-made graft with fenestrations, leading to extremely complicated surgeries with high risks for the patient and high costs. Recent techniques introduced the use of standard grafts (i.e. without fenestrations) in association with mechanical in-situ fenestration, but this procedure is limited principally by the brittleness and low stability of the environment, in addition to the difficulty of controlling the guidance of the endovascular tools due to the temporarily block of the blood flow. In this work we propose an innovative EVAR strategy, which involves in-situ fenestration with a fiber guided laser tool, controlled via an electromagnetic navigation system. The fiber is sensorized to be tracked by means of the driving system and, using a 3D model of the patient anatomy, the surgeon can drive the fiber to the aneurysm, where the stent has been previously released, to realize the proper fenestration(s). The design and construction of the catheter laser tool will be presented, togheter with preliminary fenestration tests on graft-materials, including the effects due to the presence of blood and tissues.

Results of microsurgical treatment of large and giant ICA aneurysms using the retrograde suction decompression (RSD) technique: series of 92 patients.

PubMed

Eliava, Shalva S; Filatov, Yuri M; Yakovlev, Sergei B; Shekhtman, Oleg D; Kheireddin, Ali S; Sazonov, Ilya A; Sazonova, Olga B; Okishev, Dmitry N

2010-06-01

Microsurgical treatment of large and giant paraclinoid internal carotid artery (ICA) aneurysms often requires the use of the retrograde suction decompression (RSD) technique to facilitate clipping. Surgical results, functional outcomes at discharge, and technique limitations based on single institution series are presented. Between 1996 and 2009, eighty-three consecutive patients (19 to 68 years, mean 45.5 ± 9.9 years), predominantly women (69 women and 14 men) with large (23 patients, 27.7%) or giant (60 patients, 72.3%) paraclinoid aneurysms were surgically treated with the RSD technique performed by the neck route (62 patients, 74.4%) or later on, by endovascular means (21 patients, 25.3%). Patients were admitted after hemorrhage (48 patients, 57.9%), pseudotumor course (28 patients, 33.7%), mixed symptoms (5 patients, 6%), or asymptomatic (2 patients, 2.4%). In most RSD surgeries (90.4%) aneurysms were successfully excluded: neck was clipped in 57 patients (68.7%) or clipping with ICA reconstruction was achieved in 18 patients (21.7%). In six patients aneurysms were wrapped with glue (7.2%), trapped in one patient (1.2%), and in one patient, ICA balloon deconstruction was performed (1.2%). Good or excellent results (Glasgow Outcome Scale scores 4-5) at discharge were achieved in 69 patients (83.1%), 11 patients (13.3%) remained severely disabled (Glasgow Outcome Scale 3), and 3 patients died (3.6%). Surgical clipping with the RSD method remains a treatment of choice with acceptable outcomes for patients not amenable for endovascular treatment. Copyright © 2010 Elsevier Inc. All rights reserved.

EVAR using the Nellix Sac-anchoring endoprosthesis: treatment of favourable and adverse anatomy.

PubMed

Krievins, D K; Holden, A; Savlovskis, J; Calderas, C; Donayre, C E; Moll, F L; Katzen, B; Zarins, C K

2011-07-01

The study aimed to review the results of endovascular aneurysm repair (EVAR) using a novel sac-anchoring endoprosthesis in patients with favourable and adverse anatomy. This is a prospective, multicentre, clinical trial. The Nellix endoprosthesis consists of dual, balloon-expandable endoframes, surrounded by polymer-filled endobags, which obliterate the aneurysm sac and maintain endograft position. The study reviewed worldwide clinical experience and Core Lab evaluation of computed tomography (CT) scans. From 2008 to 2010, 34 patients (age 71 ± 8 years, abdominal aortic aneurysm (AAA) diameter 5.8 ± 0.8 cm) were treated at four clinical sites. Seventeen patients (50%) met the inclusion criteria for Food and Drug Administration (FDA)-approved endografts (favourable anatomy); 17 (50%) had one or more adverse anatomic feature: neck length <10 mm (24%), neck angle >60° (9%) and iliac diameter >23 mm (38%). Device deployment was successful in all patients; iliac aneurysm treatment preserved hypogastric patency. Perioperative mortality was 1/34 (2.9%); one patient died at 10 months of congestive heart failure (CHF); one patient had a secondary procedure at 15 months. During 15 ± 6 months follow-up, there were no differences in outcome between favourable and adverse anatomy patients. Follow-up CT extending up to 2 years revealed no change in aneurysm size or endograft position and no new endoleaks. Favourable and adverse anatomy patients can be successfully treated using the Nellix sac-anchoring endoprosthesis. Early results are promising but longer-term studies are needed. Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Lipoprotein (a): a potential biological marker for unruptured intracranial aneurysms.

PubMed

Phillips, J; Roberts, G; Bolger, C; el Baghdady, A; Bouchier-Hayes, D; Farrell, M; Collins, P

1997-05-01

The diagnosis and treatment of intracranial aneurysms (IAs) prior to rupture reduces the high morbidity and mortality associated with their occurrence. Elevated serum lipoprotein (a) [Lp(a)] level, an independent risk factor for atherogenesis, has been demonstrated in sporadic IA disease (1). The purpose of this study was to assess the degree of correlation between elevated Lp(a) levels and the occurrence of IAs in asymptomatic first degree relatives of index cases from three families exhibiting a familial tendency towards IA development. 25 family members and 41 healthy controls were screened by random serum Lp(a) sampling. All family members received 4-vessel cerebral angiography. Eleven family members were found on angiography to harbour asymptomatic aneurysms and all were successfully treated by surgery. Of these 11, ten had significantly raised serum Lp(a) levels (> 30 mg%). Fourteen family members had negative angiograms. Eight of this latter group, mean age 43.6 +/- 3.8 years, had serum Lp(a) levels above the normal range. Mean Lp(a) levels were 53.7 +/- 1.2 mg% in subjects with aneurysms compared with 22.1 +/- 1.45 mg% in subjects without demonstrable aneurysms and 10.5 +/- 0.48 mg% in the control population. The prevalence of elevated Lp(a) levels in these families and the high degree of association of raised Lp(a) levels with the presence of IAs in several family members warrants follow up of angiographically negative young subjects. We require a case-control study to establish whether particular polymorphisms at the apoprotein (a) gene level are associated with the occurrence of IAs in these families.

Trends in Hospital Volume and Operative Mortality for High-Risk Surgery

PubMed Central

Finks, Jonathan F.; Osborne, Nicholas H.; Birkmeyer, John D.

2011-01-01

BACKGROUND There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. METHODS We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. RESULTS Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. CONCLUSIONS Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.) PMID:21631325

Endovascular aortic repair: first twenty years.

PubMed

Koncar, Igor; Tolić, Momcilo; Ilić, Nikola; Cvetković, Slobodan; Dragas, Marko; Cinara, Ilijas; Kostić, Dusan; Davidović, Lazar

2012-01-01

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives--engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method.

Cirsoid aneurysm of the right pre-auricular region: an unusual cause of tinnitus managed by endovascular glue embolisation.

PubMed

Kumar, A; Ahuja, C K; Khandelwal, N; Bakshi, J B

2012-09-01

We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation. A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms. Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.

Vascular Ehlers-Danlos Syndrome Presenting as a Pulsatile Neck Mass: a Case Report and Review of Literature.

PubMed

Maraj, Bharat; Harding-Theobald, Emily; Karaki, Fatima

2018-04-26

Ehlers-Danlos syndrome refers to a spectrum of connective tissue disorders typically caused by mutations in genes responsible for the synthesis of collagen. Patients with Ehlers-Danlos syndrome often exhibit hyperflexibility of joints, increased skin elasticity, and tissue fragility. Vascular Ehlers-Danlos (vEDS) is a subtype of Ehlers-Danlos syndrome with a predilection to involve blood vessels. As such, it often manifests as vascular aneurysms and vessel rupture leading to hemorrhage. There are few reports describing primary prevention of aneurysms in the setting of undiagnosed, suspected vEDS. We present a case of a 30-year-old woman who presents with a pulsatile neck mass found to have multiple arterial aneurysms on imaging, hyperflexibility, and characteristic facial features consistent with vEDS. As described in this case, management of a suspected connective tissue disorder is a multidisciplinary approach including vascular surgery, medical therapy, and genetic testing to confirm the diagnosis. We review literature regarding the care of patients with vascular Ehlers-Danlos as it might pertain to hospitalized patients.

Endovascular Management of Thoracic Aortic Aneurysms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fattori, Rossella, E-mail: rossella.fattori@unibo.it; Russo, Vincenzo; Lovato, Luigi

The overall survival of patients with thoracic aortic aneurysm (TAA) has improved significantly in the past few years. Endovascular treatment, proposed as an alternative to surgery, has been considered a therapeutic innovation because of its low degree of invasiveness, which allows the treatment of even high-surgical risk patients with limited complications and mortality. A major limitation is the lack of adequate evidence regarding long-term benefit and durability because follow-up has been limited to just a few years even in the largest series. The combination of endovascular exclusion with visceral branch revascularization for the treatment of thoraco-abdominal aortic aneurysms involving themore » visceral aorta has also been attempted. As an alternative, endografts with branches represent a technological evolution that allows treatment of complex anatomy. Even if only small numbers of patients and short follow-up are available, this technical approach, which has with limited mortality (<10%) and paraplegia rates, to expand endovascular treatment to TAA seems feasible. With improved capability to recognize proper anatomy and select clinical candidates, the choice of endovascular stent-graft placement may offer a strategy to optimize management and improve prognosis.« less

Splenic artery aneurysms encountered in the ED: 10 years' experience.

