Aneurysmal Changes Research Articles

Osteoblastoma Recurring as High-grade Osteosarcoma

Abstract Introduction/Objective Osteoblastoma is a benign, bone-forming neoplasm that presents as a well-circumscribed lesion amenable to excision. The prognosis is good despite a 20% recurrence risk. Malignant transformation is very rare. Osteoblastoma-like osteosarcoma is a rare form of osteosarcoma that shares similar clinical, radiographic, and pathological characteristics Methods/Case Report A 24-year-old female presented with a large palpable mass in the posterior occiput. The lesion progressively enlarged over 2 years, finally becoming symptomatic. Magnetic resonance imaging demonstrated an extradural posterior fossa expansile skull mass measuring 6.0 x 5.7 x 4.7 cm that showed multiple fluid/fluid levels. The mass was resected. Pathology demonstrated a well-circumscribed neoplasm that was cellular and composed of large polyhedral osteoblasts with eccentric oval nuclei and abundant amphophilic cytoplasm. Tumor cells were intimately associated with numerous small interconnecting, irregular bony trabeculae. Scattered mitotic figures of normal configuration were noted. The findings were compatible with an epithelioid osteoblastoma with prominent secondary aneurysmal bone cyst-like changes. The patient was lost to follow-up but presented 3 years later with severe migraines. Imaging demonstrated a large heterogeneous enhancing mass centered about the occipital cranioplasty with both intracranial and extracranial components. Reexcision was performed. Sections showed a well- circumscribed tumor, delineated by a rim of subperiosteal reactive bone, with an epithelioid morphology. However, it also demonstrated areas of necrosis, extensive sheet-like growth, conspicuous mitoses, and cytological atypia not seen in the previous specimen. Therefore, diagnosis of osteoblastoma-like osteosarcoma was rendered after expert consultation. Results (if a Case Study enter NA) NA Conclusion This case highlights the exceedingly rare evolving nature of osteoblastomas and their high-grade transformation potential.

Role of aneurysmal hemodynamic changes in pathogenesis of headaches associated with unruptured cerebral aneurysms.

One symptom commonly associated with the presence of unruptured intracranial aneurysms is headache. In this study, the authors aimed to analyze factors associated with headaches among patients with intracranial aneurysms, with special consideration of hemodynamic parameters. The authors prospectively included 96 patients with 122 unruptured intracranial aneurysms. The authors obtained detailed medical history including current diseases and medications, as well as blood pressure values taken during hospitalization from the patients' medical records. The short-form McGill Pain Questionnaire was administered to each patient at admission and 3-6 months after the procedure to assess type and severity of headache. Based on imaging data, the authors obtained 3D reconstruction of each patients' aneurysm dome with feeding artery. The authors performed computational fluid dynamics analysis of blood flow through prepared models using OpenFOAM. Blood was modeled as Newtonian fluid, using the incompressible transient solver. Patient-specific internal carotid artery (ICA) blood velocity waves obtained with Doppler ultrasound were set as inlet boundary conditions. After performing simulation, the authors calculated the hemodynamic parameters of the aneurysm dome. A total of 30 patients (31.25%) reported having headaches. In multivariate logistic regression analysis, female sex (OR 2.81, 95% CI 2.51-4.86; p < 0.01), ICA aneurysm location (OR 7.93, 95% CI 5.51-8.52; p < 0.01), multiple aneurysms (OR 6.05, 95% CI 1.83-11.83; p = 0.02), mean dome blood velocity (OR 3.10, 95% CI 2.01-3.30; p < 0.01) and time-averaged wall shear stress (OR 1.18, 95% CI 1.47-2.72; p = 0.04) were independently associated with the presence of headache. Additionally, 17 patients (56.67%) reported complete relief of symptoms after the procedure. In multivariate logistic regression analysis, the mean blood flow in the ICA was independently associated with complete resolution of headaches after aneurysm treatment (OR 2.32, 95% CI 1.57-3.28; p < 0.01). Hemodynamic parameters of intracranial aneurysms might be associated with headaches and their relief after aneurysm treatment.

Quantification of morpho-hemodynamic changes in unruptured intracranial aneurysms with irregular pulsation during the cardiac cycle using 4D-CTA.

