移植肾假性动脉瘤的诊断和治疗四例报告

目的 总结移植肾假性动脉瘤的诊治体会.方法 首次接受肾移植者4例,其供肾动脉均为单支,肾动脉无损伤,也未行动脉修补成形术.供肾动脉均与受者的髂外动脉行端侧吻合.术中发现受者髂外动脉有粥样斑块或动脉分层者2例.术后4例均未出现移植肾周感染,亦未行移植肾穿刺活检或其他有创检查.依据临床表现、彩色多普勒超声检查、多层螺旋CT血管成像和数字减影血管造影诊断移植肾假性动脉瘤.结果 分别在术后1.5个月、2个月、5个月和7个月诊断移植肾假性动脉瘤,其临床表现缺乏特异性,3例经数字减影血管造影、1例经多层螺旋CT血管成像确诊.1例移植肾假性动脉瘤突发破裂,急诊切除假性动脉瘤和移植肾;1例因瘤体短期迅速增大,行带膜支架置入及栓塞术;2例行移植肾动脉瘤切除及动脉裂口修补术.结论 移植肾假性动脉瘤是肾移植术后的少见并发症,其临床表现缺乏特异性,多层螺旋CT血管成像和数字减影血管造影有助于本病的诊断.对于移植肾假性动脉瘤的治疗,可选择手术切除或介入栓塞术,关键在于是否保留移植肾,并需考虑移植肾血管重建方式.     

Ischemic Colitis following Translumbar Thrombin Injection for Treatment of Endoleak

Endoleaks remain a significant challenge after endovascular abdominal aortic aneurysm repair (EVAR). Translumbar thrombin injection of the aneurysm sac has been used to treat endoleaks, with low reported morbidity. We present an unusual case of ischemic colitis following translumbar thrombin injection of an endoleak. A 67-year-old male with a 5.8-cm abdominal aortic aneurysm (AAA) was evaluated for endograft repair. The patient underwent preoperative embolization of the right hypogastric artery. The AAA was repaired using a unibody bifurcated graft (Ancure). Completion aortogram revealed no endoleak and a widely patent left hypogastric artery. Computed tomography (CT) at 2 months showed an endoleak appearing to originate from a lumbar artery near the proximal attachment site with outflow via the inferior mesenteric artery (IMA). The endoleak was successfully treated with CT-guided translumbar injection of 8000 units of thrombin into the aneurysm sac. The patient subsequently developed chronic abdominal pain, diarrhea, and a weight loss of 20 lbs. Colonoscopy revealed ischemic colitis of the rectosigmoid colon. Duplex evaluation indicated a patent superior mesenteric artery and IMA distal to its origin. Medical treatment failed and the patient underwent a low anterior resection 2 months later (4 months post-EVAR). Subsequently, the aneurysm has decreased to 5.4 cm, with no evidence of endoleak at 1 year. We conclude that ischemic colitis may occur following translumbar thrombin injection. Thrombin embolization into the rectosigmoid arcade via the IMA was most likely the cause in this case. This problem can potentially be avoided by treating the IMA endoleak outflow prior to translumbar thrombin injection of the aneurysm sac. Thorough arteriographic evaluation of endoleaks should be performed prior to any interventions. Presented at the Annual Meeting of the Southern California Vascular Surgical Society, Carlsbad, CA, April 11-13, 2003.     

Splenic artery embolization for post-traumatic splenic artery pseudoaneurysm in children

Although rare, traumatic splenic artery pseudoaneurysm (SAP) can be life threatening. The diagnostic approaches as well as the methods of treatment of SAP are yet to be determined. We present the case of a 10-year-old boy treated conservatively for a grade III blunt splenic injury (BSI). The child was discharged to home after a 5-day uneventful hospitalization but was found on routine follow-up CT scan to have a large SAP. The pseudoaneurysm was successfully angiographically embolized and subsequent abdominal CT demonstrated successful resolution of the pseudoaneurysm with a small residual splenic cyst. We reviewed the eight cases of post-traumatic SAP in children that have been published in the English literature. Unlike SAP in adult patients, the severity of the splenic injury does not have predictive value for development of SAP in children. Abdominal pain was the most frequent symptom of SAP, but three children were asymptomatic at the time of diagnosis. Therefore, the possibility of SAP should be investigated even in the asymptomatic child with mild splenic injury. When a splenic pseudoaneurysm is diagnosed, we believe splenic artery embolization is indicated.     

