Complication Of Aortic Aneurysm Research Articles

MULTIDETECTOR COMPUTED TOMOGRAPHY FOR IDENTIFICATION OF INSTABILITY OF AORTIC ANEURYSM WALL

Актуальность. Аневризма аорты – распространенное заболевание с полиморфной клинической картиной и внезапным риском развития тяжелых осложнений.

Genetic Risk for Aortic Aneurysm in Adolescent Idiopathic Scoliosis.

Scoliosis is a feature of several genetic disorders that are also associated with aortic aneurysm, including Marfan syndrome, Loeys-Dietz syndrome, and type-IV Ehlers-Danlos syndrome. Life-threatening complications of aortic aneurysm can be decreased through early diagnosis. Genetic screening for mutations in populations at risk, such as patients with adolescent idiopathic scoliosis, may improve recognition of these disorders. The coding regions of five clinically actionable genes associated with scoliosis (COL3A1, FBN1, TGFBR1, TGFBR2, and SMAD3) and aortic aneurysm were sequenced in 343 adolescent idiopathic scoliosis cases. Gene variants that had minor allele frequencies of <0.0001 or were present in human disease mutation databases were identified. Variants were classified as pathogenic, likely pathogenic, or variants of unknown significance. Pathogenic or likely pathogenic mutations were identified in 0.9% (three) of 343 adolescent idiopathic scoliosis cases. Two patients had pathogenic SMAD3 nonsense mutations consistent with type-III Loeys-Dietz syndrome and one patient had a pathogenic FBN1 mutation with subsequent confirmation of Marfan syndrome. Variants of unknown significance in COL3A1 and FBN1 were identified in 5.0% (seventeen) of 343 adolescent idiopathic scoliosis cases. Six FBN1 variants were previously reported in patients with Marfan syndrome, yet were considered variants of unknown significance based on the level of evidence. Variants of unknown significance occurred most frequently in FBN1 and were associated with greater curve severity, systemic features of Marfan syndrome, and joint hypermobility. Clinically actionable pathogenic mutations in genes associated with adolescent idiopathic scoliosis and aortic aneurysm are rare in patients with adolescent idiopathic scoliosis who are not suspected of having these disorders, although variants of unknown significance are relatively common. Routine genetic screening of all patients with adolescent idiopathic scoliosis for mutations in clinically actionable aortic aneurysm disease genes is not recommended on the basis of the high frequency of variants of unknown significance. Clinical evaluation and family history should heighten indications for genetic referral and testing.

Three-dimensional print of aortic aneurysm models aid preoperative planning in complicated endovascular repair procedure

To attempt to produce highly accurate three-dimensional (3D) printed models of aortic aneurysm models aid complicated preoperative planning in endovascular repair procedures. From October 2012 to May 2014, six patients with complicated aortic aneurysms (one aortic arch aneurysms, one thoracoabdominal aortic aneurysms and four juxtarenal abdominal aortic aneurysms) accepted preoperative contrast-enhanced CT angiography (CTA) scans for procedural planning, 4 male and 2 female, average age 64 years (range 52 to 73 years). All the CTA data were processed with FitMe 3D image processing software to get the modified 3D reconstruction pictures and computer language that can be identified by the 3D printer. With the fused deposition modeling technology, the highly accurate models were got to make preoperative endovascular planning. All the patients' models were printed before operations. By the guidance of models, the endovascular procedure plans were drawn up. Three patients were performed extracorporeal simulating operations with the models and four patients' endovascular operations were guided by the models during the intraoperative time. The procedure technique success rate was 100%. No serious complications and patients dead during the perioperative period. The technology of 3D printed highly accurate models of aortic aneurysm models is feasible and can help to make preoperative endovascular planning for improving the safety of complicated procedures.

Rare forms of complicated abdominal aortic aneurysms

Rare forms of complicated abdominal aortic aneurysms

Management of complicated aortic aneurysms using multiple overlapping uncovered stents: mid-term outcome from a cohort study.

