Aneurysm Of Sinus Research Articles

Repair of a Syphilitic Aneurysm of the Noncoronary Sinus.

About one-tenth of patients with untreated chronic syphilis and tertiary syphilis develop structural complications involving the coronary ostia, ascending aorta, or aortic root. We describe a unique case of a large aortic root aneurysm of the noncoronary sinus with extrinsic compression of the right coronary artery, a complication of tertiary syphilis. Surgical intervention involved valve-sparing aortic root reconstruction with right coronary ostia reimplantation (hemi-Yacoub). The patient's postoperative course was uneventful; he is healthy approximately 2 years later.

P1326NATIVE AVF ANEURYSMS RECONSTRUCTION: THE MULTI-CENTER EXPERIENCE

Abstract Background and Aims to analyze the results of surgical correction of native arteriovenous fistula (AVF) aneurysms in hemodialysis patients. Method A retrospective observational study included 158 patients who underwent various surgical interventions. 87 patients (55.1%) underwent pre-emptive surgeries. 71 patients (44.9%) underwent surgeries after AVF thrombosis («on demand» surgery). In the presence of high-flow AVF or in a case of high risk of fistula vein rupture, aneurysmorrhaphy was performed, which was supplemented by transposition of the reconstructed vein – fig. 1. In a case of paraanastomotic stenosis of the vein, aneurysmorrhaphy was enhanced by arteriovenous anastomosis proximalization. In a case of local proximal or distal stenosis of the functional segment of the vein, aneurysmorrhaphy was supplemented with stenosis plastic using the wall of the resected aneurysm. In a case of prolonged proximal stenosis or totally thrombosed proximal aneurysm, the fistula blood flow was switched to v. basilica with its transposition. In the case of a totally thrombosed distal aneurysm, it was excised and proximal AVF was created. Results In the case of pre-emptive surgeries, secondary patency was 69% [95% CI 44.9; 84.2] after 4.8 years (maximum follow-up). In the case of on-demand surgeries the secondary patency was 45.6% [95% CI 23.6; 65.2] after 4.3 years (maximum follow-up) – fig. 2. HR (log rank test) pre-emptive vs. on demand surgeries 0.296 [95% CI 0.147; 0.592], inverse HR = 3.381 [95% CI 1.674; 6.827], p = 0.0002. The risk AVF function loss was lower in patients who received pre-emptive surgeries compared with patients who received on-demand surgery: 2.642 [95% CI 1.406; 4.519] versus 6.268 [95% CI 3.927; 9.49] per 100 patient-years, incidence rate ratio (IRR) = 0.422 [95% CI 0.207; 0.834] (inverse estimate IRR=2.372 [95% CI 1.2; 4.842]), p = 0.0127. The need for CVC was also lower in patients who received pre-emptive surgeries: 1.728 [95% CI 1.38; 2.136] versus 2.821 [95% CI 2.292; 3.434] per 10 patient-years, IRR=0.6125 [95% CI 0.4576; 0.8185] (inverse estimate IRR= 1.633 [95% CI 1.222; 2.185]), p = 0.0009. Moreover, the number of operations was significantly higher in patients who underwent pre-emptive surgeries: 4.207 [95% CI 3.654; 4.821] versus 2.963 [95% CI 2.421; 3.59] per 10 patient-years, IRR=1.42 [95% CI 1.124; 1.802] (inverse estimate IRR= 0.704 [95% CI 0.555; 0.89]), p=0.0031. In almost all cases, fistula vein aneurism has been associated with various hemodynamic disorders. The median volume blood flow Qa was 2.9 [interquartile range - IQR 1.9; 3.8] l/min., (minimum. 1 l/min., max. 4.5 l/min.). Reconstruction in most cases led to significant change in Qa (p<0.0001). After reconstruction, the Qa median was 1.8 [IQR 1.6; 2.1] l/min. (minimum 1.4 l/min., max. 2.1 l/min). It is noteworthy that in patients with low Qa values, Qa increased slightly, and at high values, it decreased significantly. However, additional methods of blood flow reducing were not used. The median of the Qa difference was -1.2 [IQR -1.9; -0.2] l/min. (minimum -2.7 l/min, max. 1 l/min.). Conclusion The indication for surgical treatment is not just aneurism, but its complications, the high risk of complications development or a combined pathology. Preventive surgical interventions can significantly extend the AVF patency and reduce the need for central venous catheters, however, this is achieved by significantly increasing the number of surgeries. The concept of routine monitoring of a normally functioning AVF by a surgeon should replace the concept of on-demand surgery in case of AVF thrombosis or development of other serious complications.