PubMed

Liu, Chu-Feng; Kung, Chia-Te; Liu, Ber-Ming; Ng, Shu-Hang; Huang, Chung-Cheng; Ko, Sheung-Fat

2007-05-01

Our objective was to report 7 cases of splenic artery aneurysm (SAA) encountered in the emergency department (ED). A retrospective survey of our ED database revealed 7 cases of SAA (6 men, 1 woman; mean age, 56 years) of 651,347 ED visits over the last decade. Their clinical and imaging features, management, and outcomes were evaluated. Splenic artery aneurysm in the ED was rare (prevalence, 0.011%). Common presentations included acute abdomen (n = 5) and shock (n = 2). Five cases had liver cirrhosis and portal hypertension. Abdominal radiographs (n = 7) revealed 2 atherosclerotic patients with SAA. Abdominal computed tomography (n = 7) depicted all SAAs (size, 1.5-8 cm; mean, 3.8 cm). Four ruptured SAAs were successfully managed with coils embolization. Among them, 1 patient with ruptured mycotic SAA also received surgery, but the patient died of Klebsiella sepsis 3 months later. In the ED, ruptured SAA should be included as a rare differential consideration of acute abdomen, especially in middle-aged men with liver cirrhosis and portal hypertension. Although SAA may be an unexpected computed tomographic finding, once diagnosed, endovascular treatment is recommended.

The effects of preoperative cardiology consultation prior to elective abdominal aortic aneurysm repair on patient morbidity.

PubMed

Boniakowski, Anna E; Davis, Frank M; Phillips, Amanda R; Robinson, Adina B; Coleman, Dawn M; Henke, Peter K

2017-08-01

Objectives The relationship between preoperative medical consultations and postoperative complications has not been extensively studied. Thus, we investigated the impact of preoperative consultation on postoperative morbidity following elective abdominal aortic aneurysm repair. Methods A retrospective review was conducted on 469 patients (mean age 72 years, 20% female) who underwent elective abdominal aortic aneurysm repair from June 2007 to July 2014. Data elements included detailed medical history, preoperative cardiology consultation, and postoperative complications. Primary outcomes included 30-day morbidity, consult-specific morbidity, and mortality. A bivariate probit regression model accounting for the endogeneity of binary preoperative medical consult and patient variability was estimated with a maximum likelihood function. Results Eighty patients had preoperative medical consults (85% cardiology); thus, our analysis focuses on the effect of cardiac-related preoperative consults. Hyperlipidemia, increased aneurysm size, and increased revised cardiac risk index increased likelihood of referral to cardiology preoperatively. Surgery type (endovascular versus open repair) was not significant in development of postoperative complications when controlling for revised cardiac risk index ( p = 0.295). After controlling for patient comorbidities, there was no difference in postoperative cardiac-related complications between patients who did and did not undergo cardiology consultation preoperatively ( p = 0.386). Conclusions When controlling for patient disease severity using revised cardiac risk index risk stratification, preoperative cardiology consultation is not associated with postoperative cardiac morbidity.

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery.

PubMed

Davis, Frank M; Park, Yeo June; Grey, Scott F; Boniakowski, Anna E; Mansour, M Ashraf; Jain, Krishna M; Nypaver, Timothy; Grossman, Michael; Gurm, Hitinder; Henke, Peter K

2018-01-01

To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI). Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation. Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation. Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P <0.001). High preoperative consulting hospitals (rate >66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P <0.05) compared with all other hospitals. These hospitals also had a statistically greater consultation rate with a variety of medical specialties. Preoperative cardiology consultation for vascular surgery varies greatly between institutions, and does not appear to impact poMI at the patient level. However, reduction of poMI was noted at the hospitals with the highest rate of preoperative cardiology consultation as well as a variety of medical services, suggesting that other hospital culture effects play a role.

Open fenestration of the distal landing zone via a subxyphoid incision for subsequent endovascular repair of a dissecting thoracic aneurysm.

PubMed

Konings, Renske; de Bruin, Jorg L; Wisselink, Willem

2013-02-01

To describe a novel hybrid technique to address two challenges in endovascular repair of chronic dissecting thoracic aortic aneurysm (dTAA): obtaining an adequate seal of the stent-graft in a half-moon-shaped fibrotic aortic lumen and preserving flow into the distal true and false lumens. The technique is demonstrated in a 52-year-old man who presented with progressive asymptomatic dilatation of the thoracic aorta 9 years after undergoing a Bentall procedure for a Stanford type A dissection followed by arch replacement and elephant trunk construction. Imaging at this admission showed a 6.8-cm dissecting aneurysm extending distally to ∼4 cm above the celiac trunk; the dissection included both common iliac arteries. The patient refused a thoracotomy, so a hybrid procedure was devised to resect the intimal flap via a median subxyphoid incision and transperitoneal approach through the lesser sac. Two overlapping Zenith TX-2 stent-grafts were deployed into the elephant trunk, terminating just above the surgically created "flow divider" at the level of the celiac trunk. Imaging showed adequate sealing at both ends of the stent-graft and a type II endoleak that persisted into follow-up, but the aneurysm diameter decreased to 6.4 cm, and there was unobstructed flow into the visceral, renal, and iliac arteries. In this case of chronic dTAA, open surgical removal of a segment of the dissection flap via a subxyphoid incision provided a distal landing zone for subsequent endoluminal repair, with exclusion of the aneurysm and preservation of antegrade flow in both true and false lumens.

Preoperative frailty assessment predicts loss of independence after vascular surgery.

PubMed

Donald, Graham W; Ghaffarian, Amir A; Isaac, Farid; Kraiss, Larry W; Griffin, Claire L; Smith, Brigitte K; Sarfati, Mark R; Beckstrom, Julie L; Brooke, Benjamin S

2018-05-14

Frailty, a clinical syndrome associated with loss of metabolic reserves, is prevalent among patients who present to vascular surgery clinics for evaluation. The Clinical Frailty Scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures. We identified all patients living independently at home who were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for >24 hours) at an academic medical center between December 2015 and December 2017. Patient- and procedure-level clinical data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a nonhome location or 30-day mortality was evaluated using bivariate and multivariate regression models. A total of 134 independent patients were assessed using the CFS before they underwent elective open abdominal aortic aneurysm repair (8%), endovascular aneurysm repair (26%), thoracic endovascular aortic repair (6%), suprainguinal bypass (6%), infrainguinal bypass (16%), carotid endarterectomy (19%), or peripheral vascular intervention (20%). Among 39 (29%) individuals categorized as being frail using the CFS, there was no significant difference in age or ASA physical status compared with nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (62% frail vs 22% nonfrail; P < .01) and to be discharged to a nonhome location (22% frail vs 6% nonfrail; P = .01) or to die within 30 days after surgery (8% frail vs 0% nonfrail; P < .01). Preoperative frailty was associated with a >12-fold higher risk (odds ratio, 12.1; 95% confidence interval, 2.17-66.96; P < .01) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken. The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care. Published by Elsevier Inc.

Gender, smoking, body size, and aneurysm geometry influence the biomechanical rupture risk of abdominal aortic aneurysms as estimated by finite element analysis.

PubMed

Lindquist Liljeqvist, Moritz; Hultgren, Rebecka; Siika, Antti; Gasser, T Christian; Roy, Joy

2017-04-01

Finite element analysis (FEA) has been suggested to be superior to maximal diameter measurements in predicting rupture of abdominal aortic aneurysms (AAAs). Our objective was to investigate to what extent previously described rupture risk factors were associated with FEA-estimated rupture risk. One hundred forty-six patients with an asymptomatic AAA of a 40- to 60-mm diameter were retrospectively identified and consecutively included. The patients' computed tomography angiograms were analyzed by FEA without (neutral) and with (specific) input of patient-specific mean arterial pressure (MAP), gender, family history, and age. The maximal wall stress/wall strength ratio was described as a rupture risk equivalent diameter (RRED), which translated this ratio into an average aneurysm diameter of corresponding rupture risk. In multivariate linear regression, RRED neutral increased with female gender (3.7 mm; 95% confidence interval [CI], 0.13-7.3) and correlated with patient height (0.27 mm/cm; 95% CI, 0.11-0.43) and body surface area (BSA, 16 mm/m 2 ; 95% CI, 8.3-24) and inversely with body mass index (BMI, -0.40 mm/kg m -2 ; 95% CI, -0.75 to -0.054) in a wall stress-dependent manner. Wall stress-adjusted RRED neutral was raised if the patient was currently smoking (1.1 mm; 95% CI, 0.21-1.9). Age, MAP, family history, and patient weight were unrelated to RRED neutral . In specific FEA, RRED specific increased with female gender, MAP, family history positive for AAA, height, and BSA, whereas it was inversely related to BMI. All results were independent of aneurysm diameter. Peak wall stress and RRED correlated with aneurysm diameter and lumen volume. Female gender, current smoking, increased patient height and BSA, and low BMI were found to increase the mechanical rupture risk of AAAs. Previously described rupture risk factors may in part be explained by patient characteristic-dependent variations in aneurysm biomechanics. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope.