This study sought to report the mid-term outcome of a modified flow-diverting strategy in the treatment of complicated aortic aneurysms of different morphology. Historical data suggested aortic aneurysm expansion and rupture after endovascular treatment with current commercial flow-diverters, indicating the essentiality of further investigation of this technique prior to its large-scale clinical application. An alternative flow-diverting strategy using layer-by-layer assembled multiple overlapping uncovered stents was employed in this study. The treatment outcome in aneurysms of different morphology (saccular, fusiform, and dissecting) was assessed during a mid-term follow-up period.Of 42 patients enrolled in this study (30 male, mean age: 63.3 years), technical success was achieved in 40 cases. During an average follow-up period of 20.9 months, mean aneurysm diameter shrunk from 53.4 ± 13.6 mm to 48.8 ± 13.9 mm (P < 0.001), while stent-induced sac thrombosis ratio increased significantly (18.1 ± 14.9% to 93.6 ± 9.5%, P < 0.001). The majority of side branches (74/76 major visceral branches, 237/244 minor segmental arteries), covered by 3.3 stents on average, maintained their patency after stenting. Saccular aneurysms manifested the highest thrombus deposition speed (18/20 were totally thrombosed within 12 months) and most significant shrinkage (51.4 ± 13.3 mm pre-operatively vs 43.5 ± 10.2 mm during follow-up, P < 0.001) compared with fusiform and dissecting aneurysms. This modified flow-diverting strategy could be a feasible alternative in the management of complicated aortic aneurysms where vital branches need to be preserved. The treatment outcome may depend on the aneurysm type. Further studies with larger patient cohort and longer follow-up are required to substantiate these results.

Primary aortoenteric fistula.

Primary aortoenteric fistula is a rare complication of aortic aneurysms. This cause of gastrointestinal bleeding poses significant diagnostic challenges due to its nonspecific presentation. We report a case of an 80-year-old man with right flank pain and rectal bleeding. The patient had been admitted 2weeks before with the same symptoms. Upper and lower endoscopies were unremarkable, but abdominal computed tomography scan showed evidence of aortoduodenal fistula. An emergency laparotomy with aortic bypass and fistula closure was performed and the patient was able to recover in the following weeks. This case highlights the need for a high index of suspicion to avoid diagnostic delay that frequently has fatal results.

Endovascular management of pararenal aortic aneurysms with multiple overlapping uncovered stents

This study aims at evaluating the safety and efficacy of a porous stent system consisting of multiple overlapping uncovered stents in the treatment of complex aortic aneurysms with vital branches. Data of all patients with aortic aneurysms treated in our center with multiple overlapping uncovered stents between February 2010 and December 2011 were retrospectively reviewed. Preoperative characteristics, intraoperative details, and follow-up outcomes were documented. Technical success was defined as successful deployment of the stents to target locations without procedure-related complications. Clinical success was characterized by complete shrinkage or stabilization of the aneurysm, preservation of vital branches, and absence of major complications. Patients were grouped, according to rapidity of aneurysm thrombosis, into fast-thrombosis group (complete thrombosis of aneurysmal sac was achieved in ≤6 months) and a delayed-thrombosis group (>6 months required for complete thrombosis). Possible factors affecting the speed of thrombosis were analyzed statistically with the Fisher exact test and the t-test. This porous stent system was used to treat 34 patients (23 men, 11 women; mean age, 65.7 years). Technical success was achieved in all patients (100%). Regular follow-up over 6 months was achieved in 29 patients (mean length of follow-up, 11.4 months). Complete thrombosis of the aneurysm sac within 12 months was observed in 24 patients (83%). Aneurysm shrinkage was documented in seven patients (24%) and stabilization in 21 (72%). All branch arteries covered by bare stents stayed patent during follow-up. The overall clinical success rate reached 97% in the follow-up group. Risk factors for delayed thrombosis included fewer stents implanted (P = .013), longer sac entrance (P = .043), and use of antiplatelet medication (P = .040). An alternative method of management of complicated aortic aneurysm appears to be feasible using overlapping bare stents, which may prevent aneurysm growth while preserving vital branches. The short-term outcome of our study seems encouraging but is not sufficient to draw a robust conclusion. Further hemodynamic and clinical studies are warranted to evaluate long-term efficacy.

Surgical Management of Abdominal Aortic Aneurysms: A Lost Art?

Endovascular repair of abdominal aneurysms has become the dominant treatment modality for infrarenal aneurysms. Initial reports showed a constant number of open repairs although there was a shift toward complicated juxtra-renal aneurysms. In the past several years, more aggressive endoluminal approaches and the introduction of fenestrated grafts have appeared to dilute the open aneurysm operating experience. Coupled with work hours restrictions and shorter training paradigms, opportunities for training residents in open repair of abdominal aneurysms are decreasing. We envision that future treatment of complicated aortic aneurysms will likely entail advanced fellowship training in open repair and referral of complicated abdominal aneurysms to tertiary care centers.