Short interposition with a small-diameter prosthetic graft for flow reduction of a high-flow arteriovenous fistula

ObjectiveThe objective of this study was to evaluate the outcome of a short interposition using a small-diameter prosthetic graft as a flow-limiting procedure to manage symptomatic high-flow arteriovenous fistula (AVF). MethodsA retrospective review of medical records on a case series was conducted. From June 2004 to April 2017, there were 25 patients with clinical symptoms of high output cardiac failure and progressive dilation of aneurysmal fistula vein due to high-flow AVF (≥1.5 L/min) who underwent short interposition with a 5-mm prosthetic graft at Saitama Medical Center. The primary outcome was the relief of clinical symptoms; other outcome measures included technical success, surgical complications, patency of vascular access, and postoperative changes in local and systemic hemodynamics as assessed by Doppler ultrasound. ResultsTwenty-five patients underwent short interposition for cardiac indications (n = 16) and aneurysmal dilation (n = 9). The technical success rate was 100%. The clinical symptoms were relieved in 24 patients (96.0%). Mean reduction in access blood flow was 52.4%. Cumulative primary unassisted patency rates (± standard error) at 1 year, 2 years, and 3 years were 76.2% ± 9.3%, 70.4% ± 10.3%, and 58.1% ± 11.6%, respectively. Secondary patency rates (± standard error) at 1 year, 2 years, and 3 years were 81.8% ± 8.2%, 71.5% ± 9.9%, and 71.5% ± 9.9%, respectively. Complications included access occlusion due to late thrombosis (n = 5 [21.7%]) and graft infection (n = 1 [4.3%]) in the median follow-up period of 3.9 years. ConclusionsShort interposition with a prosthetic graft is a simple, effective, and durable treatment option for end-stage renal disease patients with cardiac symptoms and progressive dilation of the fistula vein due to high-flow AVF, offering clinical symptom resolution while preserving the autologous behavior of the initial access.

Our experiences with hemodialysis arteriovenous fistula aneurysm

Our experiences with hemodialysis arteriovenous fistula aneurysm

Surgical Experiences on Arteriovenous Fistula Aneurysms

Objective: Chronical renal failure (CRF) is a disease which can cause fatal complications and affect other organs directley or indirectly. Arteriovenous fistulas are strongly needed in the hemodialysis treatment of CRF. Fistula aneurysms are one the most frequent complications among the long term complications of arteriovenous fistulas. In this research, we aimed to evaluate the surgical treatments of the arteriovenous fistula aneurysm cases. Material and Methods: Thirty five patients undergoing surgical processes due to arteriovenous fistula aneurysms larger than 4 cm in Yozgat City Hospital and Bozok University Medicine Faculty Hospial between November 2015 and May 2018 were evaluated retrospectively. Sex distribution of the patients were as follows; 16 females, 19 males. Mean age of the patients were 53 ±11,2. Results: No complication such as enfection, hematoma, neurological disroders or ischemia were observed among the patients in the postoperative period. Conclusion: We think that surgical treatment of the arteriovenous fistula aneurysms still remains the first option despite the recent improvements in interventional techniques. Keywords: Arteriovenous fistula, aneurysm, hemodialysis, rupture Special Issue of Health Sciences DOI: 10.7176/JSTR/6-03-02

Asymptomatic unruptured aneurysm of the left sinus of Valsalva: a case history report

.

285 An Unusual Cause of Shortness of Breath

Sinus of Valsalva aneurysms are a rare but potentially fatal cardiac anomaly. A 76 year old gentleman presents with chronic diarrhoea and shortness of breath. Auscultation reveals systolic and diastolic murmurs. Transthoracic echocardiogram initially showed severely dilated right ventricle with systolic impairment and a dilated aortic root with moderate eccentric aortic regurgitation. Transoesophageal echocardiogram revealed a large, thin walled aneurysm of the right Sinus of Valsalva measuring up to 60mmx55mm causing right ventricular outflow tract obstruction. There was considerable spontaneous echo-contrast but no thrombus. There was no evidence of rupture. A CT coronary angiogram surprisingly revealed a second large left Sinus of Valsalva aneurysm causing possible proximal left anterior descending artery compression. Cardiothoracic opinion was sought. Given age and symptom stability, decision was to manage expectantly with close surveillance. Patient remains well after 12 months of follow-up. The patient was not anticoagulated due to risk of rupture. This is an incidental finding of a rare cardiac anomaly. In younger, symptomatic patients the treatment is usually surgical. Further research is needed to clarify the optimal management strategy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P1468 a rare cause of chest pain:sudden rupture of aortic valsalva sinus aneurysm

