Bronchial aneurysms mimicking aortic aneurysms: Endovascular treatment in two patients

Bronchial artery dilatation and aneurysm formation is a potential complication of local inflammation, especially in bronchiectasis. When the bronchial artery has an ectopic origin from the inferior segment of the aortic arch, aneurysms may mimick aortic aneurysms. Despite this particular location, endovascular treatment is possible. We report two such aneurysms that were successfully embolized with steel coils.     

Endovascular treatment of proximal anterior cerebral artery aneurysms

Introduction  Aneurysms of the proximal segment of the anterior cerebral artery (A1A) are rare and challenging to treat. No information is available regarding their management by endovascular approach. The aim of this study was to report our experience with endovascular treatment (EVT) of A1As. Patients and methods  A retrospective review of our prospectively maintained database identified all A1As treated in our institution. The clinical charts, procedural data, and angiographic results were reviewed. Results  From April 2004 to August 2008, eight patients were identified and presented with an unruptured A1A. All aneurysms but one were <3 mm in diameter and two aneurysms had a perforator at the neck. Surgery was performed in two patients with an aneurysm <2 mm. Six patients were treated by selective embolization including five patients with balloon-assisted coiling (BAC) and/or via a retrograde approach from the contralateral side through the anterior communicating artery. These adjunctive techniques were used to safely catheterize the sac or to protect a branch at the neck. All patients showed an excellent clinical outcome. A complete aneurysm occlusion was obtained in all but one patient. Follow-up imaging in four patients showed stable results. Conclusion  EVT of A1As is feasible and associated with good clinical and anatomical results. Because of their location, small size, and close relationship with perforators, EVT frequently requires the use of BAC and/or a retrograde approach. Our results suggest that EVT is an alternative therapeutic option to surgical clipping if the aneurysm size is compatible with selective embolization.     

Endovascular treatment of abdominal aortic paraanastomotic pseudoaneurysms after surgical reconstruction

Purpose

To evaluate the efficacy of endovascular treatment of paraaortic postoperative abdominal aortic pseudoaneurysms.

Materials and methods

From April 1996 to November 2007 five men with paraaortic postoperative abdominal aortic pseudoaneurysm underwent endovascular treatment. Average age was 64.2 years (range 54-73). The average time interval between the primary surgery and endovascular treatment was 12.4 years (4 months-23 years). Three patients were treated by aortouniiliacal stentgrafts and two patients by tube stentgrafts.

Results

Technical success rate was 100%. Pseudoaneurysms were primarily excluded from circulation without perioperative complications in all patients. At follow-up (mean 38.5 months) there were no deaths and no endoleaks. In one patient thrombosis of stentgraft was found and it was successfully treated by thrombectomy. All pseudoaneurysms still continued to be excluded from circulation in the last follow-up.

Conclusion

Endovascular treatment is minimally invasive, effective and safe option of surgery for paraaortic postoperative pseudoaneurysms.     

Endovascular treatment of bacterial intracranial aneurysms

We report three patients with bacterial intracranial aneurysms treated by the endovascular approach: two presented with sudden severe neurological deficits after a diagnosis of endocarditis; the other had suspected vasculitis. CT showed an intracerebral haematoma in all cases: angiography revealed bacterial aneurysms of distal branches of the middle cerebral artery in two cases and posterior cerebral artery in one. Because of the patients' condition and the location of the aneurysms, endovascular treatment was considered the fastest and safest treatment. Hyperselective catheterisation of the parent branch, close to the aneurysm, was performed with a microcatheter. A small amount of glue was injected to occlude both the aneurysm and a short segment of the diseased vessel. Follow-up angiography revealed occlusion of the aneurysm in all cases. One patient recovered completely; one recovered over some months, with neurological deficit due to the haematoma. The third patient suddenly worsened and died 9 days after treatment for a contralateral haematoma, due to rupture of a new bacterial aneurysm of the middle cerebral artery. Endovascular occlusion of the aneurysm and parent vessel may be an alternative to surgery in selected, severe cases of deep or distal bacterial intracranial aneurysms.     

