Anterior Aneurysm Research Articles

Mitral valve injury late after transcatheter aortic valve implantation

CLINICAL SUMMARY An 88-year-old man with symptomatic severe aortic stenosis underwent percutaneous TAVI with a 26-mm SAPIEN valve (Edwards Lifesciences LLC, Irvine, Calif). Comorbid conditions included coronary artery bypass with patent retrosternal grafts, transient ischemic attacks, bilateral carotid endarterectomies, atrial fibrillation, repaired abdominal aneurysm, prostate cancer, and renal failure. Estimated 30day mortality for AVR was 35% by means of logistic EuroSCORE and 11.1% by means of the Society of Thoracic Surgeons National Database Risk Calculator. The procedure was performed without difficulty, but the final valve position was suboptimal, being slightly low (ventricularly), with the ventricular aspect of the stent abutting the anterior leaflet of the mitral valve (MV). Moderate paravalvular aortic regurgitation (AR) was treated with repeated balloon redilation without altering the valve position. Six-month transthoracic echocardiographic analysis showed trivial AR and mitral regurgitation. The patient presented 11 months after implantation with fever and Streptococcus angiosus in blood cultures. Also noted were a dental visit 6 weeks before and lack of compliance with endocarditis prophylaxis. Transesophageal echocardiographic analysis demonstrated mild-to-moderate paravalvular AR, a 13 3 8–mm ruptured anterior mitral leaflet aneurysm contiguous with the aortic prosthesis, and severe mitral regurgitation (Figure 1). Redo sternotomy was performed during cardiopulmonary bypass after cannulating the right axillary artery and right internal jugular vein. The bioprosthesis was well-seated below the coronary arteries with incomplete endothelialization of the uppermost struts and covered with nodular excrescences (Figure 2). It withstood extraction while fully expanded but was removable when grasped with forceps, which were

Use of a covered stent to treat two large false aneurysms of the anterior tibial artery

A 42-year-old man was admitted to hospital complaining of a pulsatile swelling in the anterior compartment of his left lower leg. One month earlier, he had been stabbed in that area with a small knife but had not sought medical attention at that point. His medical history included diabetes mellitus and a right below knee amputation. The clinical examination revealed a large swelling in the anterior compartment of the left lower leg. All pulses were palpable in the left leg except the dorsalis pedis. Arterial duplex imaging and an angiogram demonstrated two large false aneurysms arising from the anterior and posterior wall of left anterior tibial artery (A and Cover). Through an antegrade approach by way of the left common femoral artery, a 6F sheath was negotiated into the left popliteal artery. Over a 0.035-inch wire, selective catheterization of the anterior tibial artery was undertaken, and the catheter was placed distal to the false aneurysm. Intra-arterial heparin was administered (4000 units). The catheter was exchanged for a 0.0140-inch wire, and a 3-mm × 19-mm covered stent (JOSTENT Graft, Abbott Vascular, Abbott Park, Ill) was placed at the site of the false aneurysm. Residual filling of the aneurysm was demonstrated. A further 3.5-mm × 19-mm overlapping covered stent was placed and achieved complete exclusion of the aneurysm (B and C). The patient was discharged the next day without complication. At follow-up 6 weeks later, the mass in the left anterior compartment was nonpulsatile and reducing in size. Both pedal pulses were palpable. Covered stents are increasingly being used to treat false aneurysms at a number of sites.1Saad N.E. Saad W.E. Davies M.G. Waldman D.L. Fultz P.J. Rubens D.J. Pseudoaneurysms and the role of minimally invasive techniques in their management.Radiographics. 2005; 25: S173-S189Crossref PubMed Scopus (294) Google Scholar To our knowledge, there has only been one other report of the use of a covered stent to treat an anterior tibial artery false aneurysm.2De Roo R.A. Steenvoorde P. Schuttevaer H.M. Den Outer A.J. Oskam J. Joosten P.P. Exclusion of a crural pseudoaneurysm with a PTFE-covered stent-graft.J Endovasc Ther. 2004; 11: 344-347Crossref PubMed Scopus (30) Google Scholar In that instance, the stent graft was reported to be patent at 1 year. Other options in this patient included ligation of the false aneurysm alone or ligation and anterior tibial bypass. The technical ease of treatment and quick recovery all favor an endovascular approach. The patency of stent grafts placed at this site is presently unclear and requires further study. Download .jpg (.41 MB) Help with jpg files Cover Image