Successful Long-Term Management of Aneurysm-Associated Chronic Disseminated Intravascular Coagulation with Low Molecular Weight Heparin

Disseminated intravascular coagulation (DIC) is a well-described complication of aortic aneurysm. In cases where surgical repair of the aneurysm is contraindicated, palliative therapy via medical management of the coagulopathy may be warranted. We present a case of aneurysm-associated DIC successfully managed with low molecular weight heparin.

A multilayer stent in the aorta may not seal the aneurysm, thereby leading to rupture

The multilayer stents are occasionally used for the treatment of complicated aortic aneurysms, including thoracoabdominal aneurysms. No aneurysm-related mortality among patients treated with this technique has been described in the literature to date. We describe a case of rupture of an aortic aneurysm previously treated with a multilayer stent.

Evaluation of the harmonic scalpel in open surgery for abdominal aortic aneurysm

The harmonic scalpel is a hemostatic device primarily designed for use in laparoscopic surgery. During the last few years, many surgeons have begun to use the harmonic scalpel in open surgery. Several papers have cited the benefits of the device compared with conventional knot-tying techniques; however, no evidence showing the advantages of using the harmonic scalpel in complicated abdominal aortic aneurysm (AAA) surgery has been presented. The aim of the present study is to determine the value of the harmonic scalpel in open operation for AAA. A total of 153 patients who underwent open surgery for AAA at the Department of Vascular Surgery of Guangdong General Hospital, China between January 2001 and December 2010, were retrospectively analyzed. Open surgery performed with the harmonic scalpel on 105 patients was compared with open operation using conventional knot-tying techniques on 48 patients. The operative time, intraoperative blood loss, total postoperative drainage fluid volumes, hospital stay, and postoperative complications between the two groups were compared. The harmonic scalpel group was associated with a shorter operation time (113.2 ± 23.6 min vs. 232.1 ± 39.2 min, P < 0.01) and lower intraoperative blood loss (126.1 ± 96.6 ml vs. 592.1 ± 207.2 ml, P < 0.01). Postoperative drainage fluid volumes were greater in the conventional surgery group than in the harmonic scalpel group (702.1 ± 192.8 ml vs. 198.5 ± 97.4 ml, P < 0.01). The hospital stay was shorter for the harmonic scalpel group than for the conventional surgery group (10.7 ± 3.3 d vs. 16.5 ± 4.7 d, P < 0.05). No differences between the postoperative complications or hospital mortality of the two groups were found. The harmonic scalpel is a safe and minimally invasive tool in open surgery for AAA and is associated with shorter operative time, shorter hospital stay, and lower intraoperative blood loss and postoperative drainage fluid volumes compared with conventional knot-tying techniques.

Graft-to-Endograft Anastomosis for Emergency Treatment of Distal Aortic Arch Aneurysm After Endovascular Stenting of Thoracoabdominal Type B Dissection

Emergency aortic arch surgery still remains a challenge, especially in elderly patients. We report a case about the open surgical management by graft-to-endograft anastomosis of a complicated aortic arch aneurysm because of a type I endoleak after thoracic endovascular aortic repair of a chronic type B aortic dissection.

Acute Lower Limb Ischemia as a Triggering Condition in Hypoxic Hepatitis

Acute centrilobular liver cell necrosis in hypoxic hepatitis (HH) occurs mainly in the setting of hemodynamic failure owing to cardiac failure, respiratory failure, and septic-toxic shock. Cases of HH were also reported under specific conditions such as heat stroke, grand mal seizure, obstructive sleep apnea, and complicated aortic aneurysm. In this study, we report 5 cases of HH occurring in the course of acute lower limb ischemia (ALLI). To the best of our knowledge, the association between HH and ALLI has not yet been reported. In a prospective and consecutive series of 142 cases of HH, we identified 5 cases (3.5%) in which ALLI was the triggering condition. The clinical, hemodynamic, and liver laboratory data of these 5 cases are reported. A review of the literature on liver injury observed in the case of ALLI is also made. The 5 patients were 4 males and 1 female of mean age 63 years. All 5 had typical HH after ALLI. Four of them were in shock on admission. Arterial blood pH lower than 7.15 was observed upon admission in the 3 patients who died. Other potential causes of liver hypoxia were present in all patients. Urgent and efficient revascularization of the ischemic limb was a necessary condition for survival. Acute lower limb ischemia should be added to the list of conditions able to trigger HH. In this particular setting, urgent revascularization of the ischemic limb seems to be a prerequisite for survival.