PubMed

Imizu, S; Kato, Y; Sangli, A; Oguri, D; Sano, H

2008-08-01

The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.

Flow and wall shear stress characterization after endovascular aneurysm repair and endovascular aneurysm sealing in an infrarenal aneurysm model.

PubMed

Boersen, Johannes T; Groot Jebbink, Erik; Versluis, Michel; Slump, Cornelis H; Ku, David N; de Vries, Jean-Paul P M; Reijnen, Michel M P J

2017-12-01

Endovascular aneurysm repair (EVAR) with a modular endograft has become the preferred treatment for abdominal aortic aneurysms. A novel concept is endovascular aneurysm sealing (EVAS), consisting of dual endoframes surrounded by polymer-filled endobags. This dual-lumen configuration is different from a bifurcation with a tapered trajectory of the flow lumen into the two limbs and may induce unfavorable flow conditions. These include low and oscillatory wall shear stress (WSS), linked to atherosclerosis, and high shear rates that may result in thrombosis. An in vitro study was performed to assess the impact of EVAR and EVAS on flow patterns and WSS. Four abdominal aortic aneurysm phantoms were constructed, including three stented models, to study the influence of the flow divider on flow (Endurant [Medtronic, Minneapolis, Minn], AFX [Endologix, Irvine, Calif], and Nellix [Endologix]). Experimental models were tested under physiologic resting conditions, and flow was visualized with laser particle imaging velocimetry, quantified by shear rate, WSS, and oscillatory shear index (OSI) in the suprarenal aorta, renal artery (RA), and common iliac artery. WSS and OSI were comparable for all models in the suprarenal aorta. The RA flow profile in the EVAR models was comparable to the control, but a region of lower WSS was observed on the caudal wall compared with the control. The EVAS model showed a stronger jet flow with a higher shear rate in some regions compared with the other models. Small regions of low WSS and high OSI were found near the distal end of all stents in the common iliac artery compared with the control. Maximum shear rates in each region of interest were well below the pathologic threshold for acute thrombosis. The different stent designs do not influence suprarenal flow. Lower WSS is observed in the caudal wall of the RA after EVAR and a higher shear rate after EVAS. All stented models have a small region of low WSS and high OSI near the distal outflow of the stents. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

[Use of "the Middlesex Elderly Assessment of Mental State" scale in the assessment of cognitive functioning in patients with aneurysmal subarachnoid haemorrhage].

PubMed

Chyza, Karolina Julia; Polityńska, Barbara; Kochanowicz, Jan; Lewko, Janusz

2007-03-01

It is now well established that cognitive deficits are a frequent consequence of aneurysmal subarachnoid haemorrhage (SAH). The cognitive status in the acute phase of the illness may provide valuable prognostic information in relation to the effects of the proposed treatment and long-term functioning of the patient. A prerequisite for this task is the identification of instruments that might prove useful in the diagnosis of neuropsychological deficits in patients with SAH. For these purposes we used The Middlesex Elderly Assessment of Mental State (MEAMS) in order to assess the cognitive deficits consequent upon SAH. To assess the cognitive functioning of patients undergoing treatment for SAH of aneurysmal origin in the acute stage of the illness, using a modified form of the MEAMS. 49 patients participated in the study, none of whom had a previous history of neurological or psychiatric illness. The age of the patients ranged between 23-70 years. 35 (71%) patients received surgical treatment (clipping of the aneurysm neck) and in 14 (29%) the aneurysm was embolised. The patients were assessed on two occasions: the first on admission to the Neurosurgery department following the SAH, and on the second, following treatment to secure the aneurysm. A modified version of the MEAMS in two parallel versions was used in the assessment. The results obtained were evaluated with reference to a control group. A range of cognitive impairments was identified with the aid of the MEAMS in patients undergoing treatment for aneurysmal SAH. These included deficits in visual and auditory memory, executive, perceptual and visuo-spatial functions together with the tendency to perseverate. In those patients who underwent surgery, deficits were observed in the following areas: disorientation in relation to self, time and place; perceptual, memory and visuo-spatial impairments. The results obtained indicate that the Middlesex Elderly Assessment of Mental State, in the form used in the present study appears to be a sensitive and useful instrument for the screening of cognitive impairments in patients following SAH, in the acute stages of the illness.

Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation.

PubMed

Pinto Sousa, Pedro; Veiga, Carlos; Matos, Arlindo; Sá Pinto, Pedro; Almeida, Rui

2017-01-01

Renal artery aneurysm (RAA) is a rare clinical entity with an estimated prevalence of 0.15% to 0.1%in the general population. The majority of patients present asymptomatically and the diagnosis is made incidentally during a hypertension study test, and more rarely, fortuitously after backache. Indications to treat have been subject of intense debate, nevertheless there seems to be some consensus that RAAs greater than 2 cm in diameter, expanding RAA, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. The complex (hilar) RAA constitute a subset of RAA that present a therapeutic dilemma because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. We describe a 71-year-old woman with a personal history of hypertension for more than twenty years but normal renal function. Following the study for an abdominal discomfort a complex RAA was incidentally diagnosed. Computed tomographic angiography with three-dimensional reconstruction revealed a 13mm, saccular aneurysm located at the right renal hilum. We performed hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA. The aneurysm was resected and a polar renal artery was implanted over the resected area with a latero-terminal anastomosis. Complementarily, the renal vein was augmented with a spiral great saphenous vein graft and finally the kidney was implanted into the right iliac fossa. The intervention and postoperative course were uneventful and the patient submitted to ultrasound evaluation on the day after procedure. It revealed normal renal perfusion with normal flow indices. In the last follow-up realized, two months after surgery the patient was alive with a well-functioning auto-transplant. RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. While renal artery trunk aneurysms are most often treated using an endovascular procedure it is not suitable for renal artery branch aneurysms. Hand-assisted laparoscopic nephrectomy with ex vivo repair and auto-transplantation is a challenging but feasible option for treating hilum RAA.

Anatomic characteristics and natural history of renal artery aneurysms during longitudinal imaging surveillance.

PubMed

Wayne, Erik J; Edwards, Matthew S; Stafford, Jeanette M; Hansen, Kimberley J; Corriere, Matthew A

2014-08-01

Renal artery aneurysms (RAAs) are uncommon, and rates of growth and rupture are unknown. Limited evidence therefore exists to guide clinical management of RAAs, particularly small aneurysms that are asymptomatic. To further characterize the natural history of RAAs, we studied anatomic characteristics and changes in diameter during imaging surveillance. Patients evaluated for native RAAs at a single institution during a 5-year period (July 2008 to July 2013) were identified and analyzed retrospectively. Patients with two or more cross-sectional imaging studies (computed tomography or magnetic resonance imaging) more than 1 month apart were included. Demographic and clinical data were collected from medical records, and anatomic data (including aneurysm diameter, calcification, and location) were obtained from electronic images. Changes in RAA diameters over time were evaluated by plots and Wilcoxon signed rank tests. Sixty-eight RAAs in 55 patients were analyzed. Median follow-up was 19.4 months (interquartile range, 11.2-49.0 months). Mean age at presentation was 61.8 ± 9.8 years, and 73% of patients were women. Hypertension was prevalent among 73% of patients. Multiple RAAs were present in 18% of patients, and 24% also had arterial aneurysms of other splanchnic or iliac vessels. The majority of RAAs were calcified and located at the main renal artery bifurcation. Mean initial aneurysm diameter was 16.0 ± 6.4 mm. Median annualized growth rate was 0.06 mm (interquartile range, -0.07 to 0.33 mm; P = .11). No RAA ruptures or acute symptoms occurred during surveillance, and 10.3% of RAAs were repaired electively. Risk of short-term RAA growth or rupture was low. These findings suggest that annual (or less frequent) imaging surveillance is safe in the majority of patients and do not support pre-emptive repair of asymptomatic, small-diameter RAAs. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Development of Bend Sensor for Catheter Tip

NASA Astrophysics Data System (ADS)

Nagano, Yoshitaka; Sano, Akihito; Fujimoto, Hideo

Recently, a minimally invasive surgery which makes the best use of the catheter has been becoming more popular. In endovascular coil embolization for a cerebral aneurysm, the observation of the catheter's painting phenomenon is very important to execute the appropriate manipulation of the delivery wire and the catheter. In this study, the internal bend sensor which consists of at least two bending enhanced plastic optical fibers was developed in order to measure the curvature of the catheter tip. Consequently, the painting could be more sensitively detected in the neighborhood of the aneurysm. In this paper, the basic characteristics of the developed sensor system are described and its usefulness is confirmed from the comparison of the insertion force of delivery wire and the curvature of catheter tip in the experiment of coil embolization.

Pseudoaneurysm of the saphenous vein graft related to artificial rubber pericardium--a case report.