外伤性肾动脉假性动脉瘤的诊断和治疗(附2例报告及文献复习)

目的:探讨外伤性肾动脉假性动脉瘤(Renal artery pseudoaneurysm,RAP)的诊断与治疗方法。方法:回顾性分析2例RAP患者的临床资料:均为男性,年龄分别为17岁和42岁,临床主要表现为持续性出血或迟发性肉眼血尿。血管造影示损伤动脉活动性出血,肾内见充盈造影剂的囊腔状结构。2例患者均行超选择性血管栓塞治疗。结果:2例患者术后血尿或出血均消失,无并发症发生。术后3个月以上行CT检查,肾功能均未见异常。结论:RAP临床表现为持续性出血或迟发性肉眼血尿;血管造影在诊断RAP中具有重要价值;超选择性动脉栓塞是治疗RAP的安全、有效方法。     

Calcified pseudo aneurysm of ascending aorta from cannulation site eroding into the sternum: a case report

We report the successful surgical treatment of a pseudoaneurysm of the ascending aorta in a 15 year old male who underwent surgical closure of an atrial septal defect at the age of 3 years. A Computed Tomography (CT) scan, done for investigating the palpable mass on the healed sternotomy scar, showed a densely calcified pseudoaneurysm of the ascending aorta (9.5?×?5.5 cm) at the prior cannulation site, eroding the sternum. Since the aneurysm and the ascending aorta were heavily calcified and adherent to the adjoining structures, it was repaired using a bovine pericardial gusset. The cause of the pseudoaneurysm was considered iatrogenic.     

Pseudoaneurysm at the cannulation site of the ascending aorta arising 8 days postoperatively: report of a case

A postoperative pseudoaneurysm is a rare complication that is difficult to diagnose. Computed tomography (CT) revealed a pseudoaneurysm in the ascending aorta of a 68-year-old female 8 days after mitral valve replacement and tricuspid annuloplasty. The defect was simply repaired during emergency surgery without cardiopulmonary bypass (CPB). The early detection of a postoperative pseudoaneurysm is important to avoid a second operation complicated by adhesions. Enhanced CT was useful for early detection in this patient. Pseudoaneurysm of the ascending aorta at the cannulation site can occur soon after surgery, and early recognition might allow simpler surgery without CPB.     

Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques.

OBJECTIVE: The exact significance of collateral endoleaks is unknown and a topic of great debate. Because of this uncertainty, some physicians choose to watch and wait while others aggressively treat these leaks. The purpose of this investigation was the evaluation of the efficacy of the two techniques used in the treatment of collateral endoleaks that occur after endovascular aneurysm repair. METHODS: Patients with 33 angiographically proven type 2 endoleaks underwent treatment with either transarterial inferior mesenteric artery embolization (n = 20) or direct translumbar embolization (n = 13) during an 18-month period. Embolization success was defined as resolution of endoleak on all subsequent computed tomography angiogram results. The likelihood of embolization failure between the two treatments was expressed as a risk ratio and was compared with Fisher exact test. RESULTS: Sixteen of 20 transarterial inferior mesenteric artery embolizations (80%) failed with recanalization of the original endoleak cavity over time. A single failure (8%) in the direct translumbar embolization group occurred in a patient in whom a new attachment site leak developed. The remaining 12 translumbar endoleak embolizations (92%) were successful and durable, with a median follow-up period of 254 days. The patients who underwent transarterial inferior mesenteric artery embolization were significantly more likely to have persistent endoleak than were the patients who underwent treatment with direct translumbar embolization (risk ratio, 4.6; 95% confidence interval, 1.9 to 11.2; P =.0001). CONCLUSION: The transarterial embolization of inferior mesenteric arteries for the repair of type 2 endoleaks is ineffective and should not be performed. Direct translumbar embolization of the endoleak is effective in the elimination of type 2 leaks and should be the therapy of choice when aggressive endoleak management is indicated.     

