Thoracoabdominal and abdominal aortic aneurysms involving celiac,superior mesenteric,and renal arteries

This is a report of surgical treatment of 138 patients with thoracoabdominal aortic aneurysms and aneurysms of the abdominal aorta from which the visceral vessels arise. The patients are divided into 6 groups according to location and extent of aneurysm. Group I (16 patients) involved most of the descending thoracic aorta and the upper abdominal aorta down to the celiac axis. Group II (1 patient) involved all of the aorta except the proximal ascending aorta. In Group III there were 47 patients in whom the aneurysm involved most or all of the descending thoracic and abdominal aorta. In Group IV (31 patients) the aneurysm involved the distal thoracic aorta and part or all of the abdominal aorta. Group V (28 patients) involved either the upper or all of the abdominal aorta, and in Group VI (15 patients) the aneurysm was infrarenal in location but involved the renal arteries. Treatment was by the graft inclusion technique with reattachment of branch vessels by anastomosis directly to openings made in the graft in most cases. Intercostal and lumbar arteries were reattached in some patients in Groups II and III. Aortic and renal occlusion times varied from 15 to 155 minutes. Of the 138 patients in the series, 125 (91%) survived. Transient renal insufficiency occurred in 7 patients. Death occurred in 3 other patients from renal failure, 1 of whom was on chronic hemodialysis. Paraplegia occurred in 12 patients, all submitted to extensive replacements. Intercostal and lumbar artery reattachment reduced the incidence of this problem by 50%. In the survivors, paraplegia was mild to moderate and transient in 4 and severe in 4. All of the latter are now self-sufficient. The 2 men with this problem are gainfully employed.     

Surgical treatment of a tuberculous thoracoabdominal aneurysm

We report a case of tuberculous thoracoabdominal aneurysm successfully treated by surgery. Computerized tomography was diagnostic for location and etiology. The therapeutic plan included antituberculosis drug therapy started before surgery, direct PTFE prosthetic replacement and omentoplasty. A survey of other reports dealing with tuberculous abdominal or thoracic aorta involvement shows that their frequency, as that of tuberculosis in general, is diminishing.     

Double aortic arch with aneurysm—A surgical case report

An unusual case of double aortic arch with aneurysm is described. A 61-year-old, hypertensive and syphilitic male patient complained of increasing difficulty in swallowing of approximately five months duration. Barium swallow and subsequent aortography showed the presence of an aneurysm of the ascending aorta involving the left (anterior) arch of the double aortic arch. The tightening of the vascular ring by aneurysmal dilatation of the left aortic arch appeared to be responsible for the delayed onset of the symptom. Surgical correction was made by removing the aneurysmal ascending aorta and left aortic arch and a Dacron graft was inserted between the ascending aorta and the right (posterior) aortic arch. The patient died of cerebral complication about forty hours postoperatively. Surgical problems associated with this unusual condition were discussed retrospectively from the operative and autopsy findings. In reviewing the pertinent literatures this case appeared to be the first operated case of double aortic arch associated with aneurysm.     

Arterial involvement in Behçet's disease

For many years, the known vascular complications in Behçet's disease have been attributed to thrombophlebitis, but considerable number of reports has been published in recent years relating to cases with aneurysm and arterial occlusion. We experienced arterial involvements in 6 cases with Behçet's disease up to date. In five, the histological findings of the resected specimens suggested a presence of angiitis derived from the media. Of the vascular changes in Behçet's disease, aneurysm develops relatively in early age of life and is extremely prone to rupture. Therefore, an aggressive surgical approach is mandatory for aneurysm, as soon as the diagnosis of this disease becomes definite. Histological changes of these arteries revealed derangements of the media, particularly of its elastic fibers. Although it is difficult to draw a conclusion at this stage that angiitis is one of the etiological factors of Behçet's disease, etiologic relation of these angiitic changes of unknown origin is discussed from various standpoints of view.     

