Aorto-iliac aneurysms following umbilical artery catheterization

Aneurysms of the aorta and its major branches are rare in the pediatric population and are usually associated with cardiovascular malformations. Recently, however, a number of children have emerged with aneurysms following umbilical artery catheterization (UAC). In the last 8 years, two such patients have presented at the Medical College of Virginia. These are reported in detail and compared with 18 others found in the literature (12 thoracic, 4 abdominal, 2 iliac). Several conclusions follow from the study of this group of 20 children: The history of umbilical artery catheterization in the presence of bacteremia, especially staphylococcal, is a prime risk factor in the development of aneurysms (90%, P less than .01). In addition, there was a concordance between the location of the catheter tip and the site of future aneurysm formation (P less than .05). UAC associated aneurysms are difficult to diagnose because of their rarity and have often been mistaken for tumors. The diagnosis should be suspected in the workup of a tumor in a child with an appropriate history. Though these aneurysms are probably mycotic, pus has not been encountered at surgery and there have been no reported graft infections. Patients with S aureus bacteremia complicating UAC should be followed closely to detect aneurysm formation.     

Aortic aneurysm resulting from umbilical artery catheterization: case report, literature review, and management algorithm

Aortic aneurysms in infants and children are quite rare. The use of umbilical artery catheters in the management of critically ill neonates has been associated with infection and subsequent aneurysm formation. There have been 46 cases reported (including our own); most of the aneurysms have been located in the abdominal aorta and have displayed saccular morphology. Through an analysis of the literature, we identified two factors that had significant correlation with improved survival: diagnosis before surgery and surgical repair (P <.05). This report presents the case of a 23-day-old neonate with an abdominal aortic aneurysm and hypertension. On the basis of our literature review, we offer a management algorithm for this rare but very serious complication of umbilical artery catheterization.     

Large neonatal thoracoabdominal aneurysm: case report and review of the literature

We present a neonate with a large saccular aneurysm of the thoracoabdominal aorta, extending from the intrathoracic aorta to the left common iliac artery. No underlying cause could be identified. Despite an early diagnosis, the aneurysm was deemed inoperable because of the lengthy involvement and the frail aspect of all visceral arteries. A review of the literature on congenital abdominal aortic aneurysm in infants was conducted. Eleven cases of live-born infants with a congenital abdominal aortic aneurysm have previously been published. None of them involved as large a part of the thoracic and abdominal aorta as the case presented here.     

Exclusion-bypass for aneurysms of the descending thoracic and thoracoabdominal aorta

From October 1973 to April 1985, 81 patients with aneurysms of the descending thoracic or thoracoabdominal aorta underwent surgery. Eight (10%) of these patients were treated by exclusion-bypass. The aneurysm was located in the descending aorta alone in five cases, and in the descending thoracic and thoracoabdominal aorta in three cases. In all cases, the proximal anastomosis of the bypass was performed on the ascending aorta. The site of the distal anastomosis was the supraceliac aorta in two cases, the infrarenal aorta in three cases and the iliac arteries in three other cases. Exclusion was bipolar, at each end of the aneurysm, in six cases, and unipolar, ie. proximal interruption only, in two cases. Two patients died during the first postoperative month, one of rupture of the distal portion of the aortic arch, the second, after onset of secondary paraplegia. There were no other spinal, cardiac or cerebral complications. One patient died three months postoperatively of intercurrent pulmonary infection. The five other surviving patients whose mean follow-up period is 48.1±25 months, are alive and enjoying good health. Resection and grafting as advocated by Crawford, is the usual treatment proposed for aneurysms of the descending thoracic and thoracoabdominal aorta. Exclusionbypass may however be preferred in the following cases: elderly patients with compromised respiratory status, aneurysms of the descending thoracic aorta, either voluminous, of infectious origin or associated with aneurysm of the infrarenal abdominal aorta.     

Abdominal aneurysms in childhood: report of a case and review of the literature

Abdominal aneurysms are rare in children and are usually found in association with congenital cardiac or aortic malformations, connective tissue disorders, trauma, or previous arterial catheter placement. A 4-year-old girl who had a common iliac artery aneurysm, who had no history of arterial catheter placement or trauma, and who had no evidence of Marfan's or Ehlers-Danlos syndrome, arteritis, coarctation of the aorta, or other diseases associated with childhood aneurysms is presented. Resection of the aneurysm and arterial reconstruction were performed without the use of prosthetic material or vein graft. Pathologic examination showed no evidence of inflammation or medial degeneration in any of the layers of the arterial wall. This is the fourth report found in the literature of documented idiopathic abdominal aneurysm in a child. The conditions associated with abdominal aneurysms in childhood are discussed, and the literature is reviewed.     