Previous studies predicting the rupture risk of intracranial aneurysms (IAs) have predominantly utilized static imaging data, overlooking the dynamic blood flow and biomechanical properties of the aneurysm wall. Irregular pulsation detected by 4D-CTA is a potential predictor of aneurysm rupture, albeit with uncertain clinical significance. This study aimed to analyze the changes in morpho-hemodynamic characteristics of IAs during the cardiac cycle to elucidate the dynamic changes and the associated hemodynamic mechanisms. A retrospective review was conducted on the 4D-CTA data of IA patients between January 2017 and September 2019. R-R intervals were segmented into 20-time phases, reconstructing 20 CT datasets to identify irregular pulsation and extract 3D aneurysm models. Computational fluid dynamics (CFD) simulations analyzed hemodynamic parameters such as oscillatory shear index (OSI) and relative residence time (RRT). Changes in morpho-hemodynamic characteristics were quantified in terms of the absolute change (parameter*) and relative change rate (parameter%). Rupture risk was assessed using the rupture resemblance model (RRS). Eleven UIAs from 10 patients were finally included, with five aneurysms showing irregular pulsation (45.45%). No significant differences in morpho-hemodynamic characteristics were observed between aneurysms with or without irregular pulsation. More remarkable changes in aneurysm size (size*: 0.59 ± 0.14 mm vs. 0.32 ± 0.12 mm, p = 0.010; size%: 10.49% ± 1.43% vs. 3.95% ± 1.79%, p < 0.001), volume (volume%: 13.72% vs. 6.39%, p = 0.009), OSI (OSI*: 0.02 ± 0.01 vs. 0.004 ± 0.005, p = 0.004; OSI%: 200% vs. 12.50%, p = 0.004) and RRT (RRT%: 97.14% vs. 43.95, p = 0.052) over the cardiac cycle were significantly linked to irregular pulsation. Aneurysms with irregular pulsation demonstrated a more unfavorable hemodynamic environment during the cardiac cycle, irrespective of the predicted rupture risk. Furthermore, irregular pulsation at the aneurysm dome exhibited higher hemodynamic instability than at the sidewall. Irregular pulsation may indicate hemodynamic instability within the aneurysm, leading to an increased rupture risk in the area where irregular pulsation occurs. This proof-of-concept study could enhance understanding of dynamic changes in UIAs during the cardiac cycle and the underlying hemodynamic mechanisms.

A rare case report of fibrous dysplasia with aneurysmal bone cyst-like changes of femur and innominate bone

Fibrous dysplasia (FD) is a common disorder of the skeletal system in which normal bone deposition and remodelling are disturbed and are replaced by anomalous fibrous tissue of varying stages. The age of presentation may vary depending on the genetic penetration and severity of the disease. Aneurysmal bone cyst (ABC) is a non-aggressive neoplastic pathology wherein there is the presence of blood-filled intramedullary cystic lesions and resultant aneurysm-like dilatation of the involved bone that may be a standalone true neoplasm or ABC-like changes associated with other lesions. Concurrence of FD with ABC-like changes is an uncommon entity with most of such cases involving the craniofacial location. To the best of our knowledge, only two cases of appendicular skeleton FD with ABC could be found in the literature, and neither of them is from the Indian subcontinent. Herein, we report one such case of appendicular FD with concomitant ABC-like changes presenting in the adolescent age group. Prompt and accurate diagnosis guides further surgical management and helps in avoiding inadvertent complications.

Configurational changes of ruptured intracranial aneurysms at the window between pre-operative CTA and the definite clipping surgery

Background: Ruptured intracranial aneurysms may face configurational changes in size and shape resulting from extreme weakness in their wall. These configurational changes are associated with an amplified risk of rupture and surgical challenges as these aneurysms have proven to be unstable. However, to our knowledge, no previous studies have addressed the issue of configurational aneurysmal changes between the patient’s presentation (radiological images) and intraoperative findings. This paper aims to compare aneurysmal size and shape between pre-operative Computed tomography angiography and intraoperative lesion characteristics in a cohort of patients presented to our centre. Methods: A retrospective analysis was performed on cases admitted to the Neurosurgery Teaching Hospital in Baghdad, Iraq, and underwent microsurgical clipping of ruptured aneurysms. Their records were checked for aneurysmal configurational changes by comparing pre-operative radiological images and intra-operative findings. Results: Of the 275 patients, 5 cases were enrolled with aneurysmal configurational changes. Three of them were females, and two were males. The pre-operative aneurysmal shapes based on Computed tomography angiography were (3 unicyst and two conical shapes) and the range of aneurysmal size was (7-11 mm) with a mean of 9 mm. Compared to intra-operative findings, there were total aneurysmal shape changes (connected cyst in 4 patients and spherical aneurysm in one patient). The range of aneurysmal size was (7-11 mm) with a mean of 9 mm. Conclusion: Intracranial aneurysms may undergo configurational changes through the time between pre-op imaging and surgery; early detection of these changes may ensure optimal management of such cases.