Surgical treatment of postinfarction anterior left ventricular aneurysms: linear vs. patch plasty repair

The patch plasty repair is increasingly advocated over linear closure in the surgical treatment of postinfarction anterior left ventricular aneurysm (LVA). A comparative estimate of the clinical results of these two techniques seemed in order. Between 1985 and 2004, 53 patients (mean age of 64.2+/-8.3 years) underwent repair of anterior LVA. Twenty-seven patients underwent linear repair (group 1) and 26 patients patch plasty (group 2). The mean left ventricular ejection fraction was 33.9+/-8.2% in group 1 vs. 29.7+/-10.2% in group 2 (P=0.118). Preoperatively 85.2% of patients in group 1 were in NYHA functional class III or IV vs. 88.5% in group 2 (P=0.71). All patients had preoperative recurrent ventricular tachycardia (VT) and non-guided encircling cryoablation for treatment of VT was performed in all patients. Coronary revascularization was performed in 29.6% of patients in group 1 and 42.3% in group 2 (P=0.398). The overall in-hospital mortality was 1.9% as one patient died of low cardiac output (LCO). LCO was the most frequent early postoperative complication and was observed in 66.7% of patients in group 1 vs. 65.4% in group 2 (P=1.000). LCO was related to right coronary artery disease on multivariate analysis (odds ratio 6.9, P=0.0097). Mean follow-up was 6.4+/-4.8 years (range 1 day-17.5 years). Overall survival at 10 years was 65.5% of patients in group 1 vs. 60.6% in group 2 (P=0.395). At 10 years, 91.5% of patients were free from VT or sudden death in group 1 vs. 81% in group 2 (P=0.269). At follow-up the patients' functional status improved and among survivors 76.9% in group 1 were in NYHA functional class I-II vs. 62.5% in group 2 (P=0.432). Deaths from congestive heart failure (CHF) occurred in 38.5% of patients in group 1 vs. 55.6% in group 2 (P=0.632). On multivariate analysis a preoperative left ventricular end-diastolic pressure above 20 mmHg was a predictor of mortality from CHF (odds ratio 9.6, P=0.038). Our study did not reveal significant differences between linear closure and patch plasty repair in the short- and long-term. The choice of repair technique should be adapted to each patient's anatomical and physiological characteristics.

Early surgery of ruptured anterior circulation aneurysm based on multislice helical computerised tomography angiography

The purpose of this study is to evaluate the utility of three-dimensional computed tomographic angiography (3D-CTA) as the primary diagnostic investigation in patients with spontaneous subarachnoid haemorrhage (SAH) from anterior circulation aneurysms, and to correlate the results with digital subtraction angiography (DSA) and intraoperative findings. From May 2005 to May 2007 a total of 38 consecutive patients admitted for SAH, suspicious for ruptured anterior circulation cerebral aneurysm, underwent 3D-CTA. Inclusion criteria were a SAH confirmed by a non-contrast head computed tomographic scan or by lumbar puncture. Exclusion criteria were: previous DSA, severe contrast medium allergy and severe renal failure. All patients underwent early surgical clipping of the aneurysm. The mean time between SAH onset and surgery was 43.6 h (range, 14-74 h). The 3D-CTA was performed in all cases; and in 13 out of 38 patients (34%) represented the only preoperative exam. In all patients that underwent surgery with the sole 3D-CTA, the images collected allowed a good visualisation of the morphology of aneurysms and of the anatomical relationship with the vascular structures. 3D-CTA allows accurate diagnosis with an excellent visualisation of ruptured aneurysms of the anterior circulation. Our results suggest that, in selected cases, ruptured anterior circulation aneurysms could be successfully treated on the basis of 3D-CTA alone.

