Common iliac artery pseudoaneurysm following inguinal hernia repair--a case report and literature review.

The authors report a patient presented with a ruptured infected iliac artery pseudoaneurysm 2 weeks after ipsilateral inguinal hernia repair. Pseudoaneurysms that occur because of infection develop rapidly and mandate ligation of the affected artery and extraanatomic bypass. Noninfected pseudoaneurysms are usually discovered incidentally and may be managed with either endovascular or standard surgical techniques. A percutaneously placed aortic occlusion balloon may prevent exsanguination, when used as an adjunct to surgical repair in cases of ruptured pseudoaneurysm.     

Petrous carotid artery pseudoaneurysm in bilateral carotid fibromuscular dysplasia: treatment by means of self-expanding covered stent

BACKGROUND: Pseudoaneurysms of the petrous carotid artery may occur in the setting of trauma, dissection, invasive tumors, or as a complication of surgery. These aneurysms may grow and constitute a potential source of thromboembolic complications or rupture. CASE DESCRIPTION: We present a patient with bilateral carotid FMD presenting with a large petrous pseudoaneurysm. Because carotid occlusion was not appropriate, a self-expandable covered stent was implanted. This treatment allowed complete exclusion of the pseudoaneurysm and preservation of the parent artery. CONCLUSION: The accepted treatment of psuedoaneurysms located at petrous ICA is either sacrifice of the carotid artery or exclusion of the aneurysm from the preserved carotid artery. These procedures have specific limitations, and they are technically demanding and associated with a substantial morbidity rate. The endovascular treatment of these lesions is the preferred alternative. Among the various endovascular techniques that have been tested so far, we propose self-expandable covered stents as ideal for treating arterial aneurysms and pseudoaneurysms of the petrous and cavernous carotid segments.     

Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents

OBJECT: The authors describe their preliminary clinical experience with the use of endovascular stents in the treatment of traumatic vascular lesions of the skull base region. Because adequate distal exposure and direct surgical repair of these lesions are not often possible, conventional treatment has been deliberate arterial occlusion. The purpose of this report is to demonstrate the safety and efficacy as well as limitations of endovascular stent placement in the management of craniocervical arterial injuries. METHODS: Six patients with vascular injuries were treated using endovascular stents. There were two arteriovenous fistulas and two pseudoaneurysms of the distal extracranial internal carotid or vertebral arteries resulting from penetrating trauma, and two petrous carotid pseudoaneurysms associated with basal skull fractures. In one patient a porous stent placement procedure was undertaken as well as coil occlusion of an aneurysm, whereas in the remaining five patients covered stent grafts were used as definitive treatment. There were no procedural complications. One patient in whom there was extensive traumatic arterial dissection was found to have asymptomatic stent thrombosis when angiography was repeated 1 week postoperatively. This was the only patient whose associated injuries precluded routine antithrombotic or antiplatelet therapy. Follow-up examinations in the remaining five patients included standard angiography (four patients) or computerized tomography angiography (one patient), which were performed 3 to 6 months postoperatively, and clinical assessments ranging from 3 months to 1 year in duration (mean 9 months). In all five cases the vascular injury was successfully treated and the parent artery remained widely patent. No patient experienced aneurysm recurrence or hemorrhage, and there were no thromboembolic complications. CONCLUSIONS: The authors' experience demonstrates that endovascular treatment of traumatic vascular lesions of the skull base region is both feasible and safe. The advantages of minimally invasive stent placement and parent artery preservation make this procedure for repair of neurovascular injuries a potentially important addition to existing methods.     

Endovascular occlusion of a carotid pseudoaneurysm complicating deep neck space infection in a child. Case report.