PubMed

Harada, Tomohiro; Ida, Takao; Koyanagi, Toshiya; Kasahara, Katsuhiko; Naganuma, Fumio; Hosoda, Saichi

2002-01-01

Pseudoaneurysm is an unusual complication of coronary artery bypass grafting. Such aneurysms are caused by technical surgical failures, or inflammation of the sternum and mediastinum following sternotomy observed as an early or mid-term complication of cardiac surgery. This case was an 80-year-old man with a piece of artificial rubber pericardium used for complete closure of the pericardium. A large pseudoaneurysm developed in the body of the saphenous vein graft 15 years after surgery. The old rubber synthetic pericardium was severely degenerative, which induced inflammation and disrupted the saphenous vein graft.

Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm.

PubMed

Torné, Ramon; Rodríguez-Hernández, Ana; Romero-Chala, Fabián; Arikan, Fuat; Vilalta, Jordi; Sahuquillo, Juan

2016-04-01

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH. Copyright © 2015 Elsevier Ltd. All rights reserved.

Modeling Endovascular Coils as Heterogeneous Porous Media

NASA Astrophysics Data System (ADS)

Yadollahi Farsani, H.; Herrmann, M.; Chong, B.; Frakes, D.

2016-12-01

Minimally invasive surgeries are the stat-of-the-art treatments for many pathologies. Treating brain aneurysms is no exception; invasive neurovascular clipping is no longer the only option and endovascular coiling has introduced itself as the most common treatment. Coiling isolates the aneurysm from blood circulation by promoting thrombosis within the aneurysm. One approach to studying intra-aneurysmal hemodynamics consists of virtually deploying finite element coil models and then performing computational fluid dynamics. However, this approach is often computationally expensive and requires extensive resources to perform. The porous medium approach has been considered as an alternative to the conventional coil modeling approach because it lessens the complexities of computational fluid dynamics simulations by reducing the number of mesh elements needed to discretize the domain. There have been a limited number of attempts at treating the endovascular coils as homogeneous porous media. However, the heterogeneity associated with coil configurations requires a more accurately defined porous medium in which the porosity and permeability change throughout the domain. We implemented this approach by introducing a lattice of sample volumes and utilizing techniques available in the field of interactive computer graphics. We observed that the introduction of the heterogeneity assumption was associated with significant changes in simulated aneurysmal flow velocities as compared to the homogeneous assumption case. Moreover, as the sample volume size was decreased, the flow velocities approached an asymptotical value, showing the importance of the sample volume size selection. These results demonstrate that the homogeneous assumption for porous media that are inherently heterogeneous can lead to considerable errors. Additionally, this modeling approach allowed us to simulate post-treatment flows without considering the explicit geometry of a deployed endovascular coil mass, greatly simplifying computation.

Utility of screening computed tomography of chest, abdomen and pelvis in patients after heart transplantation.

PubMed

Dasari, Tarun W; Pavlovic-Surjancev, Biljana; Dusek, Linda; Patel, Nilamkumar; Heroux, Alain L

2011-12-01

Malignancy is a late cause of mortality in heart transplant recipients. It is unknown if screening computed tomography scan would lead to early detection of such malignancies or serious vascular anomalies post heart transplantation. This is a single center observational study of patients undergoing surveillance computed tomography of chest, abdomen and pelvis at least 5 years after transplantation. Abnormal findings, included pulmonary nodules, lymphadenopathy and intra-thoracic and intra-abdominal masses and vascular anomalies such as abdominal aortic aneurysm. The clinical follow up of each of these major abnormal findings is summarized. A total of 63 patients underwent computed tomography scan of chest, abdomen and pelvis at least 5 years after transplantation. Of these, 54 (86%) were male and 9 (14%) were female. Mean age was 52±9.2 years. Computed tomography revealed 1 lung cancer (squamous cell) only. Non specific pulmonary nodules were seen in 6 patients (9.5%). The most common incidental finding was abdominal aortic aneurysms (N=6 (9.5%)), which necessitated follow up computed tomography (N=5) or surgery (N=1). Mean time to detection of abdominal aortic aneurysms from transplantation was 14.6±4.2 years. Mean age at the time of detection of abdominal aortic aneurysms was 74.5±3.2 years. Screening computed tomography scan in patients 5 years from transplantation revealed only one malignancy but lead to increased detection of abdominal aortic aneurysms. Thus the utility is low in terms of detection of malignancy. Based on this study we do not recommend routine computed tomography post heart transplantation. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

How Quickly Do Asymptomatic Infrarenal Abdominal Aortic Aneurysms Grow and What Factors Affect Aneurysm Growth Rates? Analysis of a Single Centre Surveillance Cohort Database.

PubMed

Ahmad, Mehtab; Mistry, Rakesh; Hodson, James; Bradbury, Andrew W

2017-11-01

Abdominal aortic aneurysm (AAA) maximum antero-posterior diameter (MAPD) is the parameter most commonly used to inform the timing of surgical intervention. However, other factors, such as growth rates and patient comorbidities are likely to be important considerations as they may influence AAA related complications including rupture, operative outcomes, and the clinical and cost effectiveness of continued surveillance. This was a retrospective analysis of a 20 year period of a single centre AAA surveillance database. In total, 5363 AAA measurements in 692 patients were analysed for patient demographics, including comorbidity and drug history, growth and rupture rates, and cause of death. A significant proportion of patients (n = 73; 11%) were kept under surveillance despite having a MAPD < 30 mm. Overall, mean aneurysm growth rate was 2.3 mm/year. Elective repair was undertaken in 20.1% and those who required surgical intervention had significantly faster growth rates. Only 3.9% of patients in surveillance ruptured, 40.7% of whom had a MAPD <55 mm at their last scan. Of the 214 deaths recorded, only 11.7% were related to AAA. The majority of patients who died in surveillance did so from malignancy. Patients with larger AAA (MAPD > 40 mm) on entry into surveillance were significantly more likely to receive surgical intervention, as were those whose AAA expanded >4 mm/year. Females had significantly higher growth rates, and those with diabetes had significantly smaller growth rates. Other comorbidities and drug history were not associated with AAA growth, or 5 and 10 year surgery free survival. The results highlight several areas for service improvement. Specifically, it is important not to maintain surveillance in patients who are very unlikely to ever grow to a point where AAA surgery would be contemplated on grounds or age and/or comorbidity. Similarly, patients should be discharged from surveillance when this likelihood becomes apparent. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era.

PubMed

Pecoraro, Felice; Gloekler, Steffen; Mader, Caecilia E; Roos, Malgorzata; Chaykovska, Lyubov; Veith, Frank J; Cayne, Neal S; Mangialardi, Nicola; Neff, Thomas; Lachat, Mario

2018-03-01

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90 days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.

Comparison of idiopathic (isolated) aortitis and giant cell arteritis-related aortitis. A French retrospective multicenter study of 117 patients.

PubMed

Espitia, Olivier; Samson, Maxime; Le Gallou, Thomas; Connault, Jérôme; Landron, Cedric; Lavigne, Christian; Belizna, Cristina; Magnant, Julie; de Moreuil, Claire; Roblot, Pascal; Maillot, François; Diot, Elisabeth; Jégo, Patrick; Durant, Cécile; Masseau, A; Brisseau, Jean-Marie; Pottier, Pierre; Espitia-Thibault, Alexandra; Santos, Anabele Dos; Perrin, François; Artifoni, Mathieu; Néel, Antoine; Graveleau, Julie; Moreau, Philippe; Maisonneuve, Hervé; Fau, Georges; Serfaty, Jean-Michel; Hamidou, Mohamed; Agard, Christian

2016-06-01

The aim of the study was to compare clinical/imaging findings and outcome in patients with idiopathic (isolated aortitis, IA) and with giant cell arteritis (GCA)-related aortitis. Patients from 11 French internal medicine departments were retrospectively included. Aortitis was defined by aortic wall thickening >2mm and/or an aortic aneurysm on CT-scan, associated to inflammatory syndrome. Patients with GCA had at least 3 ACR criteria. Aortic events (aneurysm, dissection, aortic surgeries) were reported, and free of aortic events-survival were compared. Among 191 patients with non-infectious aortitis, 73 with GCA and 44 with IA were included. Patients with IA were younger (65 vs 70 years, p=0.003) and comprised more past/current smokers (43 vs 15%, p=0.0007). Aortic aneurisms were more frequent (38% vs 20%, p=0.03), and aortic wall thickening was more pronounced in IA. During follow-up (median=34 months), subsequent development of aortic aneurysm was significantly lower in GCA when compared to IA (p=0.009). GCA patients required significantly less aortic surgery during follow-up than IA patients (p=0.02). Mean age, sex ratio, inflammatory parameters, and free of aortic aneurism survival were equivalent in patients with IA ≥ 60 years when compared to patients with GCA-related aortitis. IA is more severe than aortitis related to GCA, with higher proportions of aortic aneurism at diagnosis and during follow-up. IA is a heterogeneous disease and its prognosis is worse in younger patients <60 years. Most patients with IA ≥ 60 years share many features with GCA-related aortitis. Copyright © 2016 Elsevier B.V. All rights reserved.

Vocal cord paralysis after aortic surgery.