In-situ repair of a mycotic thoracoabdominal aortic aneurysm caused by MRSA bacteremia using cryopreserved artery and autogenous vein

Mycotic aortic aneurysm (MAA) is a rare disease process associated with high morbidity and mortality, especially if left untreated. Currently, there is no consensus on optimal management for MAA but early diagnosis is vital for improving chances of survival. Treatment with antibiotics is recommended followed by surgical repair. We present the unique case of a 33-year-old male who presented with a mycotic thoracoabdominal aneurysm that was treated via open in-situ repair with cryopreserved artery, celiac and superior mesenteric artery bypasses, and ligation of bilateral renal arteries. The patient subsequently underwent a successful kidney transplant several years later and currently remains dialysis free. CT imaging at 1-year and 5-years demonstrated patent bypasses without evidence of re-infection or aneurysmal changes to the cryopreserved arterial graft. This case underscores the myriad of challenges associated with managing MAA, while also presenting the opportunities to surmount these challenges through a personalized and multidisciplinary treatment approach.

Outcomes of brachial artery transposition in hemodialysis patients

ObjectiveIn hemodialysis patients with a difficult access extremity who are not suitable for an arteriovenous fistula or arteriovenous graft creation, the concept of cannulating a superficialized artery for arterial outflow in dialysis sessions has been adopted as a tertiary alternative. However, its long-term patency and complications have not been recognized widely. We report our 16-year experience with hemodialysis access creation using the brachial artery transposition (BAT) technique. MethodsThis single-center retrospective study included consecutive patients who underwent BAT for hemodialysis vascular access between June 1, 2006, and December 31, 2022. The patency of the whole access circuit and the transposed brachial artery itself was evaluated independently. ResultsIn total, 193 surgical procedures were included. The success rate was 93.2%. The mean operative time was 128 minutes. The median interval from access placement to first cannulation was 21 days. The primary patency rates for BAT were 92.3%, 91.3%, 90.3%, 86.1%, and 71.9% at 1, 2, 3, 5, and 10 years, respectively. The secondary patency rates for BAT were 96.3%, 96.3%, 95.0%, 90.1%, and 74.9% at 1, 2, 3, 5, and 10 years, respectively. The primary patency rates for the whole access circuit were 61.4%, 49.2%, 45.8%, and 26.9% at 1, 2, 3, and 5 years, respectively. The secondary patency rates for the whole access circuit were 85.1%, 83.3%, 82.0%, and 68.6% at 1, 2, 3, and 5 years, respectively. The overall patient survival rates were 79.6%, 69.6%, 54.6%, 36.5%, and 13.4% at 1, 2, 3, 5 and 10 years, respectively. The abandonments of BAT were brachial artery thrombosis (n = 6), pseudoaneurysm (n = 2), aneurysmal change (n = 1), and other reasons (n = 1). The abandonments of the whole access circuit were exhaustion of venous return (n = 26), abandonment of BAT (n = 7), and other reasons (n = 2). Complications were exhaustion of venous return (n = 26), aneurysmal change (n = 12), pseudoaneurysm (n = 6), brachial artery thrombosis (n = 7), impaired wound healing (n = 19), lymphorrhea (n = 9), skin infection (n = 5), hematoma on cannulation (n = 3), and reduced peripheral blood flow (n = 2). ConclusionsThe patency of BAT was excellent, and that of the whole access circuit was adequate, with a few complications. BAT is an effective alternative from a long-term perspective for patients who are unsuitable for conventional hemodialysis access creation.

E023 Intimomedial mucoid degeneration. A rare vascular disease mimicking giant cell arteritis presentation