Treatment Options for Traumatic Pseudoaneurysms of the Paravisceral Abdominal Aorta

Penetrating gunshot wounds (GSWs) to the abdominal aorta are frequently lethal. Alternative management options for treatment of traumatic pseudoaneurysms of the abdominal aorta are illustrated by three patient case histories. Patient A sustained two GSWs to the abdomen (midepigastrium, right subcostal region). He was hypotensive in the field. Emergent laparotomy was undertaken with suture ligature of a celiac injury and distal pancreatectomy/splenectomy for a pancreatic injury. Postoperative abdominal CT for an intraabdominal infection with leukocytosis revealed a 4 cm traumatic pseudoaneurysm of the abdominal aorta that extended from the suprarenal aorta to the level of the renal arteries. Six weeks later, he underwent an open repair. Patient B sustained multiple GSWs to his right arm and right upper quadrant. He was hemodynamically stable. He underwent abdominal exploration for a grade 3 liver laceration. Postoperative abdominal CT revealed a supraceliac abdominal aortic pseudoaneurysm. An aortogram demonstrated a 1.5 cm defect in the aortic wall above the celiac trunk communicating with the inferior vena cava (IVC). He underwent endovascular repair with covered aortic stent graft. Patient C sustained multiple thoracoabdominal GSWs. He was hemodynamically stable. Emergent laparotomy revealed multiple left colonic perforations, two duodenal lacerations, and an unsalvageable left kidney laceration. Postoperatively, he developed a duodenal-cutaneous fistula with multiple intraabdominal abscesses. Serial CT scans revealed an enlarging infrarenal aortic pseudoaneurysm. He underwent angiographic coil embolization and intraarterial injection of thrombin into the pseudoaneurysm sac. The average time from injury to surgical treatment was 46 days (range 29-67). Postoperatively, none of the patients developed paraplegia. Advances in endovascular techniques have provided options to deal with traumatic pseudoaneurysms of the abdominal aorta. In a hemodynamically stable patient with a traumatic pseudoaneurysm, careful selection of a specific intervention can be tailored to the clinical scenario electively.Presented at the 22nd Annual Meeting of the Southern California Vascular Surgery Society, La Jolla, CA, April 30-May 2, 2004.     

A case of retroperitoneal abscess accompanying pregnancy

A 40-year-old pregnant woman, who suffered a continuous episode of fever and anemia since the 26th week of pregnancy, was referred to our clinic for evaluation of her left flank pain and tumor. As retroperitoneal tumor was suspected by retrograde pyelography, sonography and CT, translumbar tumorectomy was performed under general anesthesia. The histological diagnosis was retroperitoneal abscess.     

Thoracic endovascular stent graft for late pseudoaneurysm formation after patch aortoplasty; report of a case

We report a case of a 51-year-old man presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair coarctation of the aorta. At the age of 15 years, he underwent patch angioplasty for coarctation of the aorta. However the computed tomography( CT) scan, taken after 36 years, demonstrated pseudoaneurysm of the thoracic aorta at the anastmotic site. He was treated by endovascular stent graft using Gore-TAG 3115. His postoperative course was uneventful. Follow-up CT scan demonstrated no recurrence of pseudoaneurysm.     

Studies on the animal model of traumatic pseudoaneurysm

Sixty-nine cases of pseudoaneurysm were made in 72 femoral arteries of 54 Japanese white rabbits, with a successful rate of 95.8%. Colored Doppler's ultrasonic imaging, CT, MRI, arterial angiography, anatomic dissection, and histologic observation were carried out at different times after the operation. The mechanism for the formation of pseudoaneurysm was discussed and the effects of colored Doppler's ultrasonic imaging, CT, MRI, and arterial angiography in the diagnosis of pseudoaneurysm were evaluated. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:349–353, 1998     