Abstract Introduction Sinus of Valsalva aneurysms (SOVAs) occur when there is a congenital defect in the aortic media and incomplete fusion of distal bulbar septum (primitive bulbus cordis) and truncal ridges. These aneurysms usually rupture into the right side of the heart, with the right ventricle being the most common. Case Presentation A 32 year old male patient who presented to our facility with an attack of ulcerative colitis activity ,elevated inflammatory markers and thrombocytosis. During hospital stay, he developed sudden onset of retrosternal compressing chest pain. On examination he was afebrile with a blood pressure of 130/80 mm Hg and pulse rate 110 beats per minute. He had soft systolic and early diastolic murmurs with normal chest auscultation; there was no haemodynamic discrepancy between left and right sides or stigmata of endocarditis. His ECG showed sinus rhythm with no ST segment changes, and chest x ray was normal. Full blood count revealed thrombocytosis & normochromic normocytic anemia , cardiac enzymes were normal, blood cultures were sterile. A 2D transthoracic echocardiography (TTE) revealed dilated left ventricular dimensions , there is an aneurysm of the right sinus of Valsalva which is communicating with the right ventricle (RV)confirmed by color Doppler and negative contrast seen inside RV during bubble study. 3D TTE showed a small fistulous track between the right sinus and RV. The patient refused surgical or percutaneous closure. Conclusion Congenital RSVAs account for 0.1–3.5% of congenital heart defects.It has a higher incidence in Asian versus Western populations with male to female ratio 3:1. SOVAs arise from the right sinus of Valsalva in 80–85% of these cases and from the noncoronary sinus in 5–15%. They rarely arise from the left sinus, as the left coronary cusp embryologically is not derived from bulbar septum. This is distinct from acquired SOVAs, which can occur in any of the sinuses Traditionally, surgical closure has been the mainstay of treatment for RSOVAs, with an operative mortality rate of <5% and excellent long-term outcomes. Abstract P1468 Figure. RSOVA

Upper extremity reconstruction following open surgical repair of giant arteriovenous fistula aneurysm: clinical case and systematic review of the literature.

Background:Nearly 30% of arteriovenous fistulas (AVFs) located in the upper extremity for hemodialysis access result in short- and long-term adverse effects, such as rupture, necessitating emergent surgical management and extensive soft-tissue reconstruction. With this systematic review, we aimed to compile all reported open surgical techniques used for complicated AVF repair in the upper extremity, the respective soft-tissue reconstructive outcomes, and vascular patency rates at final follow-up.Methods:Using Ovid Medline/PubMed databases, we conducted a review of the English-language literature on AVF aneurysm surgical management in the upper extremity, filtered for relevance to open surgical technique and outcomes in vascular patency after aneurysmal repair at long-term follow-up (≥6 months postoperatively). We include a detailed case of surgical removal of a giant AVF aneurysm and subsequent flap elevation and reconstruction of the upper extremity.Results:Of 150 articles found in the initial search, 19 (from 2010-2017) met inclusion criteria. From the reviewed studies, 675 patients underwent open surgical repair of AVF aneurysm in the upper extremity. Surgical approaches included partial-to-full aneurysm excision, interposition graft, tubularized extracellular matrix, sutured and stapled aneurysmorrhaphy, and stent graft. Rates of vascular patency at repair site ranged from 47% to 100%, with a pooled average of 78% at 6 months or longer postoperatively.Conclusions:For plastic and hand surgeons, aneurysmal ligation and excision is feasible even in severe cases and is associated with overall good vascular and soft-tissue reconstructive outcomes in the upper extremity. (www.actabiomedica.it)

