Subclavian artery disruption resulting from endovascular intervention: treatment options

Endovascular intervention is a commonly accepted form of treatment in patients with subclavian artery stenosis. Complications will undoubtedly occur as the utility of catheter-based intervention continues to rise. We report two cases of subclavian artery disruption as a result of endovascular intervention. One patient had contrast extravasation after the deployment of a balloon-expandable stent in a stenotic subclavian artery, and the arterial injury was successfully treated with balloon tamponade. A second patient had a large subclavian pseudoaneurysm 4 months after a balloon-expandable stent placement. Successful repair was achieved in this patient by means of arterial reconstruction with a prosthetic bypass graft. These cases illustrate different therapeutic methods of treating subclavian artery rupture due to endovascular intervention.     

Subclavian artery approach for insertion of intra-aortic balloon

Subperiosteal clavicular resection for access to the subclavian artery is described. In those patients requiring intra-aortic balloon placement in the nonsurgical setting, such an approach provides a reasonably benign alternative when aortoiliac atherosclerosis prevents the usual retrograde femoral placement. Little morbidity or functional compromise is associated with clavicular wedge resections, and the anatomic availability of a large artery without the need for major surgical maneuvers in these gravely ill patients is a distinct advantage.     

Choice of approach for transhepatic endovascular and biliary procedures

Results of diagnostic and therapeutic transhepatic procedures in 185 patients with portal hypertension and 292 patients with obstructive jaundice are analyzed. Optimal angles for introduction of instruments, optimal intercost and the most convenient for manipulation biliovascular structures of the liver were determined. These principles permitted to reduce the failure rate in endovasculary procedures from 10.5 to 3.8%, in endobiliary--from 13.2 to 0.97%.     

Surgical exposure of the carotid artery for endovascular interventional procedures

Background  

Transfemoral approach for endovascular interventions is not always possible in cases of unfavorable anatomy. We report our experience using a transcervical approach with carotid cut down and direct, controlled puncture of the carotid artery.     

The use of ultrasound for axillary artery catheterization through pectoral muscles: a new anterior approach

A palpable axillary artery pulse is a prerequisite for introducing an arterial line. The close proximity of four nerves to the artery increases the chance of nerve injury, especially in anesthetized patients. The highly colonized entry site results in frequent infection. Approaching the axillary artery through the pectoral muscles by using real-time imaging should improve success, decrease infection, and prevent nerve and vessel injuries because these structures and the needle can be visualized directly. I describe three patients who had successful axillary lines placed through the pectoral muscles by using real-time sonography. The ability to see the artery, surrounding nerves, and vein and to observe the needle going through the tissues should increase safety and success, although a large study is needed to prove these hypotheses.     

锁骨上新进路行锁骨下静脉置管在小儿的应用

目的探讨锁骨上锁骨中点内侧为进针点新进路行经皮锁骨下静脉置管用于小儿的可行性与技术特点。方法1个月~12岁小儿128例,ASAⅠ~Ⅱ级,按年龄分为四组。以锁骨中点内侧0·5cm锁骨上0·5~1cm为进针点,针体与矢状面成45~50度角,与冠状面成负10~15度角,针尖指向锁骨内1/3段中点。采用Sledinger法置入中心静脉导管。结果总穿刺成功率99·22%,一次试穿成功率87·5%。进针点至锁骨内1/3段中点的距离为(2·62±0·68)cm,进针深度为(2·28±0·68)cm,中心静脉置管成功率100%。32例颈胸部X线片示:导管尖端位于右房口21例,位于上腔静脉下段11例。无气胸、误穿动脉、神经损伤等并发症。结论锁骨上锁骨中点内侧新进路行锁骨下静脉置管标志清楚,定位明确,穿刺置管成功率和一次试穿成功率高,并发症少,可适用于小儿。     

Subclavian artery revascularization for myocardial ischemia

A 54-year-old woman had a secondary occlusion of the subclavian artery proximal to the internal mammary artery, which had been used for an anterior interventricular artery bypass, and was the source of recurrent angina. A left carotid-to-subclavian bypass was performed with success. This rare complication underscores the need for careful selection and surveillance of candidates for myocardial revascularization using the internal mammary artery.     

