Inflammatory abdominal aortic aneurysm: predictors of long-term outcome in a case-control study

BACKGROUND: Inflammatory abdominal aortic aneurysms (AAAs) are relatively rare clinical entities. The aim of this study is to ascertain the risk factors in patients with inflammatory AAAs and clarify which feature plays a role in determining the long-term outcome in these patients. METHODS: Between 1990 and 1997, 238 patients underwent surgery for an AAA at our institution, 17 (7.1%) of whom had the diagnosis of inflammatory type AAA. This group was matched in a case-control fashion to a group of 35 patients with similar characteristics of age, gender, and preoperative risk factors who were operated on for a noninflammatory AAA. All available clinical, pathologic, and postoperative variables were retrospectively reviewed, and the 2 groups were compared. In the inflammatory group, risk factor analysis was performed for poor outcome. RESULTS: All operations were performed through a standard transperitoneal median laparotomy. The 2 groups did not differ significantly in terms of clinical characteristics and preoperative risk factors Patients with inflammatory AAAs were significantly more symptomatic (100% vs 31%, P = .03) and had larger aneurysm size on admission (8.2 +/- 1.2 cm vs 6.1 +/- 0.4 cm, P = .04). In inflammatory AAAs, preoperative erythrocyte sedimentation rate was found to be significantly elevated (mean, 48 +/- 14 mm/h vs 8 +/- 3 mm/h, P = .01). Surgical morbidity and mortality rates did not differ between 2 groups. The intensive care unit and hospital stay periods were similar in both groups (2.2 days vs 1.8 days, P = .25, and 9.2 days vs 8.1 days, P = .35). Eight-year survival rates of inflammatory and noninflammatory groups were 60% and 74%, respectively (P = .01). Results from Cox proportional hazards model analysis showed that a high sedimentation rate after surgical intervention (P = .02), cardiovascular disease (P = .01), postoperative persisting fibrosis with ureteral entrapment (P = .01), and postoperative chronic renal failure (P = .02) were independent risk factors for death. Other surgical variables did not prove to be risk factors for long-term mortality. CONCLUSIONS: Although the preoperative characteristics may differ in patients with inflammatory type AAAs, they can be treated today with low morbidity and mortality rates. However, inflammatory process may continue postoperatively because of unknown reasons, and the study documented that persisting, postoperative inflammatory process with or without retroperitoneal fibrosis may place a patient at high risk for poor outcome. This is important information for the long-term management of these patients, and we believe that their follow-up protocols should be more comprehensive to further improve their long-term survival rates.     

Intracranial clips: an examination of the devices used for aneurysm surgery

A properly functioning aneurysm clip is of paramount importance in the surgical ablation of intracranial aneurysms. An appropriate match between the closing force needed to ablate an aneurysm and the force exerted by the aneurysm clip must be achieved. In this study, the opening and closing forces exerted by several commonly used aneurysm clips were tested. There was a strong correlation between the classification of the clips, according to the Dujovny system, and their mechanical behavior. Minimal variability among different lots of the same clip type and minimal hysteresis were generally exhibited by the alpha mobile fulcrum class clips, such as the Yasargil, Vari-Angle McFadden, Scoville, and Mayfield clips. Significant exceptions included several types of Mayfield and Drake clips. In contrast, pivot class clips generally showed twice as much lot variability among different lots, as well as a significant amount of hysteresis. Clips of this class include the Vari-Angle, Heifetz, and Pivot clips. Because significant variations in clip force exist and because several other factors can compound these differences, it is suggested that aneurysm clips be individually tested for their closing forces before they are used in an operation.     

Screening study of abdominal aortic aneurysm in a general population: lipid parameters

The level of blood lipids and apolipoproteins in subjects being screened for abdominal aortic aneurysms have been investigated. As part of an ultrasound screening programme in a population of 65- to 75-year-olds, blood samples were collected from 1460 of 1504 subjects with a normal aorta (97.1%) and 69 of 70 patients with an abdominal aortic aneurysm >29 mm (99%). Samples were also taken from 22 of 27 patients (81%) with an ectatic aorta (26–29 mm). Total cholesterol, HDL-cholesterol, LDL-cholesterol, Apo-AI and Apo-B levels were significantly higher in women than in men (P < 0.01). Levels of HDL-cholesterol and Apo-AI were significantly lower in patients with an abdominal aortic aneurysm than in normal subjects (P < 0.001). The mean (s.d.) body mass index was 25.1 (3.9) in women and 25.5(3.2) in men with aneurysms and not significantly greater than that of normal subjects (25.2(3.61) and 25.2(3.38) respectively). Copyright © 1996 The International Society for Cardiovascular Surgery.     

