Asymptomatic Aneurysms Research Articles

Unruptured cerebral aneurysms

The problem of high disability and mortality due to subarachnoid hemorrhage (SAH) from cerebral aneurysms has led to the fact that surgical treatment of unruptured aneurysms has been considered in Western Europe, Japan, and the United States as a method for prevention of subarachnoid hemorrhage for many years. The introduction of the so-called surgical SAH prophylaxis in Russia is a challenge that requires defining the principles of patient selection and choosing a treatment technique for unruptured cerebral aneurysms. The article highlights the modern approaches to treatment of asymptomatic unruptured cerebral aneurysms based on the concepts of aneurysm epidemiology and natural progression.

Hemodynamic and morphological characteristics of unruptured posterior communicating artery aneurysms with oculomotor nerve palsy.

OBJECT Unruptured posterior communicating artery (PCoA) aneurysms with oculomotor nerve palsy (ONP) have a very high risk of rupture. This study investigated the hemodynamic and morphological characteristics of intracranial aneurysms with high rupture risk by analyzing PCoA aneurysms with ONP. METHODS Fourteen unruptured PCoA aneurysms with ONP, 33 ruptured PCoA aneurysms, and 21 asymptomatic unruptured PCoA aneurysms were included in this study. The clinical, morphological, and hemodynamic characteristics were compared among the different groups. RESULTS The clinical characteristics did not differ among the 3 groups (p > 0.05), whereas the morphological and hemodynamic analyses showed that size, aspect ratio, size ratio, undulation index, nonsphericity index, ellipticity index, normalized wall shear stress (WSS), and percentage of low WSS area differed significantly (p < 0.05) among the 3 groups. Furthermore, multiple comparisons revealed that these parameters differed significantly between the ONP group and the asymptomatic unruptured group and between the ruptured group and the asymptomatic unruptured group, except for size, which differed significantly only between the ONP group and the asymptomatic unruptured group (p = 0.0005). No morphological or hemodynamic parameters differed between the ONP group and the ruptured group. CONCLUSIONS Unruptured PCoA aneurysms with ONP demonstrated a distinctive morphological-hemodynamic pattern that was significantly different compared with asymptomatic unruptured PCoA aneurysms and was similar to ruptured PCoA aneurysms. The larger size, more irregular shape, and lower WSS might be related to the high rupture risk of PCoA aneurysms.

The Physician Quality Reporting System (PQRS) Successfully Measures Quality of Care for Elective Procedures for Asymptomatic Abdominal Aortic Aneurysms and Asymptomatic Carotid Artery Disease

The Physician Quality Reporting System (PQRS) Successfully Measures Quality of Care for Elective Procedures for Asymptomatic Abdominal Aortic Aneurysms and Asymptomatic Carotid Artery Disease

Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey

Background: Asymptomatic aneurysms that are increasingly discovered on cranial diagnostic imaging are a growing management dilemma. Large-scale studies have shown that in most instances, conservative management is appropriate for the majority of patients with aneurysms less than 7 mm in maximum diameter. It is unclear whether international practise mirrors practise in these large trials. Objective: To determine how neurosurgeons around the world manage patients with asymptomatic aneurysms. Methods: Electronic survey of 283 clinicians managing patients with aneurysms using a 55-item questionnaire detailing characteristics of their experience, their hospitals and their present and future practises and insights regarding the management of patients with intracerebral aneurysms. Results: The 203 neurosurgeons (72%) who responded had a median of 17 years of practise with aneurysms and managed a median of 25 aneurysms annually. The majority of neurosurgeons endorsed treatment of all asymptomatic aneurysms regardless of size. Only four out of 10 neurosurgeons would manage patients with 4 mm anterior communicating artery or middle cerebral artery aneurysms non-surgically, whereas fewer than 2% would conservatively manage asymptomatic patients with 10 or 16 mm aneurysms. Neurosurgeons were split as to the recommended techniques for asymptomatic aneurysms of 10 or 16 mm with about half of them electing clipping and half coiling for ACoA and nearly three quarters favouring clipping for the MCA aneurysm. Although international differences exist between Europe, North America and the rest of the world, most state that their choice of treatment related to decisions around what option would provide the best neurological outcome and prevention of long-term bleeding. Conclusion: Despite large trials supporting the management of small asymptomatic aneurysms, most neurosurgeons internationally chooses to treat them with surgery or endovascular means. Since clinicians use a number of factors beyond the maximum diameter when considering treatment options, future trials should consider these factors in their design.