Simplified operative technique for thoracoabdominal dissecting aneurysm

A graft with branches is used to reconstruct the extensively dissected thoracoabdominal aorta. Anastomoses of the proximal end of the main graft distal to the left subclavian artery and the side branch to the distal aneurysmal descending thoracic aorta were first undertaken after the preparation of both ends under the iliac vein-artery partial bypass. A main graft with a Y graft extension was anastomosed distally to iliac arteries. This permits the blood flow within the aneurysm and the main graft to the extremities until splanchnic and spinal cord arteries have individually been transferred to the main graft. Ischemic time of the splanchnic and spinal cord arteries, using this technique, can be minimized within 10 minutes to each in the total replacement of descending thoracic and abdominal aorta.     

Descending Thoracic and Thoracoabdominal Aortic Aneurysm in Patients with Takayasu’s Disease

From June 1974 to December 2001 we performed operative treatment on 33 patients with descending thoracic or thoracoabdominal aortic aneurysm in association with Takayasu disease. There were 25 men and 8 women with a mean age of 40.2 years (range 16-64 years). Nineteen patients came from North Africa, 6 were from France, and 8 were from various locations in the world. The revealing symptom was hypertension in 12 cases, thoracic or abdominal pain in 7, isolated inflammatory syndrome in 5, neurologic or ocular manifestations in 3, rupture in 3, and embolization to the lower extremity in 1. In the remaining two cases discovery was coincidental. The aneurysm was confined to the thoracic aorta in 10 cases and involved both the thoracic and abdominal aorta in 23 cases. There were 8 type I, 6 type II, 4 type III, and 5 type IV aneurysms according to Crawfords classification. Two patients had undergone previous repair of the thoracoabdominal aorta. Four patients required first-stage treatment of a renal artery lesion to control hypertension. Six patients had associated aneurysms of the proximal aorta, including five treated via the distal elephant trunk technique in first-stage procedures. Aneurysm repair consisted of prosthetic replacement of the thoracoabdominal aorta in 31 cases, exclusion bypass in 1 case, and stent graft placement in 1 case. The procedure was performed with cross-clamping alone in 13 cases, distal perfusion in 17 cases, and deep hypothermic circulatory arrest in 3 cases. Twenty patients (61%) had associated renal and/or intestinal artery lesions that were treated during the same procedure as that for the thoracoabdominal aorta in 19 patients (58%). A total of 24 procedures were performed on renal arteries (17 revascularizations, 7 nephrectomies). Associated supraaortic trunks lesions were present in 15 patients (45%) and were treated in 12 patients, including 8 in first-stage procedures prior to thoracoabdominal aortic aneurysm repair. Three patients died of multiple organ failure, after reoperation in two cases and infection in one case involving prior long-term corticosteroid therapy. Three patients developed paraplegia, including one who had undergone emergency treatment following rupture. Two patients required reoperation, for hematoma in one case and bowel necrosis in one. Four patients developed respiratory complications requiring artificial ventilation for more than 48 hr. During follow-up, two patients died from complications after repair of the proximal aorta and one patient required nephrectomy. Despite the extent of aneurysmal lesions and high frequency of association with visceral and supraaortic vessel lesions, the outcome of surgery in patients presenting with descending thoracic or thoracoabdominal aortic aneurysm in association with Takayasu disease was satisfactory.Presented at the Eighteenth Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Toulouse, France, May 21-24, 2003.     

Giant size abdominal aortic aneurysm repair using open proximal anastomosis under hypothermic circulatory arrest: a report of two cases

Hypothermic total circulatory arrest and open proximal anastomosis techniques are not commonly used in abdominal or juxtarenal abdominal aortic aneurysm repair. Proximal aortic clamping is usually adequate for surgical repair of abdominal aortic pathologies. We present two cases of giant-sized abdominal aortic aneurysms, one was juxtarenal and one was a Crawford type IV thoracoabdominal aneurysm, that were repaired by using open proximal anastomosis under hypothermic total circulatory arrest and a transabdominal approach. This technique may be useful for both thoracoabdominal and large abdominal aortic aneurysms because it offers the opportunity to not clamp the aorta and operate in bloodless surgical field.     

Recurrent aneurysms and late vascular complications following repair of abdominal aortic aneurysms

Between 1970 and 1976, 1,112 patients underwent abdominal aortic aneurysm repair. Follow-up, ranging from six to 12 years, was complete in 1,087 patients (97.7%). The most frequent cause of late deaths was coronary artery disease (45.6%), but significant morbidity related to the peripheral vascular system had developed in 94 patients, and led to 8.4% (48 patients) of all late deaths. Forty-nine true, 14 anastomotic, and five dissecting aneurysms were detected in 59 patients (5.4%) a mean (+/- SD) of 5.2 +/- 3.1 years after the initial aneurysm repair. These aneurysms were located in the thoracic (24), thoracoabdominal (five), or abdominal aorta (11), and in the iliac (six), femoral (17), popliteal (four), and renal arteries (one). Only one of 26 patients presenting with a rupture of one of these secondary aneurysms survived. There was a significant association between preoperative hypertension and recurrent aneurysm. These findings suggest that subsequent vascular disease, including recurrent aneurysms and graft complications, cause significant late morbidity and mortality after repair of abdominal aortic aneurysm. Careful follow-up and adequate control of hypertension may allow reduction in morbidity and an improvement in late survival.     