Embolic complications after endovascular repair of abdominal aortic aneurysms

Purpose

This retrospective study aimed to review our experiences with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs), along with the incidence, risk factors and prognoses of associated embolic events. Our goal was to present the EVAR results and related risk factors from a single center, with a focus on embolic complications.

Methods

We retrospectively reviewed the data of 539 patients with AAAs who underwent elective EVAR at Jikei University from July 2006 to April 2009. Of these, 438 patients were selected after excluding those requiring fenestrated and branched EVAR.

Results

The technical success rate was 91.1 % (399/438) with no surgical mortality. Embolic complications occurred in nine patients (2 %), four of whom developed ischemic colitis and were successfully treated with bowel rest and hydration. Lower extremity atheroembolization and stroke occurred in three and one patients, respectively. Two patients died of cholesterol crystal embolization. Seven of the nine embolic complications (77.8 %) were associated with the use of Zenith stent-grafts. A Cox proportional-hazard regression analysis of the adjusted risk factors showed that smoking and severe arterial degeneration of the aorta, referred to as a shaggy aorta, to be independent predictors of embolic complications.

Conclusions

The presence of a shaggy aorta and a history of smoking are independent predictors of embolic complications associated with EVAR.     

Carotid artery aneurysm following inadvertent puncture during central venous catheterisation

Aneurysm of the carotid artery is rare. We report a case of aneurysm of the carotid artery in a 59-year-old female who has undergone a central venous catheterisation through the internal jugular vein and had history of inadvertent carotid artery punctures during jugular vein cannulation. Patient presented with progressive pulsatile swelling in the neck of 4-month duration, arising immediately after inadvertent punctures. There was no neurological deficit or compressive symptoms due to the neck mass. Patient was subjected to the excision of aneurysm sac and interposition grafting using 8 mm expanded polytetrafluroroethylene (PTFE) graft.     

Inflammatory plasma biomarkers of abdominal aortic aneurysms

Aim-Background

Osteopontin (OPN) and osteoprotegerin (OPG) have been implicated in the development and progression of atherosclerosis. We studied the correlation of these two molecules with abdominal aortic aneurysm (AAA) in terms of its development and extent, and present our preliminary results.

Methods

Osteopontin and osteoprotegerin serum values in 74 patients with AAA were compared with the corresponding values of 20 patients (control group) who had similar characteristics and no AAA. All aneurysms were classified as Types A-E, according to their anatomical extent as seen on CT imaging (EUROSTAR criteria).

Results

Our results showed that osteopontin values were higher in patients with any type of aneurysm (OPN: 3661.64 ± 1126.49ng/ml) compared to the control group (OPN: 1418.30 ± 962.68ng/ml; p = 0.017, Types A-B: p = 0.03, Types C-E: p = 0.01). Osteopontin and osteoprotegerin values did not differ among aneurysms of different extent. Osteoprotegerin values of patients with any type of aneurysm (OPG: 354.28 ± 212.1ng/ml) and of controls (OPG: 364.87 ± 159.85ng/ml) showed no significant difference.

Conclusions

Serum osteopontin may be a potential independent biomarker for AAA development, although it is not associated with the extent of the aneurysm. Serum osteoprotegerin seems to be of less prognostic value. The role of their levels concerning treatment of AAA remains questionable and needs further research.     

Clinical analysis of non-anastomotic aneurysms of implanted prosthetic grafts

Purpose

To investigate the features of non-anastomotic aneurysms (NAAs) of implanted prosthetic grafts through our case series and present a general review of NAAs.

Methods

We studied retrospectively, a series of NAAs of seven grafts in six patients treated between 2001 and 2010, and reviewed the data on NAAs reported between 1962 and 2009.