Brachial artery catheterization to facilitate endovascular grafting of abdominal aortic aneurysm: safety and rationale

PURPOSE: Endovascular treatment of abdominal aortic aneurysms (AAAs) is a technically demanding procedure that is based on the complexity and multiplicity of steps and the guidewire and catheter manipulations required. Brachial artery catheterization is an adjunctive technique that can facilitate the placement of an endoluminal prosthesis. METHODS: Brachial access was used during endoluminal AAA repair in 79 of 103 consecutive patients with a modular-design stent-graft prosthesis at two institutions. RESULTS: Left brachial access facilitated (1) angiography to guide juxtarenal device deployment, (2) antegrade contralateral limb access, (3) device delivery through disadvantaged iliac arteries by means of a brachial femoral wire, (4) access to renal arteries when necessary, and (5) catheter exchanges and a reduction in fluoroscopic positional changes. Complications included one puncture-site pseudoaneurysm, seven hematomas, and 29 patients with extensive ecchymosis. The length of stay was not prolonged in any case. There were no embolic, oculocerebral, or ischemic upper extremity events. CONCLUSIONS: Brachial artery catheterization, as an adjunctive technique to endoluminal AAA repair, offers noteworthy technical advantages with few, but self-limiting complications.     

Subclavian vein catheterization for acute and chronic haemodialysis. A safe temporary vascular access

The technique and use of a percutaneous subclavian vein catheter for haemodialysis in 20 patients are reported. The catheterization procedure carried a very low morbidity, and blood flow rates of 200–250ml/min were achieved through the catheters. Use of this angioaccess saves future possible sites for permanent vascular access. Infectious complications were not encountered. Subclavian vein catheterization is a favourable alternative to external Silastic Teflon shunt.     

Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures

OBJECT: Endovascular and surgical treatment must be clearly defined in the management of anterior communicating artery (ACoA) aneurysms. In this study the authors report their recent experience in using a combined surgical and endovascular team approach for ACoA aneurysms, and compare these results with those obtained during an earlier period in which surgical treatment was used alone. Morbidity and mortality rates, causes of unfavorable outcomes, and morphological results were also assessed. METHODS: The prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990-1995); Group B (103 microsurgically treated patients, 1996-2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996-2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I-III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed. Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2-4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (chi2 = 6.13, p = 0.01). CONCLUSIONS: The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria.     

A Subclavian artery aneurysm associated with aortitis syndrome

We performed surgery on a 61-year-old woman who had increasingly severe right shoulder pain and paresthesia in her right upper extremity as a result of a large right subclavian artery aneurysm. She had suffered from aortitis syndrome for 10 years for which she was treated with steroids and had multiple arterial lesions, including bilateral subclavian artery aneurysms, abdominal aortic aneurysm and obstruction of bilateral superficial femoral arteries. The right subclavian artery aneurysm measured 4 cm in diameter and rupture appeared imminent, prompting surgical therapy. Via the supra-clavicular incision approach and additional partial sternotomy, the aneurysm was excluded and the brachiocephalic to right axillar arterial bypass was set up using an extended polytetrafluoroethylene graft. The patient recovered without complications and a subclavian artery aneurysm demonstrated by computed tomography was thrombosed 1 month after surgery. In conclusion, we recommend the exclusion technique to treat subclavian artery aneurysms in cases in which aneurysmectomy is likely to injure adjacent veins and nerves.     

A ruptured choroidal artery aneurysm of the anterior inferior cerebellar artery obliterated via the endovascular approach: case report

Intraventricular aneurysms associated with fourth ventricular hemorrhage are rare. A case of a ruptured aneurysm in a choroidal branch of the right anterior inferior cerebellar artery (AICA) is reported here. A 56-year-old man presented with sudden onset of vertigo and nausea. CT scan showed an intraventricular hemorrhage within the fourth ventricle. Cerebellar angiography showed an aneurysm at the choroidal artery branching from the right AICA. The patient rejected both general anesthesia and craniotomy, so endovascular embolization under local anesthesia was performed using Guglielmi detachable coils (GDCs) and a fibered platinum coil. The distal portion of the right AICA and the aneurysm were obliterated. His postoperative course was fairly satisfactory. He suffered from a minimal gait disturbance caused by truncal ataxia for several days after the operation. He was discharged from hospital without neurological deficit. There have been only a few articles about choroidal artery aneurysms. As treatment, direct surgery has been recommended in past cases, but endovascular embolization of the parent artery was successfully performed in this case. Not only direct surgery but also endovascular surgery may be regarded as the treatments of choice for intraventricular aneurysms, depending on the size of the parent artery.     