Abstract Background/Aims The accuracy of giant cell arteritis (GCA) diagnosis has greatly improved in recent years with increasing use of fast track clinics and vascular ultrasound. The “halo” sign is recognised as confirmation of a positive test and is considered virtually pathognomonic of GCA in the setting of a correlating clinical presentation. There are caveats to this and “false halos” have been reported associated with arterial thickening seen in other conditions including atherosclerosis and lymphoma. In this case a focal area of arterial wall thickening mimicking a halo on ultrasound was due to a rare vascular condition called intimomedial mucoid degeneration. Methods A 63 year old female presented via the direct assessment unit to the fast track GCA service. She reported an 8 week history of a tender right forehead lump and a 3 week history of associated new headache with marked tenderness at the site of the lump. The headache was severe and had become persistent. Mild shoulder stiffness was present. No jaw claudication. Blurring while wearing glasses noted but no definite visual change. CRP 2mg/L, ESR at usual baseline of 30mm/hr. Other indices normal. On examination: No shoulder restriction. No visual field deficit. Palpable pulsatile area of artery right side of forehead that was exquisitely tender with less marked tenderness of the artery adjacent to this. No symptoms on left side. GCA probability score (GCAPS) 10 indicating intermediate probability of GCA. Results Temporal artery ultrasound performed using GE Logiq e and 10-22mHz probe. Left side imaged entirely normally. Right side symptomatic area imaged as a focal asymmetric thickened area of frontal branch artery measuring 1.5mm maximally in compression. The frontal branch artery imaged normally proximal and distal to this as did the right common superficial and parietal branches. Features were unusual however she was commenced on prednisolone 40mg daily pending further investigations. Eye assessment detected no ischaemic concerns. She returned for reassessment after 4 days. There was some symptomatic improvement however the tender lump persisted. A second opinion on the ultrasound was sought from the interventional radiologist, who felt the focal area may be a lymph node, with thickened artery adjacent. Surgical exploration and temporal artery biopsy was subsequently performed. Conclusion Histology showed there was actually mucoid change with eccentric thickening of the artery with aneurysmal change in keeping with the rare diagnosis of intimomedial mucoid degeneration. This is a very rare condition which causes predisposition to arterial aneurysm formation, and typically presents with acute pain of the artery involved. This lady had developed an aneurysm which was excised at the time of the biopsy, relieving her symptoms. This case is a reminder to pursue additional investigations and tissue diagnosis in the setting of unusual clinical and imaging findings. Disclosure S. Black: None. M. Wray: None. H. Stewart: None. E. Durkan: None. V. Serafimov: None. P. Davey: None. L. Smith: None.

Clinical and Radiological Outcomes of Accessory Renal Artery Exclusion during Endovascular Repair of Abdominal Aortic Aneurysms.

Accessory renal arteries (ARAs) frequently coexist with abdominal aortic aneurysms (AAA) and can influence treatment. This study aimed to retrospectively analyze the ARA's exclusion effect on patients undergoing standard endovascular aneurysm repair for AAA. The study focused on medium- and long-term outcomes, including type II endoleak, aneurysmal sac changes, mortality, reoperation rates, renal function, and infarction post-operatively. 76 patients treated with EVAR for AAA were included. One hundred and two ARAs were identified: 69 originated from the neck, 30 from the sac, and 3 from the iliac arteries. The ARA treatment was embolization in 15 patients and coverage in 72. Technical success was 100%. One-month post-operative computed tomography angiography (CTA) revealed that 76 ARAs (74.51%) were excluded. Thirty-day complications included renal deterioration in 7 patients (9.21%) and a blood pressure increase in 15 (19.73%). During follow-up, 16 patients (21.05%) died, with three aneurysm-related deaths (3.94%). ARA-related type II endoleak (T2EL) was significantly associated with the ARA's origin in the aneurysmatic sac. Despite reinterventions were not significantly linked to any factor, post-operative renal infarction was correlated with an ARA diameter greater than 3 mm and ARA embolization. ARAs can influence EVAR outcomes, with anatomical and procedural factors associated with T2EL and renal infarction. Further studies are needed to optimize the management of ARAs during EVAR.

Assessing the influence of aneurysm dimensions on hemodynamic patterns and wall deformation dynamics for predicting rupture risk

Cerebral aneurysms are among the most dangerous cardiovascular diseases which display no symptoms prior to reaching critical conditions. As cerebral aneurysms are deadly diseases with a very small treatment window after reaching the critical stage, numerical investigations of this phenomenon are commonly used to assess the risk of rupture. In this study, the fluid-structure interaction (FSI) method is used to analyze the effects of aneurysm size on hemodynamic factors predicting rupture in three aneurysms of different geometries, at the same location, and using the same boundary conditions. In the present study, the aneurysms experience TAWSS at values under 2 Pa in incremented areas as the aneurysmal sizes increase, this is while the relatively larger distribution of high TAWSS (as high as 20 Pa) regions are perceived in smaller aneurysms. Furthermore, the maximum OSI stands at below 0.05 in the smaller cases while the larger case experiences a maximum OSI as high as 0.2, which is considered a predictive parameter for rupture. The vortex core lines experience discontinuities with increased aneurysmal size, which is in agreement with the development of flow complexities with size. The hemodynamics factors such as the time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and vortex core line investigated in this study, suggest that greater size can be considered a major risk factor for rupture. In addition to that, we have found that the displacement trend of the aneurysm changes as size increases; developing more in the dome rather than the aneurysmal sac. This change in trend might also present a potential to be used as a predictive parameter.