PubMed

DiLisio, Ralph P; Mazzeffi, Michael A; Bodian, Carol A; Fischer, Gregory W

2013-06-01

The purpose of this study was to investigate variables associated with vocal cord paralysis during complex aortic procedures. A retrospective review. A tertiary care center. Four hundred ninety-eight patients who underwent aortic surgery between 2002 and 2007. Two groups were studied. Group A patients had procedures only involving their aortic root and/or ascending aorta. Group B patients had procedures only involving their aortic arch and/or descending aorta. The incidence of vocal cord paralysis was higher (7.26% v 0.8%) in group B patients (p < 0.0001). Increasing the duration of cardiopulmonary bypass time was associated with an increased risk of vocal cord paralysis and death in both groups A and B (p = 0.0002 and 0.002, respectively). Additionally, within group B, descending aneurysms emerged as an independent risk factor associated with vocal cord paralysis (p = 0.03). Length of stay was statistically significantly longer among group A patients who suffered vocal cord paralysis (p = 0.017) and trended toward significance in group B patients who suffered vocal cord paralysis (p = 0.059). The association between tracheostomy and vocal cord paralysis among group A patients reached statistical significance (p = 0.007) and trended toward significance in group B patients (p = 0.057). Increasing duration of cardiopulmonary bypass time was associated with a higher risk of vocal cord paralysis in patients undergoing aortic surgery. Additionally, within group B patients, descending aortic aneurysm was an independent risk factor associated with vocal cord paralysis. Most importantly, vocal cord paralysis appeared to have an association between an increased length of stay and tracheostomy among a select group of patients undergoing aortic surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

Treatment of tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis: A case series and a literature review.

PubMed

Xue, Jing; Yao, Yimin; Liu, Limin

2018-04-01

Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis is a rare disease but with very high mortality. We review the literature and find 19 reports with 22 patients. Here we report three cases with vertebral tuberculosis, who also have tuberculous pseudoaneurysm of the aorta. These patients were treated by different methods. We try to analyze the epidemiology, pathogenesis, presentation, and management of this disease to find the best treatment. The patients presented with different symptoms such as pain (chest, abdominal or back), fever, blood volume reduction or hemorrhagic shock symptoms. Large mass also could be observed by imaging. In addition to clinical manifestations, enhanced computed tomography or magnetic resonance imaging could also help the diagnosis of this disease. Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis. Three patients were treated with anti-tuberculosis(TB) drugs or combined with different sequences surgical treatment: Case 1 refused to receive pseudoaneurysm surgery and only had anti-TB drug treatment; Case 2 received thoracic spinal surgery first; Case 3 received endovascular stent grafting. Two patients (case 1 and case 2) who refused to undergo aneurysm surgery died. The last patient (case 3) underwent endovascular repair and antibiotic therapy for tuberculosis, and the postoperative course was uneventful; the patient recovered and survived. Once the diagnosis of tuberculous pseudoaneurysm is confirmed, surgical treatment should be provided immediately combined with anti-tuberculosis drugs. The aim of the treatment is to save lives, prevent relapse, and facilitate the return to normal life, regardless of the size of the pseudoaneurysm. The pseudoaneurysm should be treated first to prevent aneurysm rupture before the vertebral tuberculosis surgery.

Setting high-impact clinical research priorities for the Society for Vascular Surgery.

PubMed

Kraiss, Larry W; Conte, Michael S; Geary, Randolph L; Kibbe, Melina; Ozaki, C Keith

2013-02-01

With the overall goal of enhancing the effectiveness and efficiency of vascular care, the Society for Vascular Surgery (SVS) recently completed a process by which it identified its top clinical research priorities to address critical gaps in knowledge guiding practitioners in prevention and treatment of vascular disease. After a survey of the SVS membership, a panel of SVS committee members and opinion leaders considered 53 distinct research questions through a structured process that resulted in identification of nine clinical issues that were felt to merit immediate attention by vascular investigators and external funding agencies. These are, in order of priority: (1) define optimal management of asymptomatic carotid stenosis, (2) compare the effectiveness of medical vs invasive treatment (open or endovascular) of vasculogenic claudication, (3) compare effectiveness of open vs endovascular infrainguinal revascularization as initial treatment of critical limb ischemia, (4) develop and compare the effectiveness of clinical strategies to reduce cardiovascular and other perioperative complications (eg, wound) after vascular intervention, (5) compare the effectiveness of strategies to enhance arteriovenous fistula maturation and durability, (6) develop best practices for management of chronic venous ulcer, (7) define optimal adjunctive medical therapy to enhance the success of lower extremity revascularization, (8) identify and evaluate medical therapy to prevent abdominal aortic aneurysm growth, and (9) evaluate ultrasound vs computed tomographic angiography surveillance after endovascular aneurysm repair. Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Hip joint replacement

MedlinePlus

... Total hip replacement; Hip hemiarthroplasty; Arthritis - hip replacement; Osteoarthritis - hip replacement ... total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised ...

Assessment of open operative vascular surgical experience among general surgery residents.

PubMed

Krafcik, Brianna M; Sachs, Teviah E; Farber, Alik; Eslami, Mohammad H; Kalish, Jeffrey A; Shah, Nishant K; Peacock, Matthew R; Siracuse, Jeffrey J

2016-04-01

General surgeons have traditionally performed open vascular operations. However, endovascular interventions, vascular residencies, and work-hour limitations may have had an impact on open vascular surgery training among general surgery residents. We evaluated the temporal trend of open vascular operations performed by general surgery residents to assess any changes that have occurred. The Accreditation Council for Graduate Medical Education's database was used to evaluate graduating general surgery residents' cases from 1999 to 2013. Mean and median case volumes were analyzed for carotid endarterectomy, open aortoiliac aneurysm repair, and lower extremity bypass. Significance of temporal trends were identified using the R(2) test. The average number of carotid endarterectomies performed by general surgery residents decreased from 23.1 ± 14 (11.6 ± 9 chief, 11.4 + 10 junior) cases per resident in 1999 to 10.7 ± 9 (3.4 ± 5 chief, 7.3 ± 6 junior) in 2012 (R(2) = 0.98). Similarly, elective open aortoiliac aneurysm repairs decreased from 7.4 ± 5 (4 ± 4 chief, 3.4 ± 4 junior) in 1999 to 1.3 ± 2 (0.4 ± 1 chief, 0.8 ± 1 junior) in 2012 (R(2) = 0.98). The number of lower extremity bypasses decreased from 21 ± 12 (9.5 ± 7 chief, 11.8 ± 9 junior) in 1999 to 7.6 ± 2.6 (2.4 ± 1.3 chief, 5.2 + 1.8 junior) in 2012 (R(2) = 0.94). Infrapopliteal bypasses decreased from 8.1 ± 3.8 (3.5 ± 2.2 chief, 4.5 ± 2.9 junior) in 2001 to 3 ± 2.2 (1 ± 1.6 chief, 2 ± 1.6 junior) in 2012 (R(2) = 0.94). General surgery resident exposure to open vascular surgery has significantly decreased. Current and future graduates may not have adequate exposure to open vascular operations to be safely credentialed to perform these procedures in future practice without advanced vascular surgical training. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Cytochrome P450 3A4 activity after surgical stress.

PubMed

Haas, Curtis E; Kaufman, David C; Jones, Carolyn E; Burstein, Aaron H; Reiss, William

2003-05-01

To evaluate the relationship between the acute inflammatory response after surgical trauma and changes in hepatic cytochrome P450 3A4 activity, compare changes in cytochrome P450 3A4 activity after procedures with varying degrees of surgical stress, and to explore the time course of any potential drug-cytokine interaction after surgery. Prospective, open-label study with each patient serving as his or her own control. University-affiliated, acute care, general hospital. A total of 16 patients scheduled for elective repair of an abdominal aortic aneurysm (n = 5), complete or partial colectomy (n = 6), or peripheral vascular surgery with graft (n = 5). Cytochrome P450 3A4 activity was estimated using the carbon-14 [14C]erythromycin breath test (ERMBT) before surgery and 24, 48, and 72 hrs after surgery. Abdominal aortic aneurysm and colectomy patients also had an ERMBT performed at discharge. Blood samples were obtained before surgery, immediately after surgery, and 6, 24, 32, 48, and 72 hrs after surgery for determination of plasma concentrations of interleukin-6, interleukin-1beta, and tumor necrosis factor-alpha. Clinical markers of surgical stress that were collected included duration of surgery, estimated blood loss, and volume of fluids administered in the operating room. ERMBT results significantly declined in all three surgical groups, with the lowest value at the time of the 72-hr study in all three groups. There was a trend toward differences in ERMBT results among groups that did not reach statistical significance (p =.06). The nadir ERMBT result was significantly and negatively correlated with both peak interleukin-6 concentration (r(s) = -.541, p =.03) and log interleukin-6 area under the curve from 0 to 72 hrs (r(s) = -.597, p =.014). Subjects with a peak interleukin-6 of >100 pg/mL had a significantly lower nadir ERMBT compared with subjects with a peak interleukin-6 of <100 pg/mL (35.5% +/- 5.2% vs. 74.7% +/- 5.1%, p <.001). Acute inflammation after elective surgery was associated with a significant decline in cytochrome P450 3A4 activity, which is predictive of clinically important changes in the metabolism of commonly used drugs that are substrates for this enzyme.

Quality and Safety in Health Care, Part XXX: Transcatheter Aortic Valve Therapy.