Harms of screening for abdominal aortic aneurysm: is there more to life than a 0·46% disease-specific mortality reduction?

Harms of screening for abdominal aortic aneurysm: is there more to life than a 0·46% disease-specific mortality reduction?

The Treatment Outcome of Unruptured Cerebral Aneurysms

Introduction The management of unruptured cerebral aneurysm is still a matter of debate with regard to either indication or technique of treatment. This large study recommended treating of aneurysm if it has size larger than 7 mm, due to the risk of rupture increasing in the future. However, it depends on the individual decision in each institute. The complication after treatment is most serious for patients who presented with asymptomatic unruptured cerebral aneurysm; the technique and the adjacent devices will be the keys to improve the outcome.

C-reactive protein predicts aortic aneurysmal disease progression after endovascular repair

ObjectivesThis study aims to investigate the prognostic significance of the rate of variation of C-reactive protein (CRP) levels as a predictor of aneurysmal sac and neck expansion and, therefore, of aneurysm disease progression, in patients undergoing endovascular aneurysm repair (EVAR) in the absence of endoleaks. Methods192 patients following non-emergency elective EVAR for asymptomatic infra-renal abdominal aorta aneurysm (AAA) were included after a six-month period after intervention to ensure the treatment success and absence of endoleaks. Expansion of aneurysm sac or neck after the six-month stabilization term occurred in 120 (63%) and 128 (67%) patients for a mean follow-up of 53±23months. ResultsThe relative CRP plasma level gradient significantly differed between the subgroups of patients according to relative sac expansion quartiles (7%, 26%, 39%, and 61%; p<0.001). In the bivariate analysis, the aorta sac diameter expansion rate progressively increased in the subgroups determined by CRP gradient quartiles (−0.5±1%, 3.6±1%, 8±2%, 10±3%; p<0.01).The median (25th; 75th quartile) CRP level rise in “rapid expanders” patients (those above the median annual sac expansion rate of 5.7%) was 51% (37%; 67%) compared with 15% (3%; 28%) in “slow- or non-expanders” (p<0.001). The multivariate age-adjusted logistic model confirmed the variation of CRP level and neck length as the only factors independently associated to sac expansion (odds ratio 4.3; 95% CI: 2.3–7.9 and 1.7; 95% CI: 1.3–2.2, respectively). ConclusionThere is a significant time-related association between AAA sac diameter enlargement and CRP plasma level gradient after EVAR in the absence of endoleaks, confirming the latter as a proper marker of aneurysm disease progression and rate of expansion in these patients.