Balloon-assisted coil embolization for large-necked renal artery aneurysms

An aneurysm of the right renal artery was discovered in a patient suffering from cerebral arterial angiodysplasia and arterial hypertension. The aneurysm was large necked, which made selective endovascular treatment very difficult. To perform the embolization of the aneurysm, a balloon remodelling technique was used. This prevented migration of coils within the arterial lumen.     

Endovascular Treatment of Anastomotic Pseudoaneurysms after Aorto-iliac Surgical Reconstruction

Purpose To assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction. Materials We retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter. Results Immediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1–72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%. Conclusion Endovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.     

颅内动脉瘤破裂急性期血管内栓塞治疗

闭塞颅内动脉瘤的方式主要有开颅动脉瘤夹闭和血管内栓塞治疗,随着血管内介入技术的提高和栓塞材料及设备的改进,颅内动脉瘤的介入治疗所占比例有增多的趋势。以下通过回顾性分析比较栓塞和手术夹闭治疗颅内动脉瘤的临床效果,评价栓塞治疗在颅内动脉瘤破裂急性期治疗中的应用。     

Endoluminal Treatment of Ruptured Abdominal Aortic Aneurysm with Small Intestinal Submucosa Sandwich Endografts: A Pilot Study in Sheep

Purpose: To evaluate efficacy of small intestinal submucosa (SIS) Sandwich endografts for the treatment of acute rupture of abdominal aortic aneurysms (AAA) and to explore the short-term reaction of the aorta to this material. Methods: In eight adult sheep, an infrarenal AAA was created transluminally by dilation of a short Palmaz stent. In six sheep, the aneurysm was then ruptured by overdilation of the stent with a large angioplasty balloon. Two sheep with AAAs that were not ruptured served as controls. A SIS Sandwich endograft, consisting of a Z stent frame with 5 bodies and covered inside and out with SIS, was used to exclude the ruptured and non-ruptured AAAs. Follow-up aortography was done immediately after the procedure and before sacrifice at 4, 8, or 12 weeks. Autopsy and histologic studies followed. Results: Endograft placement was successful in all eight sheep. Both ruptured and non-ruptured AAAs were successfully excluded. Three animals with AAA rupture developed hind leg paralysis due to compromise of the arterial supply to the lower spinal cord and were sacrificed 1 day after the procedure. In five animals, three with rupture and two controls, follow-up aortograms revealed no aortic stenoses and no perigraft leaks. Gross and histologic studies revealed incorporation of the endografts into the aortic wall with replacement of SIS by dense neointima that was completely endothelialized in areas where the endograft was in direct contact with the aortic wall. In central portions of the endograft, in contact with the thrombosed aneurysm, endothelialization was incomplete even at 12 weeks. Conclusion: The SIS Sandwich endografts effectively excluded simple AAAs and ruptured AAAs. They were rapidly incorporated into the aortic wall. A detailed long-term study is warranted.     

Endovascular treatment of abdominal aortic aneurysms: a review

Abdominal aortic aneurysm (AAA) is a relatively common disease among the elderly population and may be present in up to 5.9% of the population aged 80 years. Abdominal aortic aneurysm more than 5 cm in diameter are more prone to rupture, with a significant mortality rate. Conventional surgical treatment is quite effective in the lower surgical risk population; however, in the population with a higher risk level the mortality and morbidity significantly increase. The development of less invasive techniques to treat AAA derived from the necessity to reduce the morbidity and mortality. The development of the endovascular endoprostheses was a significant landmark in the management of those patients with AAA, particularly the ones with increased risk. Although the stent-graft technology is still in its infancy, a large amount of information is available and an attempt to summarize this experience is presented herein. An extensive review of the stent-graft technology is presented, including variations in design and classification of the several systems available. Technical aspects of the use of endovascular prostheses are presented, as well as the most recent outcome information available. The problems of endoleaks is discussed and the techniques for treatment and outcomes presented. Finally, a summary of specific information on most of the devices available is presented.     