Agenesis of the Left Internal Carotid Artery Associated with Right Anterior Cerebral Artery A1 Segment Bifurcation Aneurysm: A Case Report

Agenesis of the internal carotid artery occurs in less than 0.01% of the population. Intracranial aneurysms accompany agenesis in 25-43% of the patients. We present a unique patient with a saccular aneurysm of the anterior communicating artery associated with agenesis of contralateral internal carotid artery.

Ruptured femoropopliteal artery aneurysms in von Recklinghausen neurofibromatosis

A 38-year-old woman with neurofibromatosis type 1 was referred for massive swelling of the left thigh, pain, and anemia. Angiography demonstrated three saccular aneurysms of the femoropopliteal artery. The largest measured 3 cm in diameter. Resection of the aneurysms and femoropopliteal interposition grafting using reversed saphenous vein was performed through a medial surgical approach. Arterial involvement in neurofibromatosis is a well known but infrequent occurrence. Stenotic lesions predominate. Aneurysmal defects are less common, and rupture of peripheral arteries is exceptional. Neurofibromatous invasion and dysplasia of the tunica media of the femoropopliteal vessel were confirmed by means of pathologic study. We think this is the second reported case of a femoropopliteal artery aneurysm and rupture associated with neurofibromatosis.

Intramural Dissecting Hemorrhage of the Myocardium

After suffering anterior myocardial infarction 3 months previously, a 59-year-old male patient with persistent dyspnea (New York Heart Association classification II) underwent a follow-up examination. A 12-lead ECG showed chronic ST elevation (V1 through V4) indicating left ventricular anterior aneurysm; no significant pulmonary congestion was present (Figure 1A and 1B). On echocardiography, left ventricular ejection fraction was severely depressed, and a myocardial flap was seen in the left ventricular apex; in addition, a mostly echo-free apical space, together with thrombus formation, suggested contained myocardial …

Blutungskomplikation durch Akkumulation von niedermolekularem Heparin bei einer Patientin mit Niereninsuffizienz

We report of a 71-year-old woman with a history of chronic analgesic nephropathy, who underwent coronary angiography. Because of anterior ventricular aneurysm, anticoagulation with nadroparine was installed. Continued ACE-inhibitor and ASA with additional intravenous contrast substance lead to acute tubular necrosis with rapid decline of the renal function. Due to accumulation of the low molecular weight heparin, the patient developed an extensive retroperitoneal haematoma with circulatory shock and temporary anuric kidney failure. Low molecular weight heparins are commonly used during percutaneous coronary interventions. They are as safe and efficient compared to unfractioned heparin. But due to their renal elimination, they have to be monitored by measuring anti-factor Xa-activity if creatinine-clearance is <30 ml/min.

Microsurgical treatment of complex intracranial aneurysms via keyhole approaches

To explore the feasibility and effect of microsurgical treatment of complex intracranial aneurysms via keyhole approaches. Operation via keyhole approach was performed on thirty-one patients with 42 complex intracranial aneurysms were operated on, including 2 internal carotid artery bifurcation aneurysms, 1 anterior cerebral artery aneurysm, 12 posterior communicating artery aneurysms, 2 anterior choroids artery aneurysms, 7 middle cerebral artery aneurysms, 6 anterior communicating artery aneurysms, 2 basilar artery aneurysms, 2 vertebral artery aneurysms, 4 posterior cerebral artery aneurysms and 4 ophthalmic artery aneurysms, among which were 10 cases with multiple intracranial aneurysms, 14 with giant aneurysms, and 7 with posterior circulation aneurysms, and 4 aneurysms clipped by drilling off anterior clinoid process. Six of the 31 patients who had giant aneurysms came to hospital because of the symptoms, such as dizziness, headache, oculomotor paralysis, loss of vision, etc, and the other 25 patients were grouped according to the subarachnoid hemorrhage (SAH) Grade: 5 in grade I, 12 in grade II, 7 in grade III and 1 in grade IV. Eight patients were operated on after SAH in the early-phase, while 8 in the middle-phase and 9 in the late-phase. The supraorbital subfrontal keyhole approach was used 25 times, the pterional approach 5 times, the subtemporal approach 3 times, and both the suboccipital lateral approach and the retromastoid approach once. 31 of the 42 aneurysms were clipped, 2 mini-aneurysms wrapped, 5 giant aneurysms clipped and resected, 2 aneurysms trapped with thrombotic aneurysm partially resected, 1 aneurysm trapped, while 1 ruptured before operation and untreated. Short-term Glasgow outcome scoring showed good recovery in 27 patients, moderate disability in 2, and death in 2. Operation via keyhole approaches effectively controls the immature rupture of intracranial aneurysm, removes anterior clinoid process, respects giant aneurysm, and reconstructs the parent artery of wide-neck aneurysm. Based on individualized surgical approaches and excellent microsurgical skills, the complex intracranial aneurysms can be treated safely, directly and effectively via minimally invasive keyhole approaches.