Treatment of Popliteal Artery Aneurysms by Means of Cryopreserved Homograft

Autologous saphenous vein is considered the gold standard conduit in the femoral-popliteal revascularization for popliteal artery aneurysms (PAAs). In several cases, it may be absent or unsuitable for length or diameter and so it may be considered unfit for a conduit. In such patients, a synthetic graft or the endovascular correction can be useful, but results are controversial. In this retrospective case series, we have analyzed the safety and efficacy of the cryopreserved homograft (CHg) as a conduit in the PAA revascularization. In the period between January 2005 and December 2013, 54 PAAs have been treated with an arterial CHg. Indications to surgery were asymptomatic aneurysm with >25-mm diameter in 30 cases (55.6%), ischemic symptoms in 20 (37%), and compressive symptoms in 4 (7.4%). An urgent treatment was performed in 8 cases (14.8%) for severe ischemic symptoms. All cases have been operated by the same vascular team: a posterior surgical approach was preferred whenever possible (33 cases, 61.1%). All patients received a clinical and radiologic follow-up, and all data were collected in a specific database. A >10-mm diameter increase of the conduit was considered significant for an aneurysmatic degeneration. The primary outcomes were complications and reoperation rate, limb salvage, and primary and secondary patency. Secondary outcome was the incidence of aneurysmatic degeneration of the CHg. Mean diameter of the homografts was 6.3 mm (range, 4-8 mm). In the 30-day postoperative period, 7 PAAs (13%) developed a complication: 3 wound infections, 3 graft thrombosis, and 1 anastomotic bleeding. Six cases needed a reoperation: 2 surgical revascularizations, 2 wound debridement, and 1 anastomotic hemostasis; 1 major amputation was necessary for graft failure after the revascularization. Mean follow-up was 34.8 months (range, 1-96). Five cases (9.3%) developed a graft complication with 4 reoperations necessary (7.4%): 2 grafts required a percutaneous transluminal angioplasty for a perigraft stenosis and 2 underwent a femorodistal bypass in CHg for severe ischemic symptoms after CHg occlusion. Another one CHg occlusion was treated conservatively because it was clinically asymptomatic. Primary patency was 96.3%, 93.9%, and 88.3% at 12, 36, and 60 months, respectively; secondary patency was 98.1% at 12, 36, and 60 months. Freedom from amputation resulted in 98.1%. No aneurysmatic degeneration was observed. Univariate and multivariate analysis showed urgent surgery to be independent risk factors for complications, reoperations, and CHg occlusion (P < 0.05). In this retrospective study, the use of CHg showed to be safe and effective in the surgery of PAAs, either in the short or in the long-term follow-up. Urgent surgery can be considered predictive of graft failure. In our experience, CHg can be considered a good alternative conduit to the autologous saphenous vein.

Abstract 459: Surgery for Small Asymptomatic Abdominal Aortic Aneurysms

Background: Treatment of asymptomatic abdominal aortic aneurysms (AAAs) heavily depends on the size of the aneurysm. Large asymptomatic AAAs (diameter &gt;5.5cm) are usually repaired surgically; very small AAAs (diameter &lt;4.0cm) are monitored. Debate continues over the appropriate management for AAAs of 4.0-5.5cm diameter. Methods: The Cochrane Specialised Register and the CENTRAL databases were searched for randomized controlled trials in which patients with asymptomatic AAAs of 4.0-5.5cm were randomized to immediate repair or imaging-based surveillance at least every 6months. Outcomes had to include mortality/survival. Data were independently extracted by three researchers and were cross-checked. Results: Four trials (3314 patients) fulfilled the inclusion criteria. Two trials compared surveillance with early open repair and two trials compared surveillance with early endovascular repair (EVAR). The four trials showed an early survival benefit in the surveillance group (due to 30-day surgery operative mortality) but no significant differences in long-term survival (HR=0.88; 95%CI: 0.75, 1.02, mean follow up [FUP] 10yrs; HR=1.21, 95%CI: 0.95, 1.54, mean FUP 4.9yrs; HR=0.76, 95%CI: 0.30, 1.93, mean FUP 3yrs; HR=1.01, 95%CI: 0.49, 2.07, mean FUP 20months). A pooled analysis of patient-level data from two trials (6yrs FUP) showed no statistically significant survival difference between early open repair and surveillance (propensity-score adjusted HR=0.99; 95%CI: 0.83, 1.18), and that this lack of treatment effect did not vary by AAA diameter (P=0.39) or patient age (P=0.61). The meta-analysis of mortality at one year for EVAR trials likewise showed no significant association (RR at one year 1.15, 95%CI: 0.60, 2.17). Conclusions: The results from the four trials to date demonstrate no advantage to early repair for small AAA, regardless of whether open repair or EVAR is used and, at least for open repair, regardless of patient age and AAA diameter.