PubMed

Harolds, Jay A

2017-12-01

Initially, the transcatheter aortic valve replacement procedure was approved only for patients with aortic stenosis that was both severe and symptomatic who either also had too high a risk of aortic valve replacement surgery to have the surgery or who had a high risk for the surgery. Between the years 2012 and 2015, the death rate at 30 days declined from an initial rate of 7.5% to 4.6%. There has also been more use of the transfemoral approach over the years. In 2016, the transcatheter aortic valve replacement was approved for patients with aortic stenosis at intermediate risk of surgery.

Evidence-based Surgery of Aortic Regurgitation: Results of a Questionnaire in German-speaking Countries.

PubMed

Dinges, Christian; Steindl, Johannes; Hitzl, Wolfgang; Kiesslich, Tobias; Seitelberger, Rainald

2018-06-01

evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons ( n  = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed. Georg Thieme Verlag KG Stuttgart · New York.

Predictive models for mortality after ruptured aortic aneurysm repair do not predict futility and are not useful for clinical decision making.

PubMed

Thompson, Patrick C; Dalman, Ronald L; Harris, E John; Chandra, Venita; Lee, Jason T; Mell, Matthew W

2016-12-01

The clinical decision-making utility of scoring algorithms for predicting mortality after ruptured abdominal aortic aneurysms (rAAAs) remains unknown. We sought to determine the clinical utility of the algorithms compared with our clinical decision making and outcomes for management of rAAA during a 10-year period. Patients admitted with a diagnosis rAAA at a large university hospital were identified from 2005 to 2014. The Glasgow Aneurysm Score, Hardman Index, Vancouver Score, Edinburgh Ruptured Aneurysm Score, University of Washington Ruptured Aneurysm Score, Vascular Study Group of New England rAAA Risk Score, and the Artificial Neural Network Score were analyzed for accuracy in predicting mortality. Among patients quantified into the highest-risk group (predicted mortality >80%-85%), we compared the predicted with the actual outcome to determine how well these scores predicted futility. The cohort comprised 64 patients. Of those, 24 (38%) underwent open repair, 36 (56%) underwent endovascular repair, and 4 (6%) received only comfort care. Overall mortality was 30% (open repair, 26%; endovascular repair, 24%; no repair, 100%). As assessed by the scoring systems, 5% to 35% of patients were categorized as high-mortality risk. Intersystem agreement was poor, with κ values ranging from 0.06 to 0.79. Actual mortality was lower than the predicted mortality (50%-70% vs 78%-100%) for all scoring systems, with each scoring system overestimating mortality by 10% to 50%. Mortality rates for patients not designated into the high-risk cohort were dramatically lower, ranging from 7% to 29%. Futility, defined as 100% mortality, was predicted in five of 63 patients with the Hardman Index and in two of 63 of the University of Washington score. Of these, surgery was not offered to one of five and one of two patients, respectively. If one of these two models were used to withhold operative intervention, the mortality of these patients would have been 100%. The actual mortality for these patients was 60% and 50%, respectively. Clinical algorithms for predicting mortality after rAAA were not useful for predicting futility. Most patients with rAAA were not classified in the highest-risk group by the clinical decision models. Among patients identified as highest risk, predicted mortality was overestimated compared with actual mortality. The data from this study support the limited value to surgeons of the currently published algorithms. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Bioactive titan cage Implaspin in treatment of degenerative disease of the cervcal spine--the results from 2007 till 2008.

PubMed

Filip, Michal; Linzer, Petr; Sámal, Filip; Jurek, Patrik; Strnad, Zdenek; Strnad, Jakub

2010-01-01

The authors present results of surgical treatment of cervical spine degenerative disease via Implaspin biotitanium replacement. Surgery was indicated for a group of 24 patients with symptoms of cervical spondylogenic myelopathy or the irritation decay root syndrome non-reacting to conservative treatment. Pre-surgery X-ray and MRI examinations showed spinal canal stenosis caused by the intervertebral disk osteochondrosis combined with prolapse or dorsal osteophytes. Clinical problems of the group of patients were evaluated through the JOA classification before surgery and during the 2nd, the 6th and month 12th after surgery. The surgery rate of success was evaluated in percentages during post-surgery examinations that took place in the 12th month. Based on the JOA classification, that rate of success falls into the good surgery results zone. The post-surgery X-ray examinations showed two sank replacements by 1/3 of its height into the surrounding vertebral bodies. In these cases we performed the control MRI. No signs of the new spinal compression were found and the spinal canal was free in the operated site. Based on our short-term experiences, the Implaspin bioactive replacement seems to be a suitable alternative to the other types of replacements designed for intervertebral fusion in the lower cervical spine area.

Safety and feasibility of endovascular aortic aneurysm repair as day surgery.

PubMed

Hanley, Stephen C; Steinmetz, Oren; Mathieu, Eva S; Obrand, Daniel; Mackenzie, Kent; Corriveau, Marc-Michel; Abraham, Cherrie Z; Gill, Heather L

2018-06-01

The adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. We developed criteria to identify patients for potential same-day discharge (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then implemented a prospective trial that observed patients planned for same-day discharge and compared them with a historical control group (patients who had undergone EVAR during the previous 2 years and met same-day discharge criteria). Basic demographic and operative data as well as length of stay, inpatient and perioperative complications, emergency department visits, readmissions, reinterventions, and deaths were collected. The primary outcome was the 30-day complication rate, and the study was powered to assess noninferiority. Prospectively, we assessed 266 patients and planned 110 (41%) for outpatient EVAR (62% of historical controls met outpatient criteria). Demographic characteristics were similar between planned outpatients and historical controls. In planned outpatients, hospital stay was significantly shorter (0.7 ± 2.6 days vs 2.5 ± 6.9 days; P < .01), and 79% were discharged the same day of surgery. The 30-day follow-up was available for all study patients and 94% of control patients; there were no differences in complication (11% vs 9%), readmission (2% vs 4%), reintervention (4% vs 4%), or mortality (1% vs 1%) rates, but study patients had significantly more emergency department visits (15% vs 6%; P < .05). Unsuccessful same-day discharge was associated with longer operative times, increased blood loss, and use of general anesthesia. In selected patients undergoing elective EVAR, same-day discharge is feasible without increasing complication rates. Health resource utilization remains a challenge in transitioning to an outpatient model. Copyright © 2018. Published by Elsevier Inc.

Effect of endoskeleton stent graft design on pulse wave velocity in patients undergoing endovascular repair of the aortic arch.

PubMed

Hori, Daijiro; Akiyoshi, Kei; Yuri, Koichi; Nishi, Satoshi; Nonaka, Takao; Yamamoto, Takahiro; Imamura, Yusuke; Matsumoto, Harunobu; Kimura, Naoyuki; Yamaguchi, Atsushi

2017-09-01

Pulse wave velocity (PWV), which measures vascular stiffness, is a powerful predictor of cardiovascular event. Treatment of aneurysms with endovascular prosthesis has been reported to increase PWV. The purpose of this study was to evaluate whether an endoskeleton stent graft design has less effect on PWV than the exoskeleton stent graft design. Between July 2008 and September 2016, 74 patients underwent endovascular treatment of aortic arch aneurysm in our institution. PWV before and after surgery were compared between those who underwent treatment with Najuta, an endoskeleton stent graft (n = 51), and those treated with other commercially available exoskeleton stent grafts (n = 23). Preoperative PWV (endoskeleton: 2004 ± 379.2 cm/s vs. exoskeleton: 2083 ± 454.5 cm/s, p = 0.47) was similar between the two groups. Factors that were associated with preoperative PWV were age (r = 0.37, 95% CI 0.15-0.56, p = 0.002) and mean arterial pressure (r = 0.53, 95% CI 0.34-0.68, p < 0.001). There was a significant increase in PWV in patients treated by exoskeleton stent grafts (before: 2083 ± 454.5 cm/s vs. after: 2305 ± 479.7 cm/s, p = 0.023) while endoskeleton stent graft showed no change in PWV (before: 2003 ± 379.2 vs. after: 2010 ± 521.1, p = 0.56). In a multivariate analysis, mean arterial pressure (coef 17.5, 95% CI 6.48-28.59, p = 0.002) and exoskeleton stent graft (coef 359.4, 95% CI 89.36-629.43, p = 0.010) were independently associated with PWV after surgery. Physiological changes after endovascular treatment should be considered including effect on vascular stiffness. Endoskeleton stent graft may provide aneurysm repair with minimum effect in PWV after surgery.

Towards the evaluation of the pathological state of ascending thoracic aneurysms: integration of in-vivo measurements and hemodynamic simulations

NASA Astrophysics Data System (ADS)

Boccadifuoco, Alessandro; Mariotti, Alessandro; Celi, Simona; Martini, Nicola; Salvetti, Maria Vittoria

2016-11-01

Ascending thoracic aortic aneurysms are cardiovascular diseases consisting in a dilation of the ascending thoracic aorta. Since indicating a weakness of the arterial wall, they can lead to major complications with significant mortality rate. Clinical decisions about surgery are currently based on the maximum aortic diameter, but this single index does not seem a reliable indicator of the pathological state of the aorta. Numerical simulations of the blood flow inside the aneurysm may give supplementary information by quantifying important indices that are difficult to be measured, like the wall shear stress. Our aim is to develop an efficient platform in which in-vivo measurements are used to perform the hemodynamic simulations on a patient-specific basis. In particular, we used real geometries of thoracic aorta and focused on the use of clinical information to impose accurate boundary conditions at the inlet/outlets of the computational model. Stochastic analysis was also performed, to evaluate how uncertainties in the boundary parameters affect the main hemodynamic indicators, by considering both rigid and deformable walls. Stochastic calibration of numerical parameters against clinical data is in progress and results will be possibly shown.