Nontraumatic Aneurysms Affecting Crural Arteries: Case Report and Review of the Literature

Aneurysms involving the infrapopliteal arteries are rare, with most cases being attributed to a previous traumatic event. Mycotic aneurysms in this location are even more uncommon. Owing to their infrequency, these aneurysms represent a difficult diagnostic challenge. We present a case of a symptomatic anterior tibial artery aneurysm in a 59-year-old male with a medical history significant only for an episode of bacterial endocarditis, subsequently requiring an aortic valve replacement. Surgical repair was performed with a popliteal to anterior tibial bypass with a reversed saphenous vein graft. The patient's recovery was uneventful. We also reviewed the literature on this type of aneurysm to assess the incidence, etiology, options for treatment, and outcomes.

Inflammatory Abdominal Aortic Aneurysm

Inflammatory abdominal aortic aneurysm (AAA) accounts for 5% to 10% of all cases of AAA and differs from typical atherosclerotic AAA in many important ways. Although both inflammatory and atherosclerotic AAA most commonly affect the infrarenal portion of the abdominal aorta, patients with the inflammatory variant are younger and usually symptomatic, chiefly from back or abdominal pain. Unlike patients with atherosclerotic AAA, most with the inflammatory variant have an elevated erythrocyte sedimentation rate or abnormalities of other serum inflammatory markers. Computed tomography and magnetic resonance imaging are both sensitive for demonstrating the cuff of soft tissue inflammation surrounding the aneurysm that is characteristic of inflammatory AAA. In contrast to atherosclerotic AAA, the inflammatory variant is characterized pathologically by marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and rigid adherence of the adjacent structures to the anterior aneurysm wall. An extraordinary expansion of the adventitia due to inflammation also distinguishes inflammatory from atherosclerotic AAA. Although the pathogenesis of inflammatory AAA appears to involve an immune response localized to the vessel wall, the etiology of the inflammatory reaction is unknown. Inflammatory AAA is almost never associated with inflammation of other arteries. Male sex and smoking, the main risk factors for atherosclerotic AAA, are even stronger risk factors for the inflammatory variant. Smoking cessation is the first step of medical therapy. Corticosteroids or immunosuppressive therapies may also have roles. Although inflammatory AAA appears less likely to rupture than atherosclerotic AAA, surgical intervention appears prudent once the diameter of the aneurysm exceeds 5.5 cm. Knowing the features of inflammatory AAA should allow physicians to distinguish it from atherosclerotic AAA or from systemic vasculitis and to treat it with the appropriate combination of medical and surgical therapies.