Middle Cerebral Artery Bifurcation Aneurysms: When and How to Treat Asymptomatic Unruptured Aneurysms

Management of unruptured asymptomatic cerebral aneurysms is one of the most highly controversial and most discussed topics in vascular neurosurgery. The increasing availability and use of imaging modalities, including computed tomography with and without angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography, has resulted in an increased number of diagnosed unruptured aneurysms. This trend has led more patients to ask if their vascular lesion should be treated and if so when should such treatment be done. The current medical literature shows conflicting data regarding the natural history of unruptured cerebral aneurysms and the risks associated with their management. In 2003, the International Study of Unruptured Intracranial Aneurysms (ISUIA) (11) showed that aneurysms in the anterior circulation measuring <7 mm had a 5-year cumulative risk of rupture of 0% in patients with no history of subarachnoid hemorrhage and that aneurysms measuring 7e12 mm had a 5-year cumulative risk of 2.6%, making the risk associated with any treatment modality

Prevalence of Asymptomatic Cerebral Aneurysm in General population and Ischemic Stroke Patient (I2-4A)

Prevalence of Asymptomatic Cerebral Aneurysm in General population and Ischemic Stroke Patient (I2-4A)

Prevalence of Asymptomatic Cerebral Aneurysm in General population and Ischemic Stroke Patient (S47.007)

Prevalence of Asymptomatic Cerebral Aneurysm in General population and Ischemic Stroke Patient (S47.007)

Prospective Study of Early MRI Appearances following Flow-Diverting Stent Placement for Intracranial Aneurysms.

MR imaging findings of aneurysm enlargement, aneurysm wall enhancement, perianeurysmal edema, and embolic phenomena following deployment of flow-diverting stents may be relevant to those patients who subsequently experience procedure-related intracranial hemorrhage. We sought to document the routine early postoperative MR imaging findings following flow-diverting stent insertion. Patients requiring flow-diverting stent placement for treatment or retreatment of cerebral aneurysms were prospectively included in the study during a 26-month period. Early postprocedural MR imaging studies were obtained and compared with preoperative imaging. Patient clinical outcome data were also collected. There were 34 stent-placement procedures during the study period. Aneurysm mural enhancement and mild new perianeurysmal edema were present in 50% and 14%, respectively. Any DWI lesion was present in 57% of cases. New or possibly new foci of susceptibility effect were found ipsilateral to the stent and not associated with diffusion restriction in 66% of cases. There were 2 cases (6%) of parenchymal hemorrhage and 2 major clinical complications (6%) causing permanent morbidity. Asymptomatic aneurysm mural enhancement is frequently seen following flow-diverting stent placement and should not necessarily be interpreted as a sign of impending aneurysm rupture. This finding often persists despite complete aneurysm occlusion. New small brain parenchymal susceptibility foci following stent placement have not previously been reported, to our knowledge, but were common in our series.

Surgery for small asymptomatic abdominal aortic aneurysms.

An abdominal aortic aneurysm (AAA) is an abnormal ballooning of the major abdominal artery. Some AAAs present as emergencies and require surgery; others remain asymptomatic. Treatment of asymptomatic AAAs depends on many factors, but an important one is the size of the aneurysm, as risk of rupture increases with aneurysm size. Large asymptomatic AAAs (greater than 5.5 cm in diameter) are usually repaired surgically; very small AAAs (less than 4.0 cm diameter) are monitored with ultrasonography. Debate continues over the appropriate roles of immediate repair and surveillance with repair on subsequent enlargement in people presenting with asymptomatic AAAs of 4.0 cm to 5.5 cm diameter. This is the third update of the review first published in 1999. To compare mortality, quality of life, and cost effectiveness of immediate surgical repair versus routine ultrasound surveillance in people with asymptomatic AAAs between 4.0 cm and 5.5 cm in diameter. For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (February 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1). We checked reference lists of relevant articles for additional studies. Randomised controlled trials in which men and women with asymptomatic AAAs of diameter 4.0 cm to 5.5 cm were randomly allocated to immediate repair or imaging-based surveillance at least every six months. Outcomes had to include mortality or survival. Three members of the review team independently extracted the data, which were cross-checked by other team members. Risk ratios (RR) (endovascular aneurysm repair only), hazard ratios (HR) (open repair only), and 95% confidence intervals based on Mantel-Haenszel Chi(2) statistic were estimated at one and six years (open repair only) following randomisation. We included all relevant published studies in this review. For this update, four trials with a combined total of 3314 participants fulfilled the inclusion criteria. Two trials compared surveillance with immediate open repair; two trials compared surveillance with immediate endovascular repair. Overall, the risk of bias within the included studies was low and the quality of the evidence high. The four trials showed an early survival benefit in the surveillance group (due to 30-day operative mortality with surgery) but no significant differences in long-term survival (adjusted HR 0.88, 95% confidence interval (CI) 0.75 to 1.02, mean follow-up 10 years; HR 1.21, 95% CI 0.95 to 1.54, mean follow-up 4.9 years; HR 0.76, 95% CI 0.30 to 1.93, median follow-up 32.4 months; HR 1.01, 95% CI 0.49 to 2.07, mean follow-up 20 months). A pooled analysis of participant-level data from two trials (with a maximum follow-up of seven to eight years) showed no statistically significant difference in survival between immediate open repair and surveillance (propensity score-adjusted HR 0.99; 95% CI 0.83 to 1.18), and that this lack of treatment effect did not vary by AAA diameter (P = 0.39) or participant age (P = 0.61). The meta-analysis of mortality at one year for the endovascular trials likewise showed no significant association (RR at one year 1.15, 95% CI 0.60 to 2.17). Quality-of-life results among trials were conflicting. The results from the four trials to date demonstrate no advantage to immediate repair for small AAA (4.0 cm to 5.5 cm), regardless of whether open or endovascular repair is used and, at least for open repair, regardless of patient age and AAA diameter. Thus, neither immediate open nor immediate endovascular repair of small AAAs is supported by currently available evidence.