A hidden aortic rupture heralded by recurrent brain and retinal embolism

Central MessageAn unrecognized contained aortic rupture may be responsible for repeated embolism and may be detected by means of transthoracic, transesophageal 2-dimensional echocardiography and computed tomography.See Commentary on page 17. An unrecognized contained aortic rupture may be responsible for repeated embolism and may be detected by means of transthoracic, transesophageal 2-dimensional echocardiography and computed tomography. See Commentary on page 17. Atherosclerotic changes in the aortic wall of major arterial vessels represent an important risk factor of systemic embolism. Necropsy studies have demonstrated that complicated aortic plaques are variably associated with ischemic cerebral lesion that may be clinically silent.1Khatibzadeh M. Mitusch R. Stierle U. Gromoll B. Sheikhzadeh A. Aortic atherosclerotic, plaques as a source of systemic embolism.J Am Coll Cardiol. 1996; 27: 664-669Crossref PubMed Scopus (129) Google Scholar In the patient described here, the source of systemic embolism was identified in a previously undiagnosed calcific pseudoaneurysm of the noncoronary sinus. A 65-year-old man experienced recurrent strokes with areas of brain and retinal ischemia (Figure 1, A and B). After hospitalization, continuous monitoring excluded episodes of atrial fibrillation. Transthoracic and transesophageal 2-dimensional echocardiography (Figure 1, C) showed moderate aortic regurgitation and the presence of a 7 × 5 cm saccular aneurysm of the noncoronary sinus that was confirmed by a computed tomography, which also showed gross calcification of the wall (Figure 1, D). At surgery, firm adhesions between the aortic root and the right atrium raised the suspicion of a pseudoaneurysm due to undiagnosed contained rupture (Figure 1, E); fragile calcific deposits (Figure 1, F) were considered the source of embolization. Repair of the pseudoaneurysm was obtained by replacement of the noncoronary sinus using a polyethylene terephthalate patch. The patient recovered uneventfully with no further embolic episodes at 3-month follow-up.

Management of Hemodialysis Graft/Fistula Aneurysms

Renal failure patients are obligated to have constant life-saving dialysis access. This retrospective review was designed to evaluate graft and fistula aneurysms. Once the dialysis access procedures are performed, care of patients is relegated to the nephrologists and dialysis clinics. This review is designed to validate surgical intervention of dialysis access procedures as a safe and durable procedure and determine if proactive steps could be taken to avoid this complication.

Basilic vein transposition-radial artery fistula created using the no-touch technique .

To compare the functions and complications of forearm basilic vein transposition-arteriovenous fistula (BVT-AVF) created using the no-touch technique with that of conventional radiocephalic arteriovenous fistula (RC-AVF). The no-touch technique was used to created basilic vein transposition-radial artery fistula in 22 patients. Another 30 patients received surgeries for RC-AVF. The fistula functions and complications were compared between these two groups. The two groups did not differ significantly in the incidence of postoperative bleeding, limb swelling, infection, steal syndrome, fistula thrombosis, fistula aneurysm, fistula flow, fistula maturation time, Kt/v, and fistula median survival. Forearm BVT-AVF created by the no-touch technique is a good alternative access for patients in whom the standard arteriovenous fistula cannot be established.

Dynamic Banding (DYBAND) Technique for Symptomatic High-Flow Fistulae.

High flow rates may develop in arteriovenous fistula (AVF), resulting in clinical syndromes of steal, aneurysmal fistula, or high-output cardiac failure. Various techniques with varying success have been advocated to treat this difficult problem. We present a hemodynamically validated novel banding technique. We designed a computational fluid dynamic (CFD) model of the native high-flow AVF and tested various juxta-anastomotic venous diameters to determine the effect on AVF blood flow and pressure. We translated this principle in our banding technique, wherein adjustable banding was performed in conjunction with ultrasound-guided brachial artery flow measurement to determine the optimal band diameter. Polyurethane patch was used to fashion the adjustable band. Patient demographics, AVF flow parameters pre- and postintervention, operative intervention, and ultrasound follow-up data were collected prospectively. Our CFD testing demonstrated that the band diameter needed to achieve optimal distal blood pressure and preserve AVF flow depending on blood pressure, end capillary pressure, venous pressure, and vascular diameters. Five patients subsequently underwent dynamic banding of symptomatic high-flow AVF. Mean brachial artery blood flow rates pre- and postbanding were 2964 mL/min (confidence interval [CI]: 1487-4440 mL/min) and 1099 mL/min (CI: 571.7-1627 mL/min), respectively (P = .01). All patients had symptomatic improvement, and at a mean follow-up of 1 year, this benefit was sustained with no AVF thrombosis or loss. Adjustable dynamic band using ultrasound-guided brachial artery flow shows promising results in producing accurate AVF blood flow reduction with sustained efficacy in the short term for patients with symptomatic high-flow AVF.