Nature,frequency, and predictors of secondary procedures after endovascular repair of abdominal aortic aneurysm

OBJECTIVES: Endovascular stent grafting offers a potentially less invasive option for treatment of abdominal aortic aneurysm. Clinical benefit has been demonstrated with respect to early parameters such as blood transfusion, return of gastrointestinal function, and length of hospital stay. Endovascular repair, however, has been criticized on the basis of inferior long-term outcome. Secondary procedures may be necessary to address durability issues such as migration, high-pressure endoleak, graft limb thrombosis, and degeneration of the stent-fabric structure itself, issues that may compromise the primary goal of aneurysm repair, protection from rupture. METHODS: Between 1996 and 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysm at The Cleveland Clinic Foundation. During this time, five devices were used: Ancure, AneuRx, Excluder, Talent, and Zenith. Outcome was assessed with physical examination, lower extremity arterial studies, plain abdominal radiography, and computed tomography at discharge, at 1, 6, and 12 months postoperatively, and annually thereafter. Secondary procedures were defined as any procedure, exclusive of diagnostic angiography, performed after stent graft implantation, directed at treatment of aneurysm-related events. Multivariable statistical techniques for censored data (Cox proportional hazards modeling) were used to determine baseline parameters associated with need for secondary procedures over follow-up, with calculation of hazards ratio (HR) and 95% confidence interval (CI). RESULTS: Patient follow-up averaged 12.2 +/- 11.7 months. Patient survival was 90% +/- 1.4% at 1 year, 78% +/- 2.6% at 2 years, and 70% +/- 3.8% at 3 years. Aneurysm rupture occurred in 3 patients (0.4%), accounting for rupture risk of 1.4% over the first 2 years of follow-up (Kaplan-Meier method). Overall, 128 secondary procedures were required in 104 patients (15%), with a cumulative risk of 12% +/- 1.5% at 1 year, 24% +/- 2.8% at 2 years, and 35% +/- 4.4% at 3 years after stent graft implantation. Among the secondary procedures, new stent grafts and extensions were placed in 34 patients (27%), embolization of endoleak was performed in 33 patients (26%), and open surgical conversion was undertaken in 11 patients (9%). Periprocedural mortality of secondary procedures was 8% overall, but was 18% for patients undergoing open surgical conversion. Multivariable modeling identified the date the procedure was performed (HR, 1.53 per 3-month period of study; CI, 1.22-1.92; P <.001) and aneurysm size (HR, 1.35 per centimeter of minor axis; CI, 1.13-1.60; P <.001) as independent predictors of need for secondary procedures. CONCLUSIONS: Current endovascular devices are associated with a relatively high rate of complications over mid-term follow-up, culminating in frequent need for secondary remedial procedures. With strict follow-up imaging compliance, however, risk for rupture and aneurysm-related death remain exceedingly low. Newer technology may achieve improved durability and a lower requirement for secondary procedures, while maintaining the minimally invasive nature of presently available devices.     

Intracranial mycotic aneurysm in an infant: report of a case

Although mycotic aneurysms tend to occur with greater frequency in children than adults, few cases of intracranial infectious aneurysms have been reported in children less than 1 year of age. The case of a previously healthy 7-month-old patient who suffered intracerebral and subarachnoid hemorrhage from multiple aneurysms of the middle cerebral artery is reported. The aneurysms proved to be infectious, based on culture material obtained at surgery from the aneurysm contents and adjacent brain tissue.     

Intraoperative ultrasonography with a cystoscope for the biopsy of a deep-seated brain lesion: case study

An intraoperative technique for deep brain biopsy is described. It features the use of an integrated surgical support system for the instruments and a rod that provides external topographical maintenance of the coordinates established ultrasonographically. A cystoscope, when supported mechanically by this system, permits multiple entries of the biopsy forceps to the lesion without further disturbance of the brain, as well as irrigation, coagulation, and visualization, if desired. When used in conjunction with real time intraoperative ultrasonography, the surgeon may view the entire procedure and be certain that the biopsy sample has been obtained from the lesion, major deep blood vessels have been avoided, and the biopsy site is stable after the procedure. The advantages of this technique include simplicity, low cost, accuracy, stability, and availability to every neurosurgeon in every hospital.     

Intracranial aneurysm and vasculopathy after surgery and radiation therapy for craniopharyngioma: case report

OBJECTIVE AND IMPORTANCE: This case report illustrates the possible occurrence of intracranial aneurysms after surgery and radiation-induced vasculopathy. CLINICAL PRESENTATION: An internal carotid bifurcation aneurysm was diagnosed in a 19-year-old woman in a routine follow-up examination by magnetic resonance imaging 5 years after subtotal removal of a giant cystic craniopharyngioma treated by postoperative external radiotherapy. The presence of the aneurysm was confirmed by angiography. INTERVENTION: It was decided to treat the aneurysm by embolization with Guglielmi detachable coiling. However, at the beginning of the procedure, a few weeks after the diagnosis, a dramatic reduction in the carotid artery blood flow was observed, along with signs of thrombosis inside the aneurysm. In light of these findings, the procedure was aborted. Four months later, another angiographic examination confirmed the exclusion of the aneurysm and compensatory flow through the external carotid artery. CONCLUSION: During the assessment of patients who have undergone postoperative radiotherapy, the potential for the development of aneurysms and radiation-induced vasculopathy exists and should be kept in mind. Considering the potential for spontaneous thrombosis of these aneurysms, cautious judgment is recommended before making a decision to treat them.     