Mycotic aneurysm of the descending thoracic aorta in a 2-kg neonate

Umbilical artery catheterization is often performed in critically ill neonates. Infection and thromboembolic events are relatively frequent complications, but aneurysm formation is rare. We describe the case of a premature baby who developed a rapidly expanding aneurysm of the descending thoracic aorta, secondary to a highly placed infected umbilical catheter. The rapid progression under medical therapy prompted us to replace the thoracic aorta with an 8-mm polytetrafluoroethylene graft, using extracorporeal circulation and core cooling. The baby had an excellent recovery and was discharged home after a prolonged antibiotic course. He is being followed with repeated imaging studies for a small abdominal aneurysm. We describe a novel approach to this rare and complicated problem and provide a review of the literature on the subject.     

Repair of lesions of the descending thoracic aorta with the TDMAC-heparin shunt

Utilizing a heparinized tridodecylmethylammonium chloride (TDMAC) shunt makes it possible to treat various surgical diseases of the descending thoracic aorta without cardiopulmonary bypass. Since the initial report by Gott and associates on the use of the heparinized shunt, few subsequent clinical trials have appeared in the literature. Six patients with Type III dissecting thoracic aneurysm, acquired and congenital coarctation of the aorta, saccular arteriosclerotic aneurysm, and transection of the descending thoracic aorta were operated upon by means of this technique. Only one patient had more than 500 ml. of chest tube drainage in the first 8 hours postoperatively. There were no instances of paraplegia, renal failure, or death. This technique is also recommended for repair of innominate artery aneurysms, endarterectomy of the innominate or subclavian artery, arch aneurysm, penetrating injuries of the thoracic aorta, and proximal abdominal aneurysms. Surgical indications, operative management, and postoperative follow-up are discussed.     

Inflammatory abdominal aortic aneurysms: a thirty-year review

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.     

正常人降主动脉壁及髂总动脉壁周向张力及平均应力分析

体中段平面及髂总动脉处有创测压,测量收缩压、舒张压、平均压,MRI下测量动脉内径、壁厚.通过公式计算得出动脉壁周向张力与平均应力,以自身不同部位对照.结果:收缩压自胸主动脉至髂总动脉逐渐升高(P<0.01),舒张压胸主动脉与腹主动脉相差不明显(P>0.05),髂总动脉较胸主动脉与腹主动脉低(P<0.01),平均动脉压肾下腹主动脉最高(P<0.01).自胸主动脉至髂总动脉动脉内径逐渐缩小(P<0.01),管壁亦逐渐变薄(P<0.01).动脉壁周向张力自胸主动脉至髂总动脉逐渐减少(P<0.01).肾下腹主动脉平均应力大于其它动脉(P<0.01),且在一个心动周期中变化幅度最大.结果 肾下腹主动脉处平均应力大于肾上腹主动脉、胸主动脉和髂总动脉,且在一个心动周期中变化幅度最大,可能是造成肾下腹主动脉易于受损而形成动脉瘤的原因.     

Aneurysm of lateral circumflex femoral artery in association with multiple atherosclerotic aneurysms

Femoral aneurysms are uncommon and are frequently associated with other aneurysms, particularly those of the aorta and popliteal arteries. Other peripheral aneurysms are even more rare. As far as we are aware, only one aneurysm of the lateral circumflex artery has been previously described. We describe such an aneurysm in association with a common femoral aneurysm on the same side, an abdominal aortic aneurysm and an iliac aneurysm on the contralateral side.     

Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

A rare case of multiple atherosclerotic aneurysms involving the femoral artery

Atherosclerotic aneurysm of the deep femoral artery is a rare peripheral aneurysm that is likely to have associated aortoiliac aneurysms. The case of a patient who had five atherosclerotic aneurysms located in the abdominal aorta, bilateral common iliac arteries, and the left common femoral and deep femoral arteries is reported. He underwent a semi-emergency operation for the aneurysm of the deep femoral artery, followed by a two-stage operation for the aortoiliac aneurysms. The aneurysm of the deep femoral artery was repaired, and reconstruction of the distal deep femoral artery successfully performed with direct anastomosis to the superficial artery. In this report, the clinical presentation of multiple atherosclerotic aneurysms and the details of surgical reconstruction are described. Copyright © 1996 The International Society for Cardiovascular Surgery.     

Surgical treatment of traumatic aneurysm of descending aorta with abnormal right subclavian artery

Among 11 patients with traumatic aneurysms of the descending thoracic aorta, 2 had developmental anomalies of the branches of the arch of the aorta, in particular, independent origin of the right subclavian artery from the descending thoracic aorta. The anomalous right subclavian artery plays the role of a retaining ligament in trauma, and the forming posttraumatic false aneurysm is localized distal of the ostium of the right subclavian artery. The need for clamping the thoracic aorta and both subclavian arteries for the period of aneurysm reconstruction requires catheterization of the arch of the aorta for arterial pressure control. Surgical correction of aneurysm in anomalous origin of the right subclavian artery has peculiarities of its own in the formation of the proximal anastomosis.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.