Pseudoaneurysm formation of the cervical internal carotid artery (ICA) is a rare, potentially lethal complication of deep neck space infection. This entity typically occurs following otolaryngological or upper respiratory tract infection. The pseudoaneurysm is heralded by a pulsatile neck mass, Homer's syndrome, lower cranial neuropathies, and/or hemorrhage that may be massive. The recommended treatment includes prompt arterial ligation. The authors present a case of pseudoaneurysm of the cervical ICA complicating a deep neck space infection. A parapharyngeal Staphylococcus aureus abscess developed in a previously healthy 6-year-old girl after she experienced pharyngitis. The abscess was drained via an intraoral approach. On postoperative Day 3, the patient developed a pulsatile neck mass, lethargy, ipsilateral Horner's syndrome, and hemoptysis, which resulted in hemorrhagic shock. Treatment included emergency endovascular occlusion of the cervical ICA and postembolization antibiotic treatment for 6 weeks. The patient has made an uneventful recovery as of her 18-month follow-up evaluation. Conclusions drawn.from this experience and a review of the literature include the following: 1) mycotic pseudoaneurysms of the carotid arteries have a typical clinical presentation that should enable timely recognition; 2) these lesions occur more commonly in children than in adults; 3) angiography with a view to performing endovascular occlusion should be undertaken promptly; and 4) endovascular occlusion of the pseudoaneurysm is a viable treatment option.     

Treatment of an iatrogenic petrous carotid artery pseudoaneurysm with a Symbiot covered stent: technical case report

OBJECTIVE AND IMPORTANCE: Surgery involving the middle ear or the temporal bone may cause an injury to the petrous carotid artery resulting in a pseudoaneurysm. Conventional treatment of such pseudoaneurysms has ranged from carotid occlusion to conservative management. The use of a balloon-expandable stent and/or Guglielmi detachable coils may be effective in a partially healed pseudoaneurysm. This report details the case of an acute petrous carotid pseudoaneurysm after a myringotomy procedure that was effectively treated with an expanded polytetrafluoroethylene-covered stent. CLINICAL PRESENTATION: During a right myringotomy procedure, pulsatile blood was encountered in a 42-year-old woman with a history of repeated ear infections and bilateral middle ear ventilation tube placement. The blood was adequately tamponaded with gauze packing. Computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and cerebral angiography revealed a 6-mm right petrous carotid pseudoaneurysm. INTERVENTION/TECHNIQUE: An 8-French guide catheter was positioned via a transfemoral approach into the cervical right internal carotid artery, and the patient was systemically heparinized. A 4- x 31-mm Symbiot covered stent (Boston Scientific/Scimed, Maple Grove, MN) was passed over a Choice PT exchange wire (Boston Scientific/Scimed) to cover the neck of the pseudoaneurysm, obliterating the pseudoaneurysm. The patient was given aspirin and clopidogrel after stenting, and ear exploration was possible later the same day. Follow-up computed tomographic angiography performed 6 weeks later verified patency of the stent. CONCLUSION: The use of an expanded polytetrafluoroethylene-covered stent may effectively treat intracranial internal carotid artery pseudoaneurysms in an acute setting. This treatment allows preservation of the parent artery and immediate treatment by reconstruction of the incompetent arterial wall to prevent potentially life-threatening hemorrhagic complications.     

Hybrid treatment of ascending aortic pseudoaneurysm: endovascular stent-graft placement and extraanatomic reconstruction without sternotomy.

Conventional surgical repair of ascending aortic pseudoaneurysms following prior cardiac operations is performed with a high operative mortality. We report a 67 year old female patient with an ascending aortic pseudoaneurysm detected 3 years after coronary bypass surgery. The patient was treated with ascending aortic endovascular stent graft placement and extraanatomic reconstruction of supraaortic branches without using sternotomy.     

Multiple giant anastomotic pseudoaneurysms of the carotid and femoral arteries: combined endovascular and open surgical approach

Anastomotic pseudoaneurysm is a known complication following carotid artery endarterectomy and aortobifemoral bypass surgeries. However, giant concurrent carotid and femoral artery anastomotic pseudoaneurysms are rare. We herein report a case of successful treatment of multiple giant anastomotic pseudoaneurysms using a combined endovascular and surgical approach. Our case highlights the fact that endovascular techniques can facilitate open surgical repair of complex anastomotic pseudoaneurysms.     