A hybrid approach to appendicitis with right external iliac artery pseudo aneurysm: A case report

IntroductionWhile acute appendicitis is a common surgical problem, the simultaneous occurrence of appendicitis and an infected iliac artery pseudoaneurysm is exceedingly rare. We report the successful treatment of an infected right external iliac artery pseudo aneurysm in the 1setting of acute appendicitis.Presentation of caseThe patient is an 83-year-old male who presents with severe sepsis, right lower quadrant and right leg pain. Additional past medical history is significant for rectal cancer status post resection and radiation therapy in 1997. Computed tomography (CT) on admission revealed a right iliopsoas muscle abscess, an inflamed Appendix and a pseudo aneurysm arising from the right external iliac artery. After consultations by multiple specialties, the plan was to proceed with percutaneous drainage of the abscess, antibiotic therapy and subsequent repair of the pseudoaneurysm. CT guided drainage of the iliopsoas abscess was performed with return of hemorrhagic fluid. Due to the concern of contained pseudoaneurysm rupture, the patient was taken for expedited repair. Due to the patient’s frailty and hostile abdomen, we performed embolization of the right external iliac artery pseudoaneurysm with Amplatzer I plugs (St. Jude Medical, St. Paul MN) and left common femoral to right superficial femoral bypass with cryopreserved cadaveric femoral vein. Following pseudoaneurysm exclusion, continued percutaneous drainage and antibiotic therapy, the patient has done well with no further evidence of infection.ConclusionRepair of infected pseudo aneurysms can prove challenging. Ongoing infection, a hostile surgical abdomen and patient frailty further complicates the treatment of these patients. This case displays a minimally invasive approach to this rare but morbid condition.     

Surgical treatment with the rifampicin-soaked vascular prosthesis for mycotic pseudoaneurysm after aortic root replacement

A 59-year-old man had undergone aortic root replacement for annuloaortic ectasia (AAE) and aortic regurgitation (AR) 18 years before. The computed tomography (CT) showed a pseudoaneurysm of ascending aorta 4 years after the 1st operation. Re-aortic root replacement was done 15 years after the 1st operation because of the pseudoaneurysm. However, 3 years after the 2nd operation, the patient suffered from fever and another pseudoaneurysm was revealed by CT. Echocardiography showed a vegetation attached to the aortic valve. The 3rd operation was successfully performed using rifampicin-soaked vascular prosthesis. The postoperative course was uneventful. Thus, graft infection was effectively treated with a rifampicin-soaked vascular prosthesis.     

Management of bleeding pseudoaneurysms in patients with pancreatitis

BACKGROUND: Bleeding pseudoaneurysm is a rare but frequently fatal complication in patients with pancreatitis. METHOD: The medical records of ten patients who presented to this institution with a bleeding pseudoaneurysm between 1978 and 1997 were reviewed retrospectively. Six patients had chronic pancreatitis and four had acute pancreatitis. The splenic artery was involved in six cases, a pancreaticoduodenal artery in two, the gastroduodenal artery in one and the cystic artery in one. RESULTS: Computed tomography (CT) revealed the bleeding pseudoaneurysm in all patients (n = 6) with chronic pancreatitis but in only one of three with acute pancreatitis. Arteriography always gave the correct diagnosis. Seven patients underwent pancreatic resection as an emergency (n = 3) or within 48 h (n = 4), and survived. Three patients presenting with acute pancreatitis and massive bleeding underwent transcatheter arterial embolization. Two of them had a favourable outcome and one died from a recurrent haemorrhage 7 days later. Overall, two patients suffered significant perioperative complications and one died. CONCLUSION: CT is accurate in the diagnosis of pseudoaneurysms complicating pseudocysts. Primary resection of the pseudoaneurysm, which frequently requires pancreatic resection, is the treatment of choice. Angiography followed by transcatheter embolization is effective, but should be rapidly followed by operation.     