Aortic aneurysm with valvular insufficiency: Is it due to Marfan syndrome or hypertension? A case report and review of literature

Aortic aneurysm can result from both Marfan syndrome (MFS) and hypertension. Hypertension is more easily detected by the use of ubiquitous sphygmomanometer but MFS diagnosis requires a summation of a set of clinical features, including increased cardiac output from aortic regurgitation. A common complication of aortic aneurysm may result in apparent elevation in systolic pressure in a MFS patient with aortic root dilatation and regurgitation. Thus a patient with MFS presenting with aortic regurgitation may be misdiagnosed as having hypertensive heart disease. Clinical case presentation of a 47-year-old woman referred to the cardiology unit with the diagnosis of aortic aneurysm with regurgitation secondary to hypertension was found to have MFS. Relevant literature on diagnostic criteria of MFS and differences in aortic root disease secondary to MFS and that secondary to hypertension was reviewed. Physicians should have a high index of suspicion and consider MFS as a differential diagnosis of aortic aneurysm, especially in younger patients.

Multiple complications after aortic stent-graft placement in a patient with preexisting nephrostomy and atherosclerosis of the lower extremities

Summary Background: Aortic stent-graft placement is intended to be a procedure with minimal perioperative risk in com -parison to the open procedure. However, the 1.5% mortality rate and the possibility of procedure-related complications should be taken into account. Case Report: This paper presents multiple procedure-related complications including acute limb ischemia and bowel necrosis in a patient with preexisting nephrostomy operated on with EVAR (endovascular aortic repair). Issues regarding proper anatomical planning and imaging are discussed, and ways to avoid such complications are highlighted. Conclusions: Multiple complications during EVAR may significantly reduce the early benefit of the procedure. Correct preoperative assessment of CT scans can avoid making an inappropriate decision regard-ing use of EVAR. In cases of concomitant urological pathology, any surgical intervention should be decided upon in cooperation with the vascular surgeon and urologist. key words: abdominal aortic aneurysm complications • aortic stentgrafts • nephrostomy • bowel necrosis • acute limb ischemia

External-to-Internal Iliac Stent–Graft: Medium-Term Patency Following Exclusion of a Retrogradely Perfused Common Iliac Aneurysm

Following complicated aortic aneurysm surgery a complete left iliac occlusion resulted in buttock claudication. A retrogradely perfused right common iliac aneurysm expanded. Exclusion was by external-to-internal iliac stent-graft. No deterioration in claudication occurred with medium-term stent-graft patency.

Pseudoaneurysm of the ascending aorta ruptured into the right ventricle mimicking an acute myocardial infarction

An 83-year-old man who had undergone aortic arch replacement 13 years previously was admitted to the National Cardiovascular Centre (Suita, Japan) with a suspected acute myocardial infarction. This diagnosis was based on the presence of chest pain in association with a raised white blood cell count and elevated levels of cardiac enzymes. Transthoracic echocardiography showed normal left ventricular contraction and a markedly enlarged ascending aorta. Colour Doppler examination showed the presence of shunt flow from the ascending aorta into the right ventricle (Figure 1). Computed tomographic scanning revealed a pseudoaneurysm of the ascending aorta with a maximum aortic diameter of 7.2 cm and a fistula into the right ventricle (Figure 2). Multidetector computed tomography coronary angiography showed normal coronary arteries. The patient subsequently underwent a successful ascending aorta replacement. Figure 1) Colour Doppler imaging showing shunt flow from the ascending aorta (AO) into the right ventricular outflow tract (RVOT) Figure 2) Computed tomography showing a pseudoaneurysm (P) of the ascending aorta (Ao) and a fistula (arrow) into the right ventricle (RV) Fistula formation between the aorta and the cardiac chamber has been described as a potential complication of ascending aortic diseases, such as aortic dissection (1) and sinus of Valsalva aneurysm (2). To the best of our knowledge, however, there have been no reports describing this condition as a complication of aortic aneurysms. Although the patient had a history of aortic arch repair 13 years previously, findings during surgery suggested no apparent relationship between this history and the subsequent development of the ascending aortic aneurysm.

Side-Branched AAA Stent Graft Insertion Using Navigation Technology: A Phantom Study

Objective: To evaluate the feasibility of a side-branched stent graft inserted in an artificial abdominal aortic aneurysm (AAA), using navigation technology, and to compare procedure duration and dose of radiation with control trials. Methods: A custom-made stent graft was inserted into an artificial AAA using navigation technology in combination with