Endovascular treatment of cerebral aneurysms in elderly patients

We report our experience in the endovascular treatment with detachable platinum coils of ruptured or symptomatic unruptured cerebral aneurysms in 61 patients aged 70–82 years. Complete occlusion was achieved in 38, subtotal in 17 and partial in one. The treatment failed in five patients. Clinical follow-up was performed in all patients for 8 months to 8 years. No bleeding occurred during the follow-up period. Outcome was favourable in 63% of the patients. When we compared the outcome of elderly patients with those of younger age endovascularly treated in the same period of time, we found a significantly higher frequency of poorer outcome in the elderly group (²=9.084; P=0.011). The frequency of favourable outcome in the elderly was significantly lower than in the younger group for H–H IV–V (²=9.299; P=0.010). The most important factor influencing the outcome was not age itself, but primary clinical condition on admission. The therapy of symptomatic aneurysms in elderly patients should not be purely conservative—a direct approach of the aneurysm should be considered. Endovascular treatment whenever possible seems to be a good alternative to surgery.     

Endovascular treatment of the posterior inferior cerebellar artery aneurysms

Aneurysms may arise at various locations along the course of the posterior inferior cerebellar artery. Brainstem and cranial nerves manipulation make the surgical approach to proximal aneurysms difficult, while the occlusion of the parent vessel is sometimes unavoidable in peripheral aneurysms. Endovascular treatment can be a good alternative, but also with this approach the location of the aneurysm is critical. If occlusion of the parent vessel is planned, anatomical variations and vascular territories of the brainstem should be considered. We report our experience with 18 consecutive aneurysms (12 proximal, 6 peripheral) treated by coils. Complete occlusion was achieved in 14 patients and subtotal in 4. In three patients the parent vessel had to be sacrificed. During treatment two perforations occurred; aneurysms were completely occluded without clinical consequences. Two small asymptomatic cerebellar infarctions were seen on postoperative computed tomography. Clinical outcome was good in 16 patients     

Endovascular treatment of renal aneurysms: A series of 18 cases

Purpose

To retrospectively analyze the results and complications of the endovascular treatment of 18 renal aneurysms.

Methods

From 2002 to 2011, 15 patients (aged 31–76), with 18 renal aneurysms, were admitted in our institution for treatment by embolization. Except one, all were wide-necked aneurysms. One aneurysm was treated by occluding the parent artery considering its distal location; a small-necked aneurysm was treated by simple coiling, and the remaining 16 were embolized utilizing adjunctive techniques to protect the parent artery. We analyzed the rates of technical success, complication and clinical consequence, post-operative occlusion and recurrence.

Results

There was a 100% technical success rate. 15 aneurysms showed a total occlusion on the post-treatment angiogram. 2 aneurysms demonstrated neck remnants, and one had an intrasaccular residual in-flow. Two minor post-operative complications were encountered but resolved over time. No delayed clinical complications were observed and the long-term angiographic follow-up demonstrated stability of the occlusion of the target renal aneurysm with no major recurrence.

Conclusion

Complications of the embolization of renal aneurysms are rare. Endovascular treatment should therefore be considered at first for the treatment of renal aneurysms.     