Tratamiento quirúrgico de los aneurismas del seno de Valsalva

BackgroundIn this study, we reviewed our experience of 10years in the repair of the aneurysm of the sinus of Valsalva that are intact or broken and its long-term follow-up. MethodsA retrospective, cross-sectional review of 23 patients (13 men, 10 women, mean age 31years, range 21-61years) who underwent surgery for repair of Valsalva sinus aneurysm between January 2007 and February 2017. The aneurysm of the Valsalva originated from the right coronary sinus in 19 patients (82%), the left coronary sinus in 3 patients (10%), and the non-coronary sinus in 2 patients (8%). In 2 patients, the Valsalva sinus aneurysm was intact and in 21 (91%) it was ruptured, the most frequent occurrence was right ventricular rupture in 16 (69%), whereas right atrial rupture was present in 4 (17%), left ventricle in one (4.3%) and left atrium in one (4.3%). The common defects associated were aortic insufficiency in 12 patients (52%), ventricular septal defect in 9 (39%), tricuspid insufficiency in 3 (13%), atrial septal defect and patent ductus arteriosus (4.3%). Two repair techniques were used; in 17 (74%) a patch was used to close the defect and in 6 (26%) it was excluded with square points reinforced with Teflon. ResultsWe did not have hospital mortality. Follow-up, ranging from one month to 10years, was available in 100% of survivors. One patient presented leakage through the repair technique without hemodynamic repercussion. The actual survival rate was 95.7%. The freedom of reoperation was 100%. ConclusionSurgical repair is the optimal choice for the treatment of Valsalva sinus aneurysm. Early surgical intervention after diagnosis may improve the long-term prognosis of these patients.

Florida sleeve technique for a right sinus of Valsalva aneurysm: a case report

BackgroundFlorida sleeve technique was reported by Hess et al. as a new technique of valve sparing aortic root replacement without the requirement of entire aortic root wall resection and coronary artery reconstruction. We present a rare case of an unruptured aneurysm of the right sinus of Valsalva that was successfully treated with resection of the aneurysm and the Florida sleeve technique.Case presentationA 72-year-old man was admitted for the treatment of an unruptured aneurysm of the right sinus of Valsalva. Computed tomography showed an aneurysm of the right sinus of Valsalva measuring > 40 mm and protruding into the right ventricular outflow tract. The aneurysm dilated up to 5 mm per year, and the left sinus of Valsalva and non-coronary sinus of Valsalva also showed dilation, and he underwent resection of only the right sinus of Valsalva aneurysm and valve sparing aortic root replacement with the Florida sleeve technique.ConclusionsWe performed valve-sparing aortic root replacement with the Florida sleeve technique. It could reduce surgical risks and prevent a dilatation of the residual sinus of Valsalva through coverage with a graft for a long term.

Ruptured Aneurysm of Sinus of the Valsalva: Case Series

Introduction: We present three cases of ruptured sinus of Valsalva aneurysm concomitant with a cardiac lesion in 2 cases of ventricular septal defect and 1 case of bicuspid aortic valve with mild aortic insufficiency. Case presentation: In 2/3 cases, the site of ruptured sinus of Valsalva aneurysm originated from right coronary cusps and one from non-coronary cusps. Both ruptured sinus of Valsalva aneurysm from right coronary cusps communicated to right ventricle, and one that originated from non-coronary cusps ruptured to right atrium. All cases were diagnosed by transthoracic echocardiography and confirmed by transesophageal echocardiography. Two underwent the surgery, while one did not want to continue treatment. Conclusion: ruptured sinus of Valsalva aneurysm is a rare cardiac anomaly. In the Eastern countries, the most common associated anomalies with ruptured sinus of Valsalva aneurysm are ventricular septal defect and aortic regurgitation. Ruptured sinus of Valsalva aneurysm mainly originates from right coronary cusps and is ruptured into right ventricle. Transthoracic echocardiography and transesophageal echocardiography are employed to confirm the diagnosis. In this cohort, the coexistences of ruptured sinus of Valsalva aneurysm with ventricular septal defect and aortic regurgitation (case 1), ventricular septal defect (case 2), aortic regurgitation and bicuspid aortic valve (case 3) are observed.