Surgery insight: advances in endovascular repair of abdominal aortic aneurysms.

PubMed

Baril, Donald T; Jacobs, Tikva S; Marin, Michael L

2007-04-01

Despite improvements in diagnostic and therapeutic methods and an increased awareness of their clinical significance, abdominal aortic aneurysms (AAAs) continue to be a major source of morbidity and mortality. Endovascular repair of AAAs, initially described in 1990, offers a less-invasive alternative to conventional open repair. The technology and devices used for endovascular repair of AAAs have progressed rapidly and the approach has proven to be safe and effective in short to midterm investigations. Furthermore, several large trials have demonstrated that elective endovascular repair is associated with lower perioperative morbidity and mortality than open repair. The long-term benefits of endovascular repair relative to open repair, however, continue to be studied. In addition to elective repair, the use of endovascular repair for ruptured AAAs has been increasing, and has been shown to be associated with reduced perioperative morbidity and mortality. Advances in endovascular repair of AAAs, including the development of branched and fenestrated grafts and the use of implantable devices to measure aneurysm-sac pressures following stent-graft deployment, have further broadened the application of the technique and have enhanced postoperative monitoring. Despite these advances, endovascular repair of AAAs remains a relatively novel technique, and further long-term data need to be collected.

Evaluation of a mobile screening service for abdominal aortic aneurysm in Broken Hill, a remote regional centre in far western NSW.

PubMed

Lesjak, Margaret S; Flecknoe-Brown, Stephen C; Sidford, Jan R; Payne, Kerryn; Fletcher, John P; Lyle, David M

2010-04-01

To evaluate the feasibility of a mobile screening service model for abdominal aortic aneurysm (AAA) in a remote population centre in Australia. Screening test evaluation. A remote regional centre (population: 20 000) in far western NSW. Men aged 65-74 years, identified from the Australian Electoral roll. A mobile screening service using directed ultrasonography, a basic health check and post-screening consultation. Attendance at the screening program, occurrence of AAA in the target population and effectiveness of screening processes. A total of 516 men without a previous diagnosis of AAA were screened, an estimated response rate of 60%. Of these, 463 (89.7%) had a normal aortic diameter, 28 (5.4%) ectatic and 25 (4.9%) a small, moderate or significant aneurysm. Two men with AAA were recommended for surgery. Feedback from participants indicated that the use of a personalised letter of invitation helped with recruitment, that the screening process was acceptable and the service valued. It is feasible to organise and operate a mobile AAA screening service from moderate sized rural and remote population centres. This model could be scaled up to provide national coverage for rural and remote residents.

Endovascular Repair of Abdominal Aortic Aneurysms in the Presence of a Transplanted Kidney

DOE Office of Scientific and Technical Information (OSTI.GOV)

Silverberg, Daniel, E-mail: silverberg-d@msn.com; Yalon, Tal; Halak, Moshe

PurposeTo present our experience performing endovascular repair of abdominal aortic aneurysms in kidney transplanted patients.MethodsA retrospective review of all patients who underwent endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) performed at our institution from 2007 to 2014. We identified all patients who had previously undergone a kidney transplant. Data collected included: comorbidities, preoperative imaging modalities, indication for surgery, stent graft configurations, pre- and postoperative renal function, perioperative complications, and survival rates.ResultsA total of 267 EVARs were performed. Six (2 %) had a transplanted kidney. Mean age was 74 (range, 64–82) years; five were males. Mean time from transplantation tomore » EVAR was 7.5 (range, 2–12) years. Five underwent preoperative planning with noncontrast modalities only. Devices used included bifurcated (n = 3), aortouniiliac (n = 2), and tube (n = 1) stent grafts. Technical success was achieved in all patients. None experienced deterioration in renal function. Median follow-up was 39 (range, 6–51) months. Four patients were alive at the time of the study. Two patients expired during the period of follow-up from unrelated causes.ConclusionsEVAR is an effective modality for the management of AAAs in the coexistence of a transplanted kidney. It can be performed with minimal morbidity and mortality without harming the transplanted kidney. Special consideration should be given to device configuration to minimize damage to the renal graft.« less

Three-year audit and cost assessment of open abdominal aortic aneurysm repair in a district general hospital.

PubMed

El Kafsi, J; Wake, J; Lintott, P; Northeast, A; McLaren, A

2009-11-01

The aims of this study were to audit the outcome of elective open abdominal aortic aneurysm (AAA) repair in a district general hospital, as well as investigate the true costs for this procedure in relation to the national tariff. A database is maintained on AAA surgery in the trust. Data were supplemented by drawing information from blood bank and clinical notes. Patients with symptomatic or emergency aneurysms were excluded. Data from January 2005 to December 2007 were obtained on demographics, morbidity, 30-day mortality and blood usage. Costs were obtained from the trust finance department. Between January 2005 and December 2007, 79 elective AAA procedures were undertaken. Median age was 75 years (range, 52-85 years), median aneurysm size was 63 mm (range, 42-105 mm) and median ITU stay was 3 days (range, 1-41 days). Major morbidity rate was 20.3% (16 of 79 patients) and 30-day mortality overall was 5.1% (4 of 79 patients). Average cost per case was pound15,012.91 (range, pound4,040.03- pound82,158.00), when National Tariff is pound6,722.00 ( pound5,649.00 x local Market Forces Factor of 1.19). Loss per case for our trust was pound8,290.91 with a total annual loss of pound218,299.56. Morbidity and mortality in this district general hospital compare well with national studies; however, the total cost is far in excess of the national tariff.

Fenestrated endovascular aortic repair and clinical trial devices for complex abdominal aortic aneurysms.

PubMed

Brinster, Clayton J; Milner, Ross

2018-06-01

Endovascular aortic repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysm (AAA), with consistently low reported perioperative morbidity and mortality. Universal applicability of EVAR to treat AAA is hindered by several specific anatomic constraints, however, and many patients cannot be treated with commercially available stent-grafts within the device specific instructions for use. Treatment of these complex pararenal aneurysms is increasingly accomplished by extension of EVAR into the visceral segment of the abdominal aorta with branches or fenestrations that allow perfusion of the visceral and renal arteries. Fenestrated endovascular aneurysm repair (FEVAR) was initially developed to treat high-risk patients unfit for open surgery and anatomically ineligible for standard infrarenal EVAR, but this technique has evolved over the past decade into a mature treatment option for complex AAA. High-volume, single-center reports, multicenter series and clinical reviews have demonstrated that FEVAR is a safe and effective technique with favorable results at proficient centers. Generalizability of these outcomes to less advanced centers remains unproven, and reintervention rates following FEVAR in the mid- and long-term, even among the most experienced centers, remain a concern. Several off-the-shelf devices that are undergoing clinical trial seek to broaden the anatomic applicability and overall availability of FEVAR. A significant number of patients are not candidates for off-the-shelf or customized stent-grafts, however, stressing the need for continued refinement of existing devices, development of novel devices with broader indications for use, and maintenance of open surgical skills.

Getting the aorta pants in place: a 'community of guidance' in the evolving practice of vascular implant surgery.

PubMed

Brattheim, Berit; Faxvaag, Arild; Tjora, Aksel

2011-09-01

The evolving nature of surgical treatments creates gaps between evidence-based guidelines and actual clinical practice.This article addresses the emerging clinical practice of the EndoVascular Aneurysm Repair (EVAR), a surgical treatment of patients with Abdominal Aortic Aneurysm (AAA). Drawing on a qualitative study across three hospitals, we identified three interplaying expertise traits: the collective, the interpersonal and the technical, each being present to promote surgical work. The evolvement of EVAR is contextualized within technical artefacts and patient characteristics, along with a joint decision approach. The intertwinement between various expertise traits and contextual factors forms a 'community of guidance', nourishing further EVAR innovation without formalized institutions, evidence, training or guidelines. However, the lack of a shared context limits the transfer of evolving knowledge across hospital boundaries.

Late Complication after Superficial Femoral Artery (SFA) Aneurysm: Stent-graft Expulsion Outside the Skin

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pecoraro, Felice, E-mail: felicepecoraro@libero.it; Sabatino, Ermanno R.; Dinoto, Ettore

A 78-year-old man presented with a 7-cm aneurysm in the left superficial femoral artery, which was considered unfit and anatomically unsuitable for conventional open surgery for multiple comorbidities. The patient was treated with stent-graft [Viabhan stent-graft (WL Gore and Associates, Flagstaff, AZ)]. Two years from stent-graft implantation, the patient presented a purulent secretion and a spontaneous external expulsion through a fistulous channel. No claudication symptoms or hemorrhagic signs were present. The pus and device cultures were positive for Staphylococcus aureus sensitive to piperacillin/tazobactam. Patient management consisted of fistula drainage, systemic antibiotic therapy, and daily wound dressing. At 1-month follow-up, themore » wound was closed. To our knowledge, this is the first case of this type of stent-graft complication presenting with external expulsion.« less

Back table outflow graft anastomosis technique for HeartWare HVAD implantation.