Long-term outcome of multilayer flow modulator in aortic aneurysms.

This retrospective study investigated the efficacy of endovascular treatment with multilayer flow modulators (MFMs) for treating aortic aneurysms in high-risk patients unsuitable for conventional treatments. Conducted from 2011 to 2019 at a single center, this retrospective observational study included 17 patients who underwent endovascular treatment with MFMs. These patients were selected based on their unsuitability for traditional surgical or endovascular procedures. The study involved meticulous pre-procedural planning, precise implantation of MFMs, and follow-up using CT angiography. The primary focus was on volumetric and flow volume changes in aneurysms, along with traditional diameter measurements. Moreover, the technical success and post-procedural complications were also registered. The technical success rate was 100%, and 30-day procedural complication rate was 17.6%. Post-treatment assessments revealed that 11 out of 17 patients showed a decrease in flow volume within the aneurysm sac, indicative of a favorable hemodynamic response. The median decrease in flow volume was 12 ml, with a median relative decrease of 8%. However, there was no consistent reduction in aneurysm size; most aneurysms demonstrated a median increase in volume for 46 ml and median increase in diameter for 18 mm. While MFMs offer a potential alternative for high-risk aortic aneurysm patients, their effectiveness in preventing aneurysm expansion is limited. The results suggest that MFMs can provide a stable hemodynamic environment but do not reliably reduce aneurysm size. This underscores the need for ongoing vigilance and long-term monitoring in patients treated with this technology.

The Management of Aneurysmal Degeneration of Lower Extremity Cryopreserved Saphenous Vein Bypass Grafts

Objective/BackgroundThe use of cryopreserved saphenous veins (CSVs) for the treatment of lower extremity peripheral arterial disease is an attractive option when there is no available autogenous vein. Prior studies found CSVs are at risk for aneurysmal degeneration requiring reoperation. As the management of these complications and patient outcomes is not well described, the objective of this case series is to describe the open and endovascular management of degenerative CSVs at a tertiary community center. MethodsAll CSVs implanted for lower extremity bypass at our institution between 2001 and 2021 were retrospectively reviewed. All CSVs with evidence of aneurysmal change were included in this study. CSVs with evidence of active infection were excluded. The decision to intervene was left to the discretion of the operating surgeon. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. Study endpoints included limb salvage and continued patency. Demographic data, indications for the index operation, and details about subsequent interventions for degenerative CSVs were recorded. ResultsSeventeen bypasses were identified to have aneurysmal degeneration in thirteen patients in the absence of infection between 2001 and 2021. Nine of the thirteen patients were male, and the average age and BMI during the index procedure were 72 and 28 respectively. Indications for the index bypass included acute limb ischemia (ALI) (9), popliteal aneurysm (2), and CLTI with Rutherford's class IV (5) and V (1).The mean time between the index procedure and first graft revision due to aneurysmal changes was 4 years. Most of the aneurysms did not occur at the site of anastomosis with 13 occurring in the body of the graft. Thirteen grafts were managed with open surgery and three were managed with endovascular techniques. All endovascular repairs were managed via covered stenting.Patients were followed for an average duration of 7 years from the initial bypass and 2 years from their last aneurysmal repair. Limb salvage in this cohort was 87% with 2 limbs requiring amputation, all of whom underwent open reconstruction. The mortality rate in this series was 54% and no patients died due to complications from their graft. Continued patency on Kaplan Meier survival curve analysis was 79% at 6 months, 65% at one year, 54% at three years, and 27% at 5 years. ConclusionIn our experience, aneurysmal degeneration of CSV grafts were mostly managed with standard open surgical techniques, although endovascular therapy also proved acceptable. Limb salvage rates and continued patency of repair at one year in this cohort were acceptable. This case series highlights the importance of diligent surveillance for patients with CSVs.