Results

The grafts in our series were implanted between 1986 and 2006. The primary surgical procedures were bypass between the axillary and femoral artery (n = 1), bypass between the subclavian artery and abdominal aorta (n = 1), bypass between the aorta and femoral artery (n = 1), bypass between the femoral and popliteal artery (n = 1), bypass between the femoral and femoral artery (n = 2), and bypass between the aorta and iliac artery (n = 1). The graft material was knitted Dacron in all cases and the implantation period ranged from 2.7 to 24 years (median 13.8 years). All NAAs originated from a hole in the graft. Reports of NAA have decreased dramatically, although according to the data, knitted Dacron accounted for 80 % of these implanted grafts.

Conclusions

Graft deterioration and the subsequent development of an NAA can occur even with the latest knitted Dacron grafts, even though the incidence is very low.     

Frequency,risk of hemorrhage and treatment considerations for cerebral arteriovenous malformations with associated aneurysms

Background

Data on arteriovenous malformations (AVMs) of the brain with AVM-associated aneurysms (AAA) are scarce. This study addresses the incidence, rate of hemorrhage, treatment strategies and stability during follow-up in a neurovascular center.

Methods

We retrospectively reviewed patients harboring an AVM with at least one AAA treated at our neurovascular center between 2002 and 2013.

Results

Of 216 patients, 59 (27.3 %) had at least one AAA (n?=?92 aneurysms total). Compared to patients without AAA, hemorrhagic presentation occurred more frequently (61.0 % versus 43.9 %, p?=?0.025), and the rate of infratentorial AVMs was higher (37.3 % versus 16.6 %, p?=?0.001). The aneurysm was the origin of the bleeding in most cases, most often categorized as a feeding artery aneurysm. Overall, the first and recurrent hemorrhage were associated with a high mortality and morbidity (15.3 % and 39 %, respectively). Aneurysms were treated by coiling (n?=?21), surgery (n?=?18), or embolizaton with liquid embolization agents (n?=?11). All aneurysms treated by embolization and surgery remained occluded during follow-up (mean follow-up 39.0?±?45.0 months). However, in incomplete AVM obliteration, significant recurrence of the treated aneurysm was noted after endovascular coiling (37.5 %), which may be related to the persistence of pathological blood flow.

Conclusion

In our series, AAA was a significant risk factor for hemorrhage and was associated with a poor outcome. It seems worthwhile to consider whether the aneurysm itself is a risk factor or only an epiphenomenon of severely altered hemodynamics induced by these special AVMs and therefore only the most common site of rupture. As the complication rate was low for aneurysm occlusion, we recommend treating these aneurysms whenever possible. Furthermore, obliteration of the AVM should be strived for as this subtype may be associated with an increased risk of hemorrhage.     

Seroma: An underestimated complication of vascular access for haemodialysis

Aim

The aim of the study is to describe a case-series of an underestimated complication of vascular access for haemodialysis like seroma

Background

Seroma is a rare complication of vascular surgery complicated by infection, thrombosis and pseudoaneurysm. The differential diagnosis is aneurysm and haematoma.

Patients-methods

We report eight cases of seroma of vascular access for haemodialysis: one arteriovenous and seven created by using PTFE graft. Three cases were managed intraoperatively by vacuum drainage, two by vacuum drainage postoperatively, two by complete resection of seroma and vacuum drainage and one with ligation of vascular access. Vascular access function was preserved in seven cases.

Conclusion

The diagnosis and treatment of seroma should be performed as early as possible in order to reassure the normal function of vascular access.     