PubMed

Basher, S; Bick, J; Maltais, S

2015-12-01

The management of concomitant aortic and aortic valve disease with left ventricular assist device (LVAD) implantation for patients with severe cardiomyopathy is challenging, and has not been established given the complexity of LVAD surgery with concomitant aortic interventions. A 45-year-old patient presented to our institution with end-stage heart failure symptoms and non-ischemic cardiomyopathy. The patient was found to have a bicuspid aortic valve, severe native aortic regurgitation, a significant ascending aortic aneurysm, and severely depressed left ventricular (LV) function requiring two inotropes. He underwent a successful hemiarch repair of the ascending aortic aneurysm using a back table outflow graft anastomosis technique, and subsequent placement of a HeartWare Ventricular Assist Device (HVAD) with concomitant aortic valve closure with a modified Park's stitch. The patient did well postoperatively and is currently listed for heart transplantation.

Options for Heart Valve Replacement

MedlinePlus

... which may include human or animal donor tissue) Ross Procedure — “Borrowing” your healthy valve and moving it ... Considerations for Surgery Medications Valve Repair Valve Replacement - Ross Procedure - Newer Surgery Options - What is TAVR? - Types ...

Effect of prior aortic valve intervention on results of the Ross operation.

PubMed

Sakaguchi, Hidehito; Elkins, Ronald C; Lane, Mary M; McCue, Carolyn

2003-07-01

Patient-related factors, aortic insufficiency, bicuspid aortic valve, aortic annulus dilatation, ascending aortic dilatation or aneurysm, and aortic valve endocarditis have been suggested as affecting the results of the Ross operation. The study aim was to assess the impact of prior aortic valve intervention on early and late results of a Ross operation. A total of 399 patients who underwent surgery between August 1986 and September 2000 were reviewed retrospectively. The patients were grouped as: no prior aortic valve intervention (NOAVI, n = 219); prior aortic valvuloplasty (AVP, n = 106); prior balloon aortic valvuloplasty (AVB, n = 40); and prior aortic valve replacement (AVR, n = 34). Details of operative and late mortality, autograft valve function, and homograft valve function were analyzed. Operative mortality was higher for AVB (10%; three deaths in neonates) than the other groups (from 2.3% to 5.9%) (p = 0.084). Freedom from autograft valve degeneration, defined as severe autograft valve insufficiency, non-endocarditis autograft valve reoperation or valve-related death, ranged from 93 +/- 3% for AVP to 76 +/- 8% for NOAVI at 10 years (p = 0.43). Freedom from homograft reoperation in the pulmonary position was 100% for AVB at six years, and 99 +/- 1% for AVP, 82 +/- 8% for NOAVI, and 70 +/- 13% for AVR at 10 years (p = 0.0026). There appears to be no significant difference between patients with and without prior aortic valve surgery, with respect to operative mortality or late autograft function. However, patients with prior AVR appear to have a significantly higher homograft reoperation rate after a Ross operation, the reasons for which are uncertain.

Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis.

PubMed

Wallis, Jason A; Taylor, Nicholas F

2011-12-01

To determine if pre-operative interventions for hip and knee osteoarthritis provide benefit before and after joint replacement. Systematic review with meta-analysis of randomised controlled trials (RCTs) of pre-operative interventions for people with hip or knee osteoarthritis awaiting joint replacement surgery. Standardised mean differences (SMD) were calculated for pain, musculoskeletal impairment, activity limitation, quality of life, and health service utilisation (length of stay and discharge destination). The GRADE approach was used to determine the quality of the evidence. Twenty-three RCTs involving 1461 participants awaiting hip or knee replacement surgery were identified. Meta-analysis provided moderate quality evidence that pre-operative exercise interventions for knee osteoarthritis reduced pain prior to knee replacement surgery (SMD (95% CI)=0.43 [0.13, 0.73]). None of the other meta-analyses investigating pre-operative interventions for knee osteoarthritis demonstrated any effect. Meta-analyses provided low to moderate quality evidence that exercise interventions for hip osteoarthritis reduced pain (SMD (95% CI)=0.52 [0.04, 1.01]) and improved activity (SMD (95% CI)=0.47 [0.11, 0.83]) prior to hip replacement surgery. Meta-analyses provided low quality evidence that exercise with education programs improved activity after hip replacement with reduced time to reach functional milestones during hospital stay (e.g., SMD (95% CI)=0.50 [0.10, 0.90] for first day walking). Low to moderate evidence from mostly small RCTs demonstrated that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement. Copyright © 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

The effects of acute and elective cardiac surgery on the anxiety traits of patients with Marfan syndrome.

PubMed

Benke, Kálmán; Ágg, Bence; Pólos, Miklós; Sayour, Alex Ali; Radovits, Tamás; Bartha, Elektra; Nagy, Péter; Rákóczi, Balázs; Koller, Ákos; Szokolai, Viola; Hedberg, Julianna; Merkely, Béla; Nagy, Zsolt B; Szabolcs, Zoltán

2017-07-17

Marfan syndrome is a genetic disease, presenting with dysfunction of connective tissues leading to lesions in the cardiovascular and skeletal muscle system. Within these symptoms, the most typical is weakness of the connective tissue in the aorta, manifesting as aortic dilatation (aneurysm). This could, in turn, become annuloaortic ectasia, or life-threatening dissection. As a result, life-saving and preventative cardiac surgical interventions are frequent among Marfan syndrome patients. Aortic aneurysm could turn into annuloaortic ectasia or life-threatening dissection, thus life-saving and preventive cardiac surgical interventions are frequent among patients with Marfan syndrome. We hypothesized that patients with Marfan syndrome have different level of anxiety, depression and satisfaction with life compared to that of the non-clinical patient population. Patients diagnosed with Marfan syndrome were divided into 3 groups: those scheduled for prophylactic surgery, those needing acute surgery, and those without need for surgery (n = 9, 19, 17, respectively). To examine the psychological features of the patients, Spielberger's anxiety (STAI) test, Beck's Depression questionnaire (BDI), the Berne Questionnaire of Subjective Well-being, and the Satisfaction with Life scale were applied. A significant difference was found in trait anxiety between healthy individuals and patients with Marfan syndrome after acute life-saving surgery (p < 0.01). The mean score of Marfan syndrome patients was 48.56 (standard deviation (SD): 5.8) as compared to the STAI population mean score of 43.72 (SD: 8.53). No difference was found between groups on the BDI (p > 0.1). Finally, a significant, medium size effect was found between patient groups on the Joy in Living scale (F (2.39) = 3.51, p = 0.040, η 2  = 0.15). Involving psychiatric and mental-health care, in addition to existing surgical treatment interventions, is essential for more successful recovery of patients with Marfan syndrome.

Etidronate

MedlinePlus

... the skeleton) in people who have had total hip replacement surgery (surgery to replace the hip joint with an artificial joint) or in people ... 8 ounces [180 to 240 mL]) of plain water while you are sitting or standing. Sit or ...

[Intrathecal baclofen therapy for spastic paraparesis due to aortic dissecting aneurysm; recent progress in treatment strategy].

PubMed

Nakajima, T; Akagawa, H; Ochiai, T; Hayashi, M; Goto, S; Taira, T; Okada, Y

2009-11-01

A 48-year-old man suffered from acute dissection of thoracic aortic aneurysm which eventually led to replacement of the ascending aorta with a tube graft. During this clinical course, circulatory failure in intercostal artery resulted in spinal cord infarction followed by moto-sensory disturbance below Th7 dermatomic area. Seven months later, spasticity with pain in both lower extremities became conspicuous that was uncontrollable by any oral medication. Eventually the patient underwent the implantation of continuous infusion pump for intrathecal baclofen therapy (ITB). The clinical condition was remarkably improved and now has been well controlled. ITB, authorized by Japanese Ministry of Health Labour and Welfare in 2006, has notable therapeutic effects on spasticity derived from any sort of central nervous disorder. More promotive enlightenment if ITB is indispensable for enhancement of its medical benefit in Japan.

An L-Shaped Incision for an Extensive Thoracic Aortic Aneurysm and Coronary Artery Bypass Using the Left Internal Thoracic Artery.

PubMed

Abe, Tomonobu; Suenaga, Hiroto; Oshima, Hideki; Araki, Yoshimori; Mutsuga, Masato; Fujimoto, Kazuro; Usui, Akihiko

2015-04-01

An L-shaped incision combining an upper half mid-sternotomy and a left antero-lateral thoracotomy at the fourth intercostal space has been proposed by several authors for extensive aneurysms involving the aortic arch and the proximal thoracic descending aorta. This approach usually requires the division of the left internal thoracic artery at its mid position, thus making it unusable for coronary artery bypass. We herein report a modified surgical approach for simultaneous extensive arch and proximal thoracic descending aorta replacement and coronary artery bypass using the left internal thoracic artery combining a left antero-lateral thoracotomy at the sixth intercostal space and upper mid-sternotomy. The visualization of the whole diseased aorta down to the level below the hilum of the left lung was good, and the integrity of the left internal thoracic artery graft was preserved by early heparin administration before sternotomy.