Pre-emptive Aortic Side Branch Embolization during Endovascular Aneurysm Repair Using the Excluder Stent-Graft System: A Prospective Multicenter study

PurposeTo evaluate the effectiveness and safety of pre-emptive transcatheter arterial embolization (P-TAE) for aortic side branches (ASBs) to prevent Type 2 endoleaks (EL2) before endovascular aneurysm repair (EVAR) using the Excluder stent-graft system (Excluder). Materials and MethodsIn this prospective, multicenter study, 80 patients (mean age, 79.1 years [SD ± 6.7]; 85.0% were men; mean aneurysmal sac diameter, 48.4 mm [SD ± 7.4]) meeting the eligibility criteria were prospectively enrolled from 9 hospitals. Before EVAR, P-TAE was performed to embolize the patent ASBs originating from the abdominal aortic aneurysm. Contrast-enhanced computed tomography (CT) was performed at 1 month and 6 months after EVAR. The primary endpoint was EL2 incidence at 6 months, and the secondary endpoints were aneurysmal sac diameter changes at 6 and 12 months, P-TAE outcomes, adverse events related to P-TAE, reintervention, and aneurysm-related mortality. ResultsAll patients successfully underwent P-TAE without serious. Coil embolization was successful in 81.6% of ASBs. EL2 incidence at 6 months was identified in 18 of 70 (25.7%) patients. Aneurysmal sac diameter shrinkage (≥5 mm) was observed in 30.0% of patients at 6 months and in 40.9% at 12 months. Only 1 patient required reintervention for EL2 within 1 year of EVAR; aneurysm-related deaths were not observed. ConclusionsP-TAE for ASBs before EVAR using Excluder is a safe and effective strategy. It aids in achieving early aneurysmal sac shrinkage and reduces EL2 reintervention at 1 year after EVAR.

Surgical treatment in the chronic phase for uncomplicated Stanford type B aortic dissection.

The most appropriate surgical method for patients with uncomplicated type B aortic dissection (UTBAD) in the chronic phase remains controversial. This study evaluated the outcomes of patients with UTBAD who needed aortic treatment as well as the impact of the treatment method or indication criteria on their prognosis. This retrospective review of 106 consecutive patients with aortic events in the chronic phase who underwent initial treatment for UTBAD between 2004 and 2021 comprised three groups: 19 patients who underwent endovascular repair (TEVAR), 38 who underwent open aortic repair and the medication group that included 49 patients. Aortic events were defined as a late operation or indication for operation for dissected aorta, aortic diameter (AD) ≥ 55 mm, rapid aortic enlargement (≥5 mm/6 months), and saccular aneurysmal change. The endpoint was all-cause death. We assessed the association between treatment methods or surgical indication criteria and mortality using a Cox regression analysis. The 5-year actuarial mortality rates were 27.1% in the TEVAR group, 19.6% in the open aortic repair group, and 38.4% in the medication group (p = 0.86). Moreover, the 5-year actuarial mortality rates in patients who had AD ≥ 55 mm were significantly higher than those patients with other surgical indication criteria (41.2% vs. 18.7%, p < 0.01). Multivariable analysis revealed a significant difference in AD ≥ 55 mm (hazard ratio [HR]: 2.88, 95% confidence interval [CI] 1.38-6.02, p < 0.01) and age (HR: 1.09, 95% CI 1.05-1.13, p < 0.01). Under the existing surgical indication criteria, there was no difference in mortality rates among patients with UTBAD based on their surgical treatment.

Fibrous dysplasia with aneurysmal bone cyst-like change occurring in pediatric orbit: case report and literature review.

We report a case of fibrous dysplasia (FD) with aneurysmal bone cyst (ABC)-like change in a child with orbital involvement, review the related cases, and discuss clinical features, therapy, and prognosis of this disease. A 10-year-old girl had right proptosis (degree of exophthalmos: OD 16mm, OS 13mm) and limited vision (visual acuity: OD 1.0, OS 0.8) without trauma. Preoperative CT showed a 5.0*4.3cm right-sided crania-orbital communicating tumor. MRI indicated a well-defined multicystic mass with scattered fluid levels and soap bubble-like alterations. The child underwent total tumor resection and orbital parietal titanium mesh reconstruction. At 20months of follow-up, the child has recovered from ocular problems, and the tumor has not recurred. FD combined with ABC rarely occurs in orbit and generally begins with ocular symptoms. The etiology is uncertain. Early diagnosis and surgery are essential. Complete resection is suggested whenever possible because residual lesions may recur.

Initial experience of thrombectomy using vascular snare with multiple loops for chronic organized thrombi in patients with thrombosed native hemodialysis fistulas.