肠系膜动脉瘤破裂出血的诊治分析：附8例报告

背景与目的 肠系膜动脉瘤是一种罕见的疾病,大部分患者确诊时动脉瘤已出现破裂大出血,病情危重,治疗风险大。本文回顾性分析肠系膜动脉瘤破裂患者的病例特点,探讨该疾病诊断和治疗方式的选择。方法 回顾性分析于2016年1月—2020年12月在湖南省郴州市第一人民医院血管外科收治的8例肠系膜动脉瘤破裂出血患者的临床资料和随访情况。结果 8例患者行腹部CTA或腹部增强CT明确诊断为肠系膜动脉瘤破裂出血。患者均行急诊手术治疗,其中6例行腹腔动脉造影+栓塞术;1例因腔内治疗失败后选择行开放手术;1例首选开放手术。8例患者均抢救成功,3例患者腔内治疗术后出现腹痛腹胀,药物保守治疗好转;1例患者开放手术术后出现创伤性胰腺炎,予以药物治疗治愈。所有患者住院期间均无再出血、肠缺血、肠坏死等并发症与再次手术。8例患者均随访12个月,患者正常饮食后无腹痛腹胀不适,无再次出血;复查腹部增强CT或CTA提示动脉瘤栓塞良好,血肿明显吸收。结论 临床医生要提高对肠系膜动脉瘤破裂出血疾病的认识和警惕,及时做出正确诊断。手术治疗方案可分为开放手术和腔内治疗,均安全和有效,术前应根据患者病情、瘤体位置和形态决定具体手术方案。     

Arterial manifestations in behçet's disease: Four new cases

Four new arterial lesions observed with Behçet's disease are reported: two popliteal aneurysms, one carotid aneurysm and one carotid stenosis. The clinical features, therapeutic modalities and postoperative complications of these uncommon lesions are reviewed briefly.     

Thoracoabdominal aortic aneurysm associated with umbilical artery catheterization: case report and review of the literature.

Aneurysms in infants and children are rare and are usually associated with cardiovascular malformations or connective tissue disorders. A new subgroup of patients has become recognized over the past two decades--those with aneurysms associated with umbilical artery catheterization. Critically ill newborns who have required umbilical artery catheterization and have developed sepsis, usually staphylococcal, are at risk for the development of mycotic aneurysm disease of the aorta or its major branches or both. Since first described in 1970, 34 cases have been reported in the literature, 14 involving the descending thoracic aorta, 10 the abdominal aorta, 6 the iliac arteries, and 4 either the thoracoabdominal aorta or multiple aneurysms involving both the thoracic and abdominal aorta. This report presents a case we recently treated of a 15-month-old-boy with a large thoracoabdominal aortic aneurysm and aneurysms of the infrarenal abdominal aorta and proximal right common iliac artery. It includes a review of the recent literature to analyze pathogenesis, clinical manifestations, and to formulate methods of treatment.     

Hybridverfahren zur Therapie thorakoabdomineller Aortenaneurysmen (TAAA)

Introduction

Open replacement of the aorta for treatment of thoracoabdominal aortic aneurysms (TAAA) is liable to complications. The combination therapy consisting in endovascular bypass of the TAAA and proximal/distal diversion of supraaortal vessels and of the visceral and renal arteries (debranching) could be a technical alternative for the high-risk patient.

Patients and methods

We report on a consecutive prospective series of 47 patients with TAAA (29.8% female; median age 65.5 years, range 37–81 years; 44 in ASA stage >3). In 51% of cases the aneurysm was an arteriosclerotic TAAA, while in 38.3% a secondarily expanding type B aortic dissection was present and in 10.6%, a plaque rupture or a Carrel patch stretched by an aneurysm. Six patients (12.6%) were treated as emergencies because of a free or concealed aortic rupture; 21.3% had back pain, and 66% had no symptoms. In 55.3% and in 23.4% a TAAA affecting a long section of the aorta and classifiable as Cawford extents II or III, respectively, was present. The median maximum diameter of a TAAA in this series was 74 mm (range 45–120 mm), and 57.4% of the patients had already undergone surgery of the abdominal or thoracic aorta previously. In 7 patients (14.9%) proximal debranching was first performed to create a proximal landing area offset in time against the hybrid operation. In 51% of patients it was necessary to replace the infrarenal aorta with a prosthesis before a distal landing area could be created. The median duration of surgery was 368 min for the abdominal intervention and 499 (range 250–935) min for the entire procedure. All patients underwent clinical examination and spiral CT investigation at 6-month intervals with prospective documentation.