Delayed stenosis following placement of a polyethylene terephthalate endograft in the cervical carotid artery. Report of three cases

Three patients with carotid artery (CA) pseudoaneurysms were treated using four polyethylene terephthalate endografts (Wallgraft endoprostheses). Two patients received a single graft and one patient with bilateral pseudoaneurysms received two grafts. Complete occlusion of the pseudoaneurysm with patency of the arterial lumen was achieved following endograft placement in all patients. The clinical follow-up interval ranged from 12 to 18 months and included angiography or ultrasonography studies or both. One patient experienced neurological symptoms, and in-graft stenosis ranging from 50 to 100% occurred in three of the four grafts. Although the Wallgraft endoprosthesis produced good initial results for the treatment of cervical CA pseudoaneurysms, as demonstrated on radiography, it was associated with a high rate of stenosis or occlusion in all three patients.     

Endovascular treatment of a giant aorto-ostial renal artery pseudoaneurysm

Vascular complications after lumbar laminectomy are rare, but are potentially life-threatening. A 59-year-old man presented with progressive and worsening abdominal pain over several weeks. Multidetector computed tomography angiography revealed a large aorto-ostial left renal artery pseudoaneurysm 3 years after lumbar laminectomy. The pseudoaneurysm was successfully treated with a combination of various endovascular techniques ("jailed" microcatheter technique, stent-graft implantation, thrombin injection, balloon remodeling technique, Onyx application), with preserved patency of the left renal artery and pseudoaneurysm exclusion on 6-month follow-up multidetector computed tomography angiography. The size and location of this pseudoaneurysm and the combination of different techniques for endovascular treatment provides an update on current endovascular technology. Combination of different endovascular techniques can be a safe and feasible alternative for the treatment of complicated iatrogenic postlaminectomy vascular injuries and renal artery pseudoaneurysms.     

Endovascular Exclusion of a Postendarterectomy Carotid Pseudoaneurysm

Carotid pseudoaneurysms are rare occurrences. They often result from trauma, but can also present following carotid endarterectomy. Treating such pseudoaneurysms can be difficult due to previous surgery and limited access to the high internal carotid artery. A case involving a postendarterectomy carotid pseudoaneurysm treated via a femoral approach with a covered stent using endoluminal techniques is presented.     

Covered stent-graft repair of the brachiocephalic arteries: technical note

OBJECTIVE: The use of a covered stent-graft to repair disruptions of the cervical carotid and vertebral arteries is described. This device maintains vessel patency while effectively excluding pseudoaneurysms, arteriovenous fistulae, and other breaches in the integrity of the arterial wall. METHODS: Patient 1 bled from a large rent in the proximal common carotid artery as a result of tumor invasion. Patient 2 developed a vertebral arteriovenous fistula after a stab injury to the neck. Patient 3 developed cerebral infarction and an enlarging pseudoaneurysm of the internal carotid artery, also after a stab wound to the neck. RESULTS: All three patients were treated with the Wallgraft endoprosthesis (Boston Scientific, Watertown, MA). In each case, the vessel wall defect was repaired while antegrade flow through the artery was preserved or restored. No neurological complications occurred as a result of stent-graft deployment. CONCLUSION: Covered stent-grafts offer an alternative to endovascular occlusion of the parent vessel, thereby expanding the therapeutic options for patients with extracranial cerebrovascular disease. These three cases highlight the usefulness and versatility of these devices for endoluminal reconstruction of the brachiocephalic vasculature.     

Recurrent stenosis of common carotid-intracranial internal carotid interposition saphenous vein bypass graft caused by intimal hyperplasia and treated with endovascular stent placement. Case report and review of the literature

Intimal hyperplasia is a well-known cause of delayed stenosis in vein bypass grafts in all types of vascular surgery. Options for treatment of stenosis in peripheral and coronary artery bypass grafts include revision surgery and the application of endovascular techniques such as balloon angioplasty and stent placement. The authors present a case of stenosis caused by intimal hyperplasia in a high-flow common carotid artery-intracranial internal carotid artery (IICA) saphenous vein interposition bypass graft that had been constructed to treat a traumatic pseudoaneurysm of the intracavernous ICA. The stenosis recurred after revision surgery and was successfully treated by endovascular stent placement in the vein graft. The literature on stent placement for vein graft stenoses is reviewed, and the authors add a report of its application to external carotid-internal carotid bypass grafts. Further study is required to define the role of endovascular techniques in the management of stenotic cerebrovascular disease.     