Penetrating atherosclerotic ulcer of the descending thoracic aorta: Treatment by endovascular stent-Graft

Purpose: To present four cases of penetrating ulcer of the descending thoracic aorta treated by transfemoral insertion of an endoluminal stent-graft. Methods: Four patients with penetrating aortic ulcers were reviewed. Three cases were complicated by rupture, false aneurysm, or retrograde dissection. All patients were treated by endovascular stent-graft and were followed by helical computed tomography (CT). Results: Endovascular stent-graft deployment was successful in all patients. However, in one case we observed a perigraft leak that spontaneously disappeared within the first month, and two interventions were needed for another patient. Following treatment, one episode of transient spinal ischemia was observed. The 30-day survival rate was 100%, but one patient died from pneumonia with cardiac failure 34 days after the procedure. In one patient, helical CT performed at 3 months showed a false aneurysm independent of the first ulcer. This patient refused any further treatment and suddenly died at home (unknown cause) after a 6-month follow-up period. Conclusion: Transluminal placement of endovascular stent-grafts for treatment of penetrating ulcers of the descending thoracic aorta appears to be a possible alternative to classical surgery. After treatment, follow-up by CT is essential to detect possible complications of the disease.     

Endoluminal grafting of abdominal aortic aneurysms: experience with the Talent endoluminal stent graft

The aim of this study was to evaluate the Talent endoluminal stent graft (TESG) in treating abdominal aortic aneurysms (AAA). The TESG is a polyester-covered nitinol endograft (proximal diameters 20–38 mm and iliac limb diameters 8–22 mm). Twenty-two men were treated with the TESG via bilateral femoral arteriotomies. Pre-implantation, coil embolization of various vessels arising from the aneurysm was performed in 6 patients. Plain radiographs and spiral CT angiograms (CTA) were carried out at 7 days, 3, 6, and 12 months following TESG implantation or re-intervention. Median aortic and iliac diameters were 27 mm (range 20–34 mm) and 14 mm (range 10–19 mm). The corresponding graft diameters were 30 mm (range 24–38 mm) and 14 mm (range 12–20 mm). No patient was rejected purely on the basis of too large aortic or iliac diameters. Eight patients required custom-made grafts. Graft implantation was successful in all patients. There were no blood transfusions, distal embolic episodes, or conversions to open surgery. Re-intervention was necessary in 1 patient. Complications included one fatal myocardial infarction, one inguinal hematoma, and two superficial wound infections. The aneurysm thrombosed completely following implantation in 14 patients and at 3 or 6 months in 4 other patients. One patient with endoleak is awaiting his 3-month control and 2 patients show tiny endoleaks but reduction of aneurysm size. The mean aneurysm size decreased significantly from 58 ± 10 to 53 ± 13 mm (p < 0.0005). Due to the large sizes available and the option of custom-made grafts, the TESG helps widen the spectrum of patients who can be treated with endoluminal grafting. The treatment is associated with a significant reduction in aneurysm size. Received: 30 March 1999; Revised: 6 July 1999; Accepted: 23 August 1999     

Endovascular treatment of posterior cerebral artery aneurysms using detachable coils

Introduction Aneurysms of the posterior cerebral artery (PCA) are rare, and most of the studies reported in the literature in which the endovascular approach was applied were carried out on a limited number of patients with PCA aneurysms. We retrospectively reviewed our cases of PCA aneurysms – at various locations and of differing shapes – that received endovascular treatment and evaluated the treatment outcome. Methods From January 1996 to December 2006, 13 patients (eight females and five males) with 17 PCA aneurysms (nine fusiform and eight saccular) were treated using the endovascular approach. The age of the patients ranged from 20 to 67 years, with a mean age of 44 years. Of the 13 patients, ten presented with intracranial hemorrhage, and one patient, with a large P2 aneurysm, presented with trigeminal neuralgia; the aneurysms were asymptomatic in the remaining two patients. Results All 13 patients were successfully treated, with only one procedure-related symptomatic complication. Seven patients were treated by occlusion of the aneurysm and parent artery together; five patients, by selective embolization of the aneurysm; one patient, by partial coiling. Although infarctions were found in two patients treated with selective embolization and in three patients treated with parent artery occlusion, only one patient with a ruptured P2 aneurysm treated with parent artery occlusion developed transient amnesia as an ischemic symptom. Conclusion Posterior cerebral artery aneurysms can be treated safely with either occlusion of the aneurysm together with the PCA or with a selective coil embolization. Infarctions may occur after endovascular treatment, but they are rarely the cause of a disabling symptom.     