Abdominal aortic aneurysm repair in octogenarians: outcomes and predictors.

OBJECTIVES: This study was undertaken to evaluate predictors and outcomes of octogenarians who underwent abdominal aortic aneurysm repair. DESIGN: A prospective observational study. MATERIALS AND METHODS: Between January 1st, 1997 and April 15th, 2005, 31 octogenarians were admitted to our Department with the diagnosis of abdominal aortic aneurysm. Mean follow-up time was 53.7+/-27.2 months. All patients were in good clinical condition and represented a selected healthy group of octogenarians. RESULTS: The overall perioperative (30-days) mortality rate was 3.1%. The total in-hospital morbidity rate was 22.6%. Overall survival estimates at 48 and 96 months were 81+/-8% and 46+/-21%, respectively. The actuarial freedom from aneurysm-related death at 48 and 96 months was 96+/-4% and 96+/-4%, respectively. The actuarial freedom from aneurysm-unrelated death at 48 and 96 months was 84+/-7% and 48+/-21%. Only coronary artery disease was a significant predictor of survival using multivariate stepwise logistic regression analysis. CONCLUSIONS: In this series, AAA surgery was carried out in selected octogenarians without affecting long-term survival.     

Intracranial arterial aneurysm in children. A cooperative study. Apropos of 43 cases

This joint study describes 43 cases of intracranial arterial aneurysms in children diagnosed on the basis of clinical symptoms. In the pediatric age group, this malformation is notable because of the marked sex predilection in males (70%) and an unequal topographic incidence in the circle of Willis, where carotid artery (39.3%) and anterior communicating artery lesions (30%) predominate. The most frequent clinical sign was subarachnoid hemorrhage (81%), although symptoms caused by compression revealed the abnormality in 2.3% of patients. In this series, 11% of the patients suffered a head injury at the time of the hemorrhagic accident; this finding has been reported previously in the literature. Today, treatment is always surgical, consisting in removal of the aneurysmal sac. Surgical results are encouraging; all grade lesions considered together, 63.4% of the children were cured without any sequelae, 19.5% lost one school year but were able to lead a normal life, and 4.8% remained severely handicapped; overall postoperative mortality was 12.3%. Cerebral plasticity and tolerance of spasm in children are fundamental features of this aneurysmal pathology which partially explain the favorable results obtained with surgery.     

Retrospective survey of endovascular treatment for ruptured intracranial aneurysm in Japan: Retrospective Endovascular Subarachnoid Aneurysm Treatment (RESAT) study

Annual retrospective surveys of 20 to 31 medical centers performing endovascular treatment of cerebral aneurysms in Japan from 1997 to 2008 were performed to analyze technical and clinical outcomes of endovascular treatment for ruptured cerebral aneurysm. Patients treated with dome embolization using bare platinum coils within 14 days after onset were retrospectively selected, and clinical features, and technical and clinical outcomes at discharge were studied. Retrospective Endovascular Subarachnoid Aneurysm Treatment (RESAT) 1 covers patients treated from 1997, when the Guglielmi detachable coil was introduced, to 2002, just after International Subarachnoid Aneurysm Trial was reported. RESAT 2 to RESAT 7 were conducted annually between 2003 and 2008. Among 5,624 patients with ruptured aneurysms treated within 14 days after onset, 4,782 patients were treated by dome embolization using platinum detachable coils. The patients in this large retrospective survey included 35.8% aged over 70 years, 36.6% with posterior circulation aneurysms, and 29.3% with poor grades (Hunt and Kosnik grades IV and V). The proportion of patients aged over 70 years tended to increase each year from 33.4% in RESAT 1 to 39.8% in RESAT 7, and the proportion of those with posterior circulation aneurysms decreased from 44.2% in RESAT 1 to 23.8% in RESAT 7 (p<0.001). Overall technical success was obtained in 4,666 patients (97.6%), and favorable clinical outcome (good recovery and moderate disability) at discharge was obtained in 88.0% of grade I-III cases and 73.6% of grade I-V cases. Procedure-related morbidity was 2.9% and mortality was 0.8%. Despite this survey involving high proportions of aged, posterior circulation, and poor-grade patients, the technical success rate and immediate clinical results were relatively favorable. The patient prognosis and aneurysm changes must be investigated over a longer period, together with the effects of the introduction of new endovascular devices for cerebral aneurysms.