Outcome of elective treatment of abdominal aortic aneurysm in elderly patients

IntroductionOptimal management of an abdominal aortic aneurysm (AAA) in the elderly is not straightforward. We evaluated treatment results of elderly patients with asymptomatic abdominal aortic aneurysm that met the treatment criteria in our clinic. MethodsHospital charts between January 2005–December 2012 were reviewed of all patients 70 years and older diagnosed with AAA with a diameter that met the treatment criteria. Patients were stratified by age (group I: 70–79 years, group II: 80 years or older) and treatment. Outcome was measured in terms of survival and complications. ResultsIn total 283 patients (240 (85%) men, median age 77.4 years) were included, 211 (75%) in group I and 72 (25%) in group II. There was an overall significantly higher mortality rate in the octogenarians (p < 0.01). This difference was not seen in the groups treated conservatively and with OPEN repair. However, in the EVAR group there was a significantly higher mortality rate in octogenarians (p < 0.01). ConclusionLong-term outcome after EVAR procedures results in higher mortality rates for the population older than 80 years as compared to the group aged 70–79 years.

Three-Dimensional Ultrasound Evaluation of Small Asymptomatic Abdominal Aortic Aneurysms

Non-invasive and reproducible size measurements that correlate well with computed tomography (CT) are desirable in the management of small abdominal aortic aneurysms (AAA). Three dimensional ultrasound (3D-US) technology may reduce inaccuracy because of variations in orientation of the image planes and axis. This study aimed to determine any differences in paired size estimation associated with three 3D-US derived methods using 3D-CT as the gold standard. When CTA was not available, the patients were enrolled anyway to assess 3D-US reproducibility in terms of agreement between two physicians. In the period from 1 March 2013 to 27 February 2014, consecutive patients with a small AAA, <5.5cm for men and <5.2cm for women, underwent 3D-US examination and three AAA size measures were obtained: dual plane diameter, diameter perpendicular to the residual sac's centreline and a partial volume. In all, 122 consecutive US examinations were performed. Patients were excluded because of inadequate AAA size (n=11) and for technical reasons (n=11). Thus, 100 patients (F/M; 20/80) with a median maximum AAA diameter of 46 (range 31-55) mm were analysed. The mean US dual plane diameter and the 3D-US centreline diameter were 2.6mm and 1.8mm smaller than the mean 3D-CT centreline diameter, respectively (p=.003). The inter-observer reproducibility coefficient was 3.7mm for the US dual plane diameter and 3.2mm for the 3D-US centreline diameter (p=0.222). For the partial volume, the reproducibility was 8-12%, corresponding to a diameter variability of ±3mm. The median time used for post-processing of the 3D-US acquisition was 72 (range 46-108) seconds per examination. 3D-US demonstrated an acceptable reproducibility and a good agreement with 3D-CT, and has the potential to improve future AAA management through more reliable ultrasound guided size estimates.