Thrombi in native hemodialysis access frequently exhibit chronic organized feature because they have formed over a long period. Removal of these is quite difficult owing to relatively large volume, resilient feature, limitations of the introducer sheath size, etc. In this study, we report our experience using a vascular snare for the removal of these thrombi in native arteriovenous fistula (AVF). The medical records of patients who underwent recanalization for thrombosed AVFs from January 2019 to August 2023 were reviewed. During the study period, a total of 29 native fistulas (19 brachiocephalic, nine radiocephalic, and one radiobasilic) in 25 patients were treated using a vascular snare with multiple loops (19 men and six women). Characteristics of the AVFs, endovascular procedures, technical and clinical results, and complications were evaluated. Anatomic and clinical success rates were 96.6% and 100%, respectively. Total thrombosis was observed in 21 (72.4%) fistulas. Aneurysmal changes were found in 22 (75.9%) fistulas. The mean fistula age at the time of the procedure was 60.9 months (standard deviation, 52.2). Thrombectomy was initiated using a vascular snare in 14 fistulas. In 15 fistulas for which the procedures were initiated using a rotational percutaneous thrombectomy device (PTD), a vascular snare was subsequently used because recanalization failed or was insufficient due to chronic organizing thrombi. Additional aspiration and balloon angioplasty were performed in 27 (93.1%) and 28 (96.6%), respectively. Pharmacological thrombolysis was performed in one fistula for long segmental thrombosis combined with arterial thrombosis. The mean procedure time, excluding thrombolysis, was 91.9 min (standard deviation, 55.5). No complications related to the use of the vascular snare was observed. The use of a vascular snare with multiple loops was safe and highly effective for the removal of chronic organized thrombi in the recanalization of thrombosed AVFs.

Flow Diverter Performance Comparison of Different Wire Materials for Effective Intracranial Aneurysm Treatment.

A flow diverter (FD) is an effective method for treating wide-necked intracranial aneurysms by inducing hemodynamic changes in aneurysms. However, the procedural technique remains challenging, and it is often not performed properly in many cases of deployment or placements. In this study, three types of FDs that changed the material of the wire were prepared within the same structure. Differences in physical properties, such as before and after delivery loading stent size, radial force, and radiopacity, were evaluated. The performances in terms of deployment and trackability force were also evaluated in a simulated model using these FDs. Furthermore, changes of deployment patterns when these FDs were applied to a 3D-printed aneurysm model were determined. The NiTi FD using only nitinol (NiTi) wire showed 100% size recovery and 42% to 45% metal coverage after loading. The low trackability force (10.9 to 22.9 gf) allows smooth movement within the delivery system. However, NiTi FD cannot be used in actual surgeries due to difficulties in X-ray identification. NiTi-Pt/W FD, a combination of NiTi wire and platinum/tungsten (Pt/W) wire, had the highest radiopacity and compression force (6.03 ± 0.29 gf) among the three FDs. However, it suffered from high trackability force (22.4 to 39.9 gf) and the end part braiding mesh tended to loosen easily, so the procedure became more challenging. The NiTi(Pt) FD using a platinum core nitinol (NiTi(Pt)) wire had similar trackability force (11.3 to 22.1 gf) to NiTi FD and uniform deployment, enhancing procedural convenience. However, concerns about low expansion force (1.79 ± 0.30 gf) and the potential for migration remained. This comparative analysis contributes to a comprehensive understanding of how different wire materials influence the performance of FDs. While this study is still in its early stages and requires further research, its development has the potential to guide clinicians and researchers in optimizing the selection and development of FDs for the effective treatment of intracranial aneurysms.

Traumatic thigh AV fistula leading to aneurysmal changes in aorta and iliac arteries

Penetrating traumatic arteriovenous fistulas (AVFs) have the tendency to be clinically silent for many years and could be misdiagnosed as deep venous thrombosis (DVT) on initial presentation. A 52-year-old male underwent a duplex scan to evaluate swelling of the limb, which detected an AVF in the thigh. He was stabbed in the lateral aspect of the thigh 16 years previously. His left leg was larger with a palpable thrill in the thigh. A CT angiogram confirmed the AVF and aneurysmal changes in the common iliac artery (29 mm) and infrarenal aorta (32 mm). A moulding balloon was placed across the AVF by an antegrade puncture of the common femoral artery to control the arterial inflow and outflow. Following disconnection of the AVF, the defect in the side wall of the femoral vein was primarily repaired with Prolene. The defect in the superficial femoral artery was repaired by transection, spatulation and end-to-end anastomosis of the arteries. A Duplex scan performed six months postoperatively showed that the aorta (29 mm) and the common iliac artery (27 mm) had regressed. The authors suggest that, when faced with an AVF with a huge calibre mismatch between the arterial segment proximal and distal to the fistulous tract in a young patient, a hybrid approach should be considered for control and surgical disconnection of the fistula.