Combined surgical and endovascular treatment of infected pseudoaneurysm after carotid endarterectomy. Case report

A 67-year-old male presented with a rare pseudoaneurysm caused by infection after carotid endarterectomy (CEA) performed for stenosis of the left internal carotid artery (ICA). Wound infection and recurrent bleeding from the operated ICA developed 1 month after surgery. Serial angiography showed that the post-CEA pseudoaneurysm gradually increased in size. The carotid balloon occlusion test revealed that the patient could not tolerate permanent ICA occlusion because of poorly developed collaterals. Direct surgical exposure of the aneurysm was impossible due to tight adhesion of the surrounding tissue, so common carotid to middle cerebral artery bypass using a radial artery graft was performed followed by ligation of the distal common carotid artery. Subsequently, retrograde blood flow from the ICA to the aneurysm was interrupted by embolization of the external carotid artery coil through the facial artery. Combined surgical and endovascular treatment is a therapeutic option for patients with post-CEA pseudoaneurysm, if either direct or endovascular surgery is unfeasible.     

创伤性血管病变的腔内治疗

目的 探讨微创血管腔内技术治疗创伤性血管病变的可行性。方法 对已进行腔内治疗的6例创伤性血管病变进行回顾性分析。结果 6例创伤性血管病变包括颈总动脉假性动脉瘤、锁骨下动静脉瘘、胸主动脉假性动脉瘤、髂动静脉瘘、髂动脉假性动脉瘤、股浅动脉假性动脉瘤各1例。所有病变均在局部麻醉下进行，经腔内移植物治疗后均立刻重建血流通道。6例均得到随访，2个月至4年内所有移植物均通畅。无任何并发症。结论 腔内技术治疗创伤性血管病变具有成功率高、并发症少、损伤小等优点，可望成为创伤性血管病变的重要治疗手段。     

Reconstructive stent-buttressed coil embolization of a traumatic pseudoaneurysm of the supraclinoid internal carotid artery

It is critical that traumatic intracranial pseudoaneurysms should be removed completely from the parent artery because there is a possibility of significant morbidity and mortality from the high risk of rebleeding from any remnants of the pseudoaneurysm. However, the deconstruction of the parent artery has the risk of ischemic damage to the distal to the trapped artery. We describe a case of a successful reconstructive stent-buttressed coil embolization in a patient with a traumatic pseudoaneurysm of the intracranial internal carotid artery. A 30-year-old man with a stuporous mentality was admitted to our institution after a traffic accident. The initial computed tomography scan showed a diffuse subarachnoid hemorrhage and a pseudoaneurysm of the left supraclinoid internal carotid artery. A reconstructive endovascular treatment using stent-assisted coil embolization with a stent-within-a-stent technique was conducted in order to save carotid blood flow. The pseudoaneurysm was completely obliterated and the patient recovered without any neurological deficit. We suggest that multiple stent placements with coiling may be considered as a treatment option for intracranial traumatic pseudoaneurysms as a reconstructive treatment.     

Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.     

Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits

BACKGROUND: Carotid stenting has been advocated in patients with grade III blunt carotid artery injuries (hereafter referred to as "blunt CAIs") because of the persistence of the pseudoaneurysm and concern for subsequent embolization or rupture. HYPOTHESIS: Carotid stenting is safe and effective for blunt CAIs. DESIGN: Analysis of a prospective database of all patients with blunt CAIs. SETTING: A state-designated, level I, urban trauma center.Patients and METHODS: In January 1, 1996, we initiated comprehensive screening for blunt CAIs with angiography based on injury patterns. Patients without contraindications receive anticoagulation therapy immediately for documented lesions. Patients with persistent pseudoaneurysms on a second angiography at 7 to 10 days after injury are candidates for stent placement. RESULTS: During the study period (January 1, 1996, to May 1, 2004), 46 patients sustained blunt carotid pseudoaneurysms; 23 (50%) underwent carotid stent placement. There were 4 complications in patients undergoing carotid stent placement: 3 strokes and 1 subclavian dissection. Follow-up angiography was performed in 38 patients (18 patients with stents who received antithrombotic agents, 20 patients who received antithrombotic agents alone); 8 patients had poststent carotid occlusion despite having received concurrent anticoagulation therapy. Carotid occlusion rates were significantly different (45% in patients with stents vs 5% in those who received antithrombotic agents alone). In the patients not undergoing stent placement, the only complication was a middle cerebral artery stroke in a patient not treated with antithrombotic therapy. CONCLUSIONS: Patients who have carotid stents placed for blunt carotid pseudoaneurysms have a 21% complication rate and a documented occlusion rate of 45%. In contrast, patients treated with antithrombotic agents alone had an occlusion rate of 5%; no asymptomatic patient treated with antithrombotic agents for their injury had a stroke. Antithrombotic therapy remains the recommended therapy for blunt CAIs, but the role of intraluminal stents remains to be defined.     