What Is the Role of Cerebral Bypass Surgery Today?

The current indications for cerebral bypass surgery are unquestionably diminishing. As a result of rapid and progressive advances, endovascular techniques are now capable of dealing with more and more challenging aneurysms that could have been optimally managed only with open surgical techniques just afewyearsago. Similarly, therecent resultsof the Carotid Occlusion Surgery Study (COSS) have emphasized the effectiveness of modern medical therapy for the management of intracranial ischemia and dampened enthusiasm for bypass surgery (3). However, despite these advances, there still remains a subset of patients who benefit from revascularization surgery. InapaperrecentlypublishedinWORLD NEUROSURGERY, Kalanietal. attempt to define the current indications and outcomes of bypass surgery in the modern endovascular era. The authors present a contemporary series of direct cerebrovascular revascularization procedures performed at the Barrow Neurological Institute (BNI) over a 7-year period (2006e2013). There were 131 direct bypass procedures performed in 121 patients. Indications for bypass surgery included moyamoya disease in 40 patients (47 bypasses), complex aneurysms in 54 patients (56 bypasses), and occlusive vascular disease in27 patients (28 bypasses).Amongpatients with moyamoya angiopathy, revascularization resulted in improvement of symptomsin 77.5%.Morbidity and mortality rates were 5%and 0%, respectively. Long-term angiographic follow-up was available in only 60% of the patients and demonstrated graft patency in 96.8%. Among the patients with complex aneurysms, 81.5% of the patients had afavorable outcome. Morbidity and mortality rates were 16.6% and 13%, respectively. Long-term angiographic follow-up was available in 94.4% of the surviving patients and demonstrated graft patency in 76.7%. Among patients with occlusive vascular disease, symptom improvement was seen in 55.5%. Morbidity and mortality rates were 14.8% and 0%, respectively. Long-term angiographic follow-up was available in 59.3% of patients and showed a 100% graft patency rate. It is always useful to hear the experience of such a renowned center as the BNI. The article has some limitations, such as the retrospective nature of the review; the heterogeneous group of patients; and the limited long-term angiographic follow-up, particularly in the patients with moyamoya disease and vascular occlusive disease. This single-institution experience limits the general applicability of the results; very few surgeons in the world can hope to achieve the generally excellent results reported in this study. The authors use the Glasgow Outcome Scale, which was originally designed for assessment of outcomes in patients with severe head trauma. Although a Glasgow Outcome Scale score of 4 may be a “good” result for a patient with a severe head injury, such an outcome (“independent withmildto moderateneurologic deficit”) maynot be a “good” outcome for an intact patient presenting with an asymptomatic complex aneurysm. Use of the modified Rankin Scale, which is a more accurate indicator of outcomes, may have been

Giant dissecting aortic aneurysm in an asymptomatic young male.

Giant aortic aneurysm is defined as aneurysm in the aorta greater than 10 cm in diameter. It is a rare finding since most patients will present with complications of dissection or rupture before the size of aneurysm reaches that magnitude. Etiological factors include atherosclerosis, Marfan's syndrome, giant cell arteritis, tuberculosis, syphilis, HIV-associated vasculitis, hereditary hemorrhagic telangiectasia, and medial agenesis. Once diagnosed, prompt surgical intervention is the treatment of choice. Although asymptomatic unruptured giant aortic aneurysm has been reported in the literature, there has not been any case of asymptomatic giant dissecting aortic aneurysm reported in the literature thus far. We report a case of giant dissecting ascending aortic aneurysm in an asymptomatic young male who was referred to our institution for abnormal findings on physical exam.

Endovascular management of visceral artery aneurysms: When to watch, when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.

Innominate Artery Aneurysm: Simulating a Thyroid Nodule.