内頸動脈瘤に対するＴｒａｐｐｉｎｇ ａｎｄ Ｒａｄｉａｌ Ａｒｔｅｒｙ Ｇｒａｆｔ Ｂｙｐａｓｓの検討

Internal carotid artery (ICA) trapping+radial artery graft could be performed for ICA cavernous, paraclinoid portion aneurysms. Direct clipping procedures are not always possible to carry out in these cases, because there are a lot of neurostructures surrounding aneurysms. These nerve structures could be easily damaged during the direct clipping procedure. Compared with direct clipping procedure, ICA trapping+radial artery graft could be a safe and easy method to achieve intra-aneurysm thrombosis and neurological improvement. However, treatment strategy may differ among nonbleeding and bleeding cases. Endovascular proximal occlusion is the first choice for nonbleeding cases who mainly suffered from ophthalmoparesis. But it is important to estimate ischemic tolerance before permanent proximal occlusion by balloon occlusion test (BOT). ICA trapping+radial artery graft should be selected in cases without ischemic tolerance for BOT. On the other hand, ICA trapping+radial artery graft should be primarily performed for patients with ruptured anterior wall ICA aneurysms without the BOT procedure, because re-bleeding may occur during the BOT procedure.

Hypoxia at the Site of Abdominal Aortic Aneurysm Rupture Is Not Associated with Increased Lactate

The mechanisms of hypoxia-mediated aneurysm wall weakening and rupture are unknown. During hypoxia, strategies to maintain cellular ATP levels include increasing glycolysis (glycolytic strategy) or decreasing ATP consumption (metabolic depression). This study demonstrated that compared to anterior aneurysm sac, rupture edge overexpressed hypoxia-inducible factor-1-alpha (marker of hypoxia) and showed no significant difference in levels of combined ADP and ATP or lactate (glycolytic end product). Further studies are needed to confirm whether hypoxic AAA cells adapt through metabolic depression rather than glycolysis. The downregulation of protein synthesis during such metabolic depression may be a factor in hypoxia-mediated wall weakening.

Modified Upper Blepharoplasty Incision Technique for Neurosurgical Access to Intracranial Anterior Circulatory Aneurysms

Statement of the Problem: Develop a new technique for access to the intracranial anterior circulatory aneurysms via the supraorbital and orbitopterional keyhole approaches.

Abdominal Aortic Aneurysm Rupture Is Associated With Increased Medial Neovascularization and Overexpression of Proangiogenic Cytokines

Matrix metalloproteinase (MMP) activity has been linked to abdominal aortic aneurysm (AAA) rupture. Medial neovascularization (MNV), a histopathologic characteristic of AAAs, involves proteolytic degradation of extracellular matrix by MMPs to facilitate endothelial cell migration. The role of MNV in aneurysm rupture is unknown. This study investigated whether MNV is increased in aneurysm rupture. Biopsy samples from aneurysm rupture edge were compared with control biopsy samples from aneurysm wall at the level of rupture and from anterior sac in 12 ruptured AAAs. Further controls were obtained from anterior sac of 10 nonruptured AAAs. MNV, microvessel diameter, maturity index, and inflammatory infiltrate were quantified using morphometric analyses following immunohistochemistry. Expression of proangiogenic mediators was quantified using quantitative real-time-polymerase chain reaction. Compared with anterior sac and aneurysm wall at level of rupture, MNV was increased (P<0.001) in rupture edge biopsy samples and consisted of smaller diameter (P<0.001) and more immature microvessels (P<0.001). mRNA expression of alpha(v)-integrin, vascular endothelial growth factor, vascular endothelial-cadherin, monocyte chemoattractant protein-1, and vimentin was increased (P<0.05) in rupture edge biopsy samples. This study demonstrated increased medial neovascularization and overexpression of proangiogenic cytokines at aneurysm rupture edge. Further investigations into whether this angiogenic response was a causative factor of aneurysm rupture are needed.