Results

The 30-day mortality was 12.6% (6/47 patients) for the whole series and 7.4% (3/41) for those with nonruptured TAAA. The corresponding paraparesis/paraplegia rates were 4.2% and 8.5%. In 8.5% renal insufficiency requiring dialysis arose in the postoperative period. The mean length of stay in hospital was 21.3–26 (11–68) days and the mean length of stay in the intensive care unit, 9 (2–31) days. The postoperative CT investigation showed 11 endoleaks in 10 patients (type I n=6; type II n= 4; type III n=1) and 7 occluded bypasses (only renal arteries). Type I and II endoleaks were corrected by endovascular techniques.

Conclusions

The hybrid operation is a technically and logistically challenging alternative to conventional thoracoabdominal aortic replacement for the high risk patient. To optimise the result, the procedure must be evaluated prospectively against the conventional standard treatment.     

Multiple sites of vascular dilation or aneurysmal disease and matrix metalloproteinase genetic variants in patients with abdominal aortic aneurysm

Objective

The objective of this study was to assess whether functional genetic polymorphisms of matrix metalloproteinases (MMPs) 1, 3, 9, and 12 are associated with arterial enlargements or aneurysms of the thoracic aorta or popliteal arteries in patients with abdominal aortic aneurysm (AAA).

Abdominal blast injuries: different patterns,severity, management,and prognosis according to the main mechanism of injury

Purpose

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

Methods

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

Results

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

Conclusions

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.     

Aortic involvement in relapsing polychondritis

Objective

To assess prevalence of aortic involvement in relapsing polychondritis (RP) patients; to evaluate clinical features and long-term outcome of RP patients exhibiting aortitis, aortic ectasia and/or aneurysm.

Perspectives,personal experiences and personalized threshold for intervention in abdominal aortic aneurysm

Background

Current threshold for intervention for ubiquitous abdominal aortic aneurysm of 5.5 cm may not be one size fits all on a global perspective. We analysed long-term results with open repair of abdominal aortic aneurysm and postulated to provide proof of concept for personalized threshold, globally applicable for abdominal aortic aneurysm.

Methods

From 1998 to date, open conventional repair of abdominal aortic aneurysms performed in 274 consecutive patients, with 214 elective and 60 emergent, formed basis of this report. Thirty-two of the elective procedures were performed for small aneurysms of 4–5.4 cm. Concurrently, body weight and height were recorded in 100 patients undergoing computed tomography of abdomen for non-vascular reasons and 32 patients with small aneurysm who underwent elective repair. Aortic diameter was measured at predetermined domains of infrarenal aorta.

Results

Thirty-day mortality for elective and emergent groups was 3.73 and 28 %, respectively. Aortic diameter ranged from 1.4 to 1.8 cm and calculated body surface area from 1.44 to 1.7 m². Normal aortic size, with proven relationship to body surface area, becomes aneurismal when >150 % times its size. Threshold diameter of 5.5 cm has ingrained ‘defining number 3’ considering body surface area in Western males of ≥1.8 m² (5.5?÷?1.8?=?3).

Conclusion

Elective repair of abdominal aortic aneurysm is safe, durable with low reintervention rates and easy surveillance protocol. Body surface area, calculated using Mosteller formula from individual’s height and weight, multiplied by threshold factor ‘3’ to determine personalized threshold, so optimal size and time to intervene, in patients with small aneurysm, is at best proof of concept applicable to Indian and Asian populations.     

Surgical repair of Kommerell’s diverticulum and an aberrant subclavian artery

Purpose

The coexistence of Kommerell’s diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies.

Methods

Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell’s diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required.

Results

One patient died of mediastinitis, subsequent to a ruptured Kommerell’s diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6–58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications.

Conclusions

Aortic disease with an ASCA and Kommerell’s diverticulum can be repaired safely under elective conditions.     

Surgical strategy for the treatment of aortoesophageal fistula

Objective

To present a surgical strategy for aortoesophageal fistula (AEF).