We report a 69-year-old lady who was referred for the evaluation of a suspected solitary thyroid nodule. The patient noticed a gradually increasing neck swelling of over a year duration along with a history of intermittent dysphagia to solid food without other compressive symptoms. There were no signs and symptoms of hypothyroidism or hyperthyroidism. She had other co-morbidities including Type 2 Diabetes mellitus, Systemic Hypertension and Coronary Artery Disease with no prior history of local trauma. Examination revealed a non-tender soft and non-pulsatile, fluctuant swelling of size 2X 2cm on the right side of the neck just above the sternoclavicular joint [Table/Fig-1]. The swelling moved with deglutition. There was no cervical lymphadenopathy or tracheal deviation. Laboratory investigations revealed a normal Thyroid Stimulating Hormone (TSH) -4.24uIU/ml (Normal-0.8-4.5), Total Thyroxine (T4) of 9.7ug/dl (Normal-4.5-12.5), Free Thyroxine (FT4) – 0.95ng/dl (Normal-0.8-2), with negative anti-thyroid antibodies. The fasting blood glucose was 123mg% (Normal-70-100), Post prandial blood glucose was 185mg% (Normal<140) and Glycated Haemogloin, (HbA1c) of 5.3% (Normal<7%). The lipid profile showed total cholesterol 206 mg% (Normal-<160), LDL–C- 136 mg% (Low Density Lipoproteins) (Normal <100), TG -189 mg% (Trigly cerides) (Normal<150). Ultrasonography of the thyroid did not reveal any thyroid nodule; however the Colour Doppler revealed a focal fusiform dilatation of the right innominate artery measuring 2x2cm in diameter [Table/Fig-2] and no obvious thrombus was detected. Barium swallow showed left ward displacement of the cervical oesophagus [Table/Fig-3] which could be the cause for her dysphagia. Thus, although she was clinically diagnosed to have a thyroid nodule, the Colour Doppler showed a right innominate artery aneurysm. Thus FNAC and thyroid scintigraphy was avoided. [Table/Fig-1]: Clinical image of the patient showing nodule in the right side of the neck (shown in arrow) [Table/Fig-2]: Colour Doppler showed a focal fusiform dilatation of the right innominate artery measuring 2x2 cm in diameter [Table/Fig-3]: Barium swallow showed left ward displacement of the cervical oesophagus (shown in arrow) The vascular lesions in front of the neck such as aneurysm or tortuous artery can sometimes resemble a thyroid nodule [1]. The indexed case was of right innominate artery aneurysm, which was initially suspected to be a solitary thyroid nodule. An innominate artery aneurysm is an uncommon entity which occurs exclusively in middle aged women who are at high risk for atherosclerotic disorders [2]. It may be sometimes difficult to appreciate the pulsatility of the aneurysm because of the overlying connective tissues [3]. When ultrasound shows no obvious thyroid nodules, a Colour Doppler study of the neck is helpful in determining the nature of neck swelling as in our patient [4]. Fine needle aspiration in such a circumstance can be catastrophic with potential lethal complications. There is a previous report of a similar case where scintigraphy was done initially that revealed a cold area in the lower lobe. They subsequently performed an ultrasound that led to the diagnosis and stressed the importance of Colour Doppler Sonography as a compliment to nuclear medicine procedures in that scenario [1,5]. The patients’ clinical picture is suggestive of atherosclerotic disease, which probably played a causal role in the development of aneurysmal disease. The other causes of innominate artery aneurysm are trauma, infection, connective tissue disease, Kawasaki’s disease, and Takayasu’s arteritis [6], Small size innominate artery aneurysm is usually asymptomatic, present either as an incidentally detected neck mass or as a superior mediastinal mass on chest x-ray [7]. Patients with innominate artery aneurysm may presents with symptoms like hoarseness of voice or dysphagia due to compression of localized structures and neurological symptoms due to thrombo-embolism [8]. Ultrasound with Doppler is diagnostic, when lesions are located in the neck region. However, CT scan is indicated in case of mediastinal lesion. Asymptomatic innominate artery aneurysms are usually managed conservatively. Surgery is indicated if the size of aneurysm is more than 3 cm in transverse diameter or in the presence of thrombus or if complicated by thrombo-embolism [9]. In our case surgery was not offered as there was no definite indication. She is currently under regular follow-up without any worsening of symptoms.