经小腿动脉逆向入路治疗腘动脉及膝下流出道闭塞性病变

目的 探讨经小腿动脉逆向入路治疗腘动脉及膝下流出道闭塞性病变的技术要点和注意事项.方法 2010年1月至2012年3月,对28例顺行血管腔内治疗失败的膝下动脉闭塞患者进行了经小腿动脉逆向入路血管重建,其中男性16例,女性12例;年龄59 ～ 93岁,平均年龄(78±9)岁.按Rutherford下肢缺血分级标准:严重间歇性跛行(3级)3例,重度下肢缺血(4～6级)25例.将逆向操作分为两类:一类采取小腿远端动脉穿刺建立逆向入路,一类采用经小腿动脉侧支逆向动脉重建.结果 全组总技术成功率92.8％(26/28).远端穿刺无严重并发症,轻微并发症3例(10.7％).23例患者获得3 ～ 29个月的随访,平均随访(14±9)个月,随访率88.4％(23/26).术后6个月累积通畅率73.9％(17/23),12个月累积通畅率47.8％(11/23).病死率4.3％(1/23).保肢率95.7％(22/23).1例溃疡未愈合,溃疡愈合率9/10.结论 对于顺行血管腔内治疗失败的腘动脉及膝下动脉病变,通过小腿动脉逆向入路可进一步提高血管腔内治疗的成功率.     

Management of huge splenic artery aneurysm with new hybrid procedure including endovascular and open surgical approach: Case series

IntroductionSplenic artery aneurysms (SAAs) account for more than half of all visceral artery aneurysms. Small SAAs are usually asymptomatic, but giant aneurysms are more likely to cause symptoms and result in life-threatening complications; these aneurysms treatment can be challenging. Splenic artery aneurysms treatment includes laparotomy, laparoscopy, or endovascular techniques.Case presentationThis case series reports the details of successful management of three patients with huge splenic artery aneurysms who underwent hybrid surgery, endovascular inflow control with a balloon, and open aneurysm resection.DiscussionAlthough endovascular treatment options are increasingly favored, only selected aneurysms are suitable for these procedures, as marked tortuosity of the artery or SAA in the proximal splenic artery may not be suitable for endovascular management.ConclusionOpen surgery escorted by endovascular techniques can be considered an ideal treatment of SAA in the proximal region of the splenic artery.     

A novel access method for endovascular procedures in the porcine model

Objective To evaluate the use of the saphenous artery as an alternative access for endovascular procedures in the porcine model. Methods Fourteen adult pigs (25-35kg) were used in this study, 3 pigs from an acute study and 11 from chronic studies. A 2-3 cm incision was made and a saphenous artery cutdown was performed in 24 sides. Micropunc ture sets (Boston Scientific) or 18 G puncture needles were used to access the artery. Different sizes of introducers (4-7F) were used to establish endovascular access. Angiographic catheters were then used to confirm if the access was usable. Four saphenous arteries were explanted in the pigs from a chronic study 4 to 28 days after surgical procedure. Results The saphenous artery was very easy to expose and 4-5 F introducer sheaths were able to be inserted to establish access for endovascular procedures in the pigs. The saphenous artery was unable to accomodate an introducer with a size larger than 6 F. Four saphenous arteries were injured when 5 and 6 F introducers were used, but angiographic procedures could still be performed. Morphologic evaluation of the explanted arteries demonstrated occlusion of the saphenous arteries without injury or disruption of the adjacent femoral arteries. Conclusion The saphenous artery can be used as an access site in pigs for angiographic and interventional procedures if the catheter size is less than 6 F. This vessel is easier to access and can preserve the femoral artery for repeat procedures in the future.     

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.