Matrix Metalloproteinase-8 and -9 Are Increased at the Site of Abdominal Aortic Aneurysm Rupture

Abdominal aortic aneurysm (AAA) expansion is characterized by extracellular matrix degradation and widespread inflammation. In contrast, the processes that characterize AAA rupture are not well understood. The aim of this study was to investigate the proteolytic and cellular activity of ruptured AAA, focusing on matrix metalloproteinases (MMPs) and their inhibitors (TIMPs). Anterior aneurysm wall biopsies were taken from 55 nonruptured and 21 ruptured AAAs. A further biopsy from the site of rupture was taken from 12 of the ruptured AAAs. MMP-1, -2, -3, -8, -9, and -13, as well as TIMP-1 and -2, were quantified in each biopsy with ELISA. A comparison of anterior aneurysm biopsies showed no difference in MMP or TIMP concentrations between nonruptured and ruptured AAA. In a comparison of ruptured AAA biopsies, MMP-8 and -9 levels were significantly elevated in the 12 rupture site biopsies compared with their 12 paired anterior wall biopsies, whereas other MMPs and TIMPs showed no difference (MMP-8, P<0.001; MMP-9, P=0.01). MMP-8 and -9 expression was mediated by native mesenchymal cells and was independent of the inflammatory infiltrate. A localized increase in MMP-8 and -9, mediated by native mesenchymal cells, presents a potential pathway for collagen breakdown and AAA rupture.

Giant Left Anterior Descending Artery Aneurysm An Unusual Case of Dense and Extensive Calcification of Aorta

Giant Left Anterior Descending Artery Aneurysm An Unusual Case of Dense and Extensive Calcification of Aorta

Distal Anterior Cerebral Artery Mirror Aneurysms and Middle Cerebral Artery Aneurysms-Case Report-

A 52-year-old woman presented with bilateral distal anterior cerebral artery (ACA) mirror aneurysms, in addition to two right middle cerebral artery (MCA) aneurysms. The left distal ACA and right MCA aneurysms were clipped through right interhemispheric and right pterional craniotomies. The right distal ACA aneurysm was thrombosed. Distal ACA aneurysms tend to be multiple, but mirror aneurysms are rare, especially in the absence of congenital vascular anomaly. Single stage unilateral craniotomy is recommended for surgical treatment.

Hypothalamic Hamartoma Associated With Anterior Paraclinoid Aneurysm of the Internal Carotid Artery-Case Report-

A 15-year-old boy presented with a history of medically refractory gelastic seizures and cognitive impairments. Neuroimaging demonstrated a sessile type hypothalamic hamartoma, which was treated by gamma knife surgery. However, the gelastic seizures only partially decreased and the frequency of seizures remained unchanged. One year later, angiography before surgery detected anterior paraclinoid aneurysm of the left internal carotid artery. Blood pressure and endocrinological examinations showed no abnormality. Direct surgery was performed to treat the aneurysm and hamartoma. No sclerotic changes were noted in the arterial wall. The aneurysm was treated with clipping, and the hamartoma was partially removed. Postoperative course was uneventful and the gelastic seizures disappeared. No evidence for a causal relationship between the hamartoma and aneurysm was found.

Pneumocephalus in a patient with a ventriculoperitoneal shunt after percutaneous gastrojejunostomy catheter placement: case report

Background Percutaneous gastrostomy and/or jejunostomy associated with ventriculoperitoneal (VP) shunting in critically ill neurosurgical patients is not an uncommon combination. Massive intraventricular pneumocephalus has not been previously reported as a complication of percutaneous gastrostomy and/or jejunostomy placement in a patient with a VP shunt. A case is presented here where we believe such a complication occurred. Case Description Our patient is a 68-year-old woman who experienced a subarachnoid hemorrhage from a right anterior choroidal aneurysm rupture. The patient underwent endovascular coiling. The patient developed a communicating hydrocephalus and eventually necessitated a VP shunt. Two weeks after shunt placement, our patient had a fluoroscopic percutaneous gastrostomy and/or jejunostomy catheter placed. A computed tomographic scan of the brain obtained after feeding tube placement for a change in mental status revealed a significant amount of air in the lateral ventricles. The patient was managed expectantly over the next several days with slow clinical and radiographic improvement. Conclusions The etiology for the increased intraventricular pneumocephalus is believed to be retrograde leakage of air into the ventricles via the VP shunt during insufflation of the abdomen for percutaneous placement of a gastrojejunostomy feeding tube.