Giant unruptured aneurysm of the left coronary sinus of Valsalva presenting as acute coronary syndrome: a case report.

BackgroundSinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. Unruptured aneurysms may be asymptomatic but can present as malignant arrhythmias, acute chest pain, and even sudden cardiac death. Both ruptured and unruptured SVAs may have fatal complications, thus prompt diagnosis and surgery is critical.Case summaryWe report a successful surgical repair of an unruptured aneurysm of the left sinus of Valsalva presenting as acute coronary syndrome. Coronary angiography (CAG) and cardiac multislice computed tomography (CT) revealed a large unruptured aneurysm of the left sinus of Valsalva. Surgical repair was performed by resection of the aneurysm, aortic valve replacement with composite graft, and coronary artery bypass.DiscussionAneurysm of the left sinus of Valsalva is an extremely rare condition. Correct diagnosis can be done by echocardiography, CAG, or CT. Non-ruptured aneurysms should be surgically repaired if they are associated with significant symptoms or if their size enlarge rapidly.

Concurrent congenital pseudoaneurysm of mitral-aortic intervalvular fibrosa and left sinus of Valsalva aneurysm

Either the pseudoaneurysm of mitral-aortic intervalvular fibrosa or the aneurysms of Valsalva are rare cardiac conditions. Concomitant diagnosis in the same patient is extremely rare with only one case report. Herein, we described an extremely rare case of concomitant pseudoaneurysm of mitral-aortic intervalvular fibrosa and aneurysm of left sinus of Valsalva in 21-year-old black man admitted with new-onset of heart failure (NYHA class III) diagnosed by transesophageal echocardiography. Despite medical therapy optimization for heart failure, the patient died waiting for cardiac surgery. Regarding the case, we discussed possible etiology, clinical presentation and the role of echocardiography in the diagnosis and surgical approach of this very rare association.

Partial aneurysmectomy for treatment of autologous hemodialysis fistula aneurysm is safe and effective

ObjectiveThe purpose of this study was to evaluate the outcome and the factors associated with stenosis after treatment using partial aneurysmectomy for aneurysm in autologous arteriovenous fistulas. MethodsThis retrospective cohort study was conducted from July 2007 to June 2016 and included patients with complicated aneurysms in upper extremity autologous arteriovenous fistulas were treated by partial aneurysmectomy. Vascular ultrasound examination was performed every 6 months after the surgery. ResultsForty-one patients (median age, 37 years; 70.7% males) were included. Of the patients, 95.1% had a radial-cephalic fistula in the forearm and nearly 88% had 1 or 2 aneurysms in arteriovenous fistulas that had been created for 10 to 84 months. Technical success of partial aneurysmectomy was achieved in all patients. The access diameter (44.0 ± 5.1 mm vs 10.4 ± 1.8 mm; P < .01) and brachial artery blood flow (1618.2 ± 277.0 mL/min vs 772.1 ± 127.4 mL/min; P < .01) were significantly decreased after the surgery. The median follow-up time was 27 months (range, 12-43 months). The primary patency rates at 6 and 12 months were 100% and 95%, respectively. Loss of patency was due to stenosis of the remodeled fistulas, which occurred in seven patients (17%). Multivariate COX regression analysis revealed that diabetes (hazard ratio, 114.28; 95% confidence interval, 2.85-4583.94; P = .01) was a risk factor for the impaired primary patency rates. A larger postprocedure residual diameter trended to favor fistula patency (hazard ratio, 0.46; P = .07). Stenosis was successfully treated with percutaneous transluminal angioplasty. ConclusionsPartial aneurysmectomy is an effective and safe method for treating aneurysm of upper extremity autologous arteriovenous fistulas, leading to good 12-month primary patency and no aneurysm recurrence. Using a larger catheter to size the revised fistula during aneurysmectomy may increase access patency.

A giant aneurysm of the left sinus of Valsalva

A giant aneurysm of the left sinus of Valsalva