Massive epistaxis due to traumatic internal carotid artery pseudoaneurysm: a case report

We present a case of traumatic pseudoaneurysm of the internal carotid artery (ICA) accompanied by skull base fracture, which was treated by endovascular trapping of the internal carotid artery. A 70-year-old woman met with a traffic accident and was admitted to our institution with epistaxis and accomapanied with shock. Angiography on day 2 showed carotidcavernous fistula. The patient had no eye symptom and was treated conservatively. A second angiography, two weeks aftrer the trauma, revealed development of a pseudoaneurysm on the C3-4 portion. We attempted balloon test occlusion (BTO) of the right internal carotid artery, and if torelated, the ICA may have been occluded. The day before BTO, she rebleed massively. Endovascular trapping of the ICA was performed. Although epistaxis was controlled completely, she suffered left hemiparesis due to an embolism during the procedure. Epistaxis from a traumatic aneurysm of the internal carotid artery may be fatal and emergency occlusion is proposed.     

Pseudoaneurysm of the superior mesenteric artery after pancreas transplantation treated by endovascular stenting

Pseudoaneurysm after pancreas transplantation can have serious consequences, including rupture, hemorrhage, and graft loss. We describe a 38-year-old patient who presented with a pseudoaneurysm of the donor superior mesenteric artery 1 month after pancreas transplantation. Selective arteriography was performed and the lesion was repaired with endovascular placement of a 28-mm covered stent. Laparotomy was avoided. The pancreatic graft was continuing to function well 9 months later. As far as we know, this minimally invasive approach was not previously reported. According to published series, pseudoaneurysms often occur secondary to infection and require operative intervention necessitating graft pancreatectomy. Patients can present with serious symptoms including hypotension and shock. Therefore, it is important to detect pseudoaneurysm in a timely manner. Computed tomography and Doppler ultrasound are important diagnostic tools in this regard. We demonstrated the utility of endovascular stenting in the treatment of pseudoaneurysm after pancreas transplantation. When used in a timely manner in well selected patients, endovascular stenting can abrogate the need for operative intervention and its attendant morbidity.     

Arterial complications after living-related liver transplantation: single-center experience from West China

Vascular complications after liver transplantation remain a major source of morbidity and mortality for recipients. In particular, patients receiving living-related liver transplantation (LRLT) experience a higher rate of vascular complications owing to the complex vascular reconstruction. Between July 2001 and December 2005, LRLTs were performed in our center on 33 patients with end-stage liver diseases. The 23 men and 10 women had a mean age of 32.6 +/- 11.3 years (range = 5 to 58 years). Of the 33 patients, the percentage of vascular complications was 9.09% (3 cases), including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), or hepatic artery pseudoaneurysm (HAP) in one patient, respectively. No portal vein or hepatic vein complication occurred in our patients. Thrombectomy was performed in the patient with thrombosis. The patient with stenosis was treated with balloon angioplasty and endoluminal stent placement. The pseudoaneurysm was also successfully embolized to restore the blood flow toward the donor liver. Mean follow-up for all patients after LRLT was 18.0 +/- 5.4 months. The overall postoperative 30-day mortality rate was 6.06% (2/33). The 1-year survival rate was 86.36% in 22 patients with benign diseases and 72.73% in 11 patients with malignant diseases. However, no death was associated with vascular complications. Careful preoperative evaluation and intraoperative microsurgical technique for hepatic artery reconstructions are the keys to prevent vascular complications following LRLT. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated by balloon angioplasty and endoluminal stent placement. Embolization may be a safe and effective approach in the treatment of a pseudoaneurysm of the hepatic artery.