Abstract 13710: Cardiac Platypnea-Orthodeoxia Syndrome: How the Stars Aligned

Case description: A 79-year-old man with recurrent falls, dyslipidemia and recent exercise intolerance presented after a fall. He was putting on shoes, lost his balance and fell. There was no pre-syncope, syncope, dyspnea, chest pain, palpitations or dizziness. On admission, vital signs were normal except oxygen saturation (O2 sat) 79% on room air (and no improvement with supplemental O2). An arterial blood gas (ABG) revealed partial pressure of oxygen 42 mmHg with oxygen saturation 80%. He had lower thoracic spine tenderness, normal respiratory and cardiac exam. CT head showed no acute intracranial abnormalities. CTA chest had no pulmonary embolism, arterio-venous malformations or parenchymal lung disease. There was a thoracic aorta aneurysm (4.5cm at aortic root and 5.1cm at posterior arch). Subsequently, O2 sat was 92% supine and 79% standing. He also had a compression fracture of T12 and spinal asymmetry. A transesophageal echocardiogram (TEE) showed an aneurysmal, hypermobile interatrial septum with early right to left shunt with agitated saline due to a large patent foramen ovale (PFO). Right heart catheterization revealed no pulmonary hypertension and confirmed a step down from the pulmonary vein to left atrium (delta O2 sat 6%). A 30mm Gore Cardioform occluder was used to close the defect and immediately supplemental oxygen was removed, and O2 sat on room air was 95%. Follow up echocardiogram showed no residual shunt and exercise intolerance resolved. Discussion: Unexplained positional hypoxemia raised our suspicion for cardiac POS. Hypoxemia is caused by right to left shunting via the PFO, exacerbated by the thoracic aortic aneurysm and spinal changes such as the T12 fracture and spinal asymmetry. Going from being recumbent to erect there is stretching of the atria causing his PFO to enlarge, increasing the shunt. Additionally, the dilated thoracic aorta exerts mechanical pressure on the right atrium (RA) and interatrial septum, increasing PFO patency and augmenting flow from the inferior vena cava through the PFO. The spinal abnormality may cause more aortic distortion and exert forces on the RA, exacerbating shunting. Percutaneous PFO closure is the treatment of choice with closure immediately leading to significant improvement of hypoxemia.

Aortic Remodeling After Thoracic Endovascular Aortic Repair for Nonacute Uncomplicated Type B Aortic Dissection

Entry closure with thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) results in aortic remodeling recently. This study aimed to evaluate the relationship between aortic diameter or timing of surgical intervention from onset and remodeling after TEVAR for uncomplicated nonacute TBAD. Between April 2014 and December 2021, 83 consecutive patients underwent TEVAR for TBAD at our center. Forty patients with subacute and chronic uncomplicated TBADs with a patent false lumen, who could be followed up for at least 6months, were included in this study. Indications for TEVAR included aortic diameter enlargement and preemptive treatment to prevent future aneurysmal changes in patients at risk of aortic diameter enlargement. Aortic remodeling was accessed, and data between the remodeling and nonremodeling groups were compared. The technical success rate was 97.5%, with a type Ia endoleak remaining in 1 patient. No operative or in-hospital mortality occurred. Paraparesis occurred in only 1 patient (2.5%). Follow-up was completed at a median of 53.5months. Late death occurred in 3 cases, but there were no aortic-related deaths. Late aortic remodeling was achieved in 22 patients (55%). The preoperative maximum aortic diameter (PMAD) in the thoracic aortic region was 51.5mm in the nonremodeling group, significantly larger than 42.5mm in the remodeling group (P<0.0001). The cutoff value of the PMAD for predicting aortic remodeling was 45mm (area under the curve, 0.917; P=0.028). The remodeling group had an earlier time from onset to intervention than the nonremodeling group, with a cutoff value of 6.3months (area under the curve, 0.743; P=0.021). TEVAR for nonacute uncomplicated TBAD resulted in a late aortic remodeling rate of 55%. This study suggested that a PMAD of >45mm or a period >6.3months between dissection onset and surgery hinders aortic remodeling after TEVAR.