Hydatid embolism from a thoracic aortic pseudoaneurysm presenting as gangrenous toes

Cystic echinococcosis (hydatid cyst), caused by Echinococcus granulosus, has worldwide distribution and poses a health problem in endemic areas. Embolization of hydatid cysts into the vascular tree is an unusual manifestation of the disease. The hydatid embolism results from spontaneous or traumatic rupture of the cyst, and rare case reports of this kind are not well documented in the literature. We report a case of a hydatid embolism from a ruptured hydatid in a pseudoaneurysm of the thoracic aorta. A 45-year-old woman presented with gangrenous changes of the toes of her right foot. After embolectomy, the histopathology of the embolus was doubtful about its being blood clots around hydatid membranes. Postoperatively, computed tomography (CT) of the chest revealed a pseudoaneurysm of the descending thoracic aorta. Definitive surgery for the pseudoaneurysm was done during a second operation. Numerous hydatid cysts were evacuated from the pseudoaneurysm. This report emphasizes the need for an early diagnosis and treatment of echinococcosis before disabling and life-threatening complications occur.     

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa following aortic valve replacement - diagnosis and dynamic evaluation with multidetector CT and transesophageal echocardiography

Sixteen-slice multidetector CT findings of a pulsatile pseudoaneurysm of the mitral-aortic intervalvular fibrosa, in a woman following aortic valve replacement, are presented. Multidetector CT depicted the pseudoaneurysm and enabled dynamic evaluation of its lumen through the cardiac cycle, documenting expansion during systole and almost complete collapse during diastole. This case illustrates the capabilities of multidetector cardiac CT in the evaluation of aortic valve pathology.     

Spontaneous resolution of an inferior epigastric artery pseudoaneurysm secondary to surgical drain placement

We report the case of a 73-year-old woman who was found to have an inferior epigastric artery pseudoaneurysm caused by surgical drain placement during a laparotomy for an appendix abscess. She presented with pain around the drain site two months following surgery and intravenous contrast computed tomography (CT) revealed a right inferior epigastric artery pseudoaneurysm. A decision was made to manage this expectantly as she remained stable with no other complications. Following a period of nine months of observation, repeat intravenous contrast CT showed evidence of spontaneous regression and thrombosis of the pseudoaneurysm. She remains well and her symptoms have now resolved.     

Spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm.

We report on the rare and successful surgical treatment of a case of spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm. A 72-year-old male who had complained of sudden onset of severe chest pain was admitted to our hospital. Initially, acute type A closing aortic dissection was suspected because computed tomography (CT) showed a small ulcer-like projection (ULP) in the posterior aspect of the ascending aortic wall, but it also revealed no intimal flap, false lumen or aortic aneurysm. CT and magnetic resonance imaging (MRI) indicated a change in the radiographic aspect of the ULP and revealed a mimicking saccular-type pseudoaneurysm and gradual increasing size of the pseudoaneurysm. Surgery was performed after considering the risk of pseudoaneurysmal rupture. We replaced the ascending aorta and diagnosed it as a spontaneous aortic rupture by histological examination of the rupture site after failing to observe an aneurysm or dissection. We discuss these results with reference to the literature, including our pathological and radiographical findings.     

Pseudoaneurysm rupture causing hemoperitoneum following rectal impalement injury: A case report

IntroductionAlthough vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare.Case presentationA 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL–7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful.DiscussionRectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm.ConclusionAlthough pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.     

Periaortic endograft infection due to Listeria monocytogenes treated with graft preservation

A 67-year-old man presented to our hospital with general malaise, fever and diffuse abdominal and lower back pain 7 weeks after endovascular aneurysm repair. Blood samples showed a leukocyte count of 10.9 x 10(9)/l and a C-reactive protein of 239 mg/l. The computed tomography (CT)-scan showed fluid collections behind the proximal part of the endovascular graft and dorsal to the aorta. CT-guided translumbar needle aspiration of these collections yielded growth with Listeria monocytogenes. Prosthetic endograft infection is an extremely rare event, especially when it is caused by L. monocytogenes. Given the scarcity of this complication, no consensus has been reached for its treatment. In the described case, radiological drainage and prolonged antibiotic treatment resulted in favourable outcome at midterm follow-up with preservation of the endograft.