Endovascular treatment of unruptured intracranial aneurysms and circulating endothelial cells

Objectives

To evaluate the potential implication of circulating endothelial cells (CECs) in complications following endovascular treatment (EVT) of unruptured intracranial aneurysms. CECs characterized as CD146⁺/CD105⁺/CD45⁻/DAPI⁺ were considered to originate from an altered endothelial cell layer of the vessel wall.

Study design

In 15 patients, CECs were characterized and enumerated by the CellTracks^® System in blood samples from: (1) femoral artery (FA), (2) internal carotid artery (ICA) before (ICA₁) and after procedure (ICA₂), and (3) a peripheral vein before (PV₁) and after EVT (PV₂). Ischemic brain events were assessed using diffusion weighted imaging (DWI-MRI) before and 24 h after EVT.

Results

In ICA₁, the median number of single CECs and clusters of 2–5 CECs were higher than in FA, ICA₂, PV₁ and PV₂ samples (P < 0.001). Clusters >5 cells, sometimes >50 μm, were mainly observed in ICA₁ and never in PV₁, PV₂ or PV samples from ten healthy subjects. This distribution of CECs suggested femoral and ICA injury by the devices used, leading to endothelium shearing and desquamation of CECs. All patients discharged on day two (NIHSS score = 0), however silent ischemic brain lesions were observed in 9/15 (60%).

Conclusions

EVT detaches single and clusters of CECs from wall arteries that may be implicated in silent ischemic brain lesions genesis. Enumeration of CECs associated with DWI-MRI might represent an interesting strategy for monitoring and optimizing endovascular devices, and further limit EVT-related complications.     

Treatment of chronic type B aortic dissection with endovascular stent-graft placement

A 74-year-old man with chronic aortic dissection was treated with an endovascular stent graft, fabricated from expanded polytetrafluoroethylene and a Z-stent. It was placed in the true lumen to close an entry tear. Closure was obtained immediately and thrombosis of the false lumen at the descending thoracic aorta was observed on computed tomography (CT) obtained 1 week later. No procedure-related complications developed. The patient is doing well with no adverse events including aortic rupture or aortic branch ischemia.     

Endovascular treatment of a portal vein tear during TIPSS

During a transjugular portosystemic stent-shunt (TIPSS) procedure a portal vein laceration occurred with subsequent intraperitoneal hemorrhage. A PTFE-covered nitinol stent was successfully placed eliminating the leak and creating a functioning portosystemic shunt. This case demonstrates both the importance of portal vein puncture more than 1 cm from the bifurcation and the necessity of maintaining a stock of available stent-grafts.     

A System for Computer-Assisted Design of Stent-Grafts for Aortic Aneurysms Using 3-D Morphological Models

A three-dimensional model was constructed from helical CT images for abdominal aortic aneurysm (AAA) and thoracic aortic aneurysm (TAA). A stent-graft was designed and positioned endoluminally on the computer. One hundred and nine stent-grafts for 101 patients were designed by this method and deployed well in all patients. The design time was reduced from 4 to 0.5 hr.     

Treatment of TIPS Stenosis with ePTFE Graft-Covered Stents

Midshunt stenosis and recurrent variceal bleeding occurred in 2 patients after transjugular intrahepatic portosystemic shunts (TIPS). Repeat angioplasty was performed in both cases but recurrent stenosis again led to hemorrhage. Expanded polytetrafluoroethylene (ePTFE) graft-covered stents were expanded in each of the TIPS at the midshunt, reducing the portosystemic gradient for both patients. Variceal bleeding ceased, and follow-up studies showed no evidence of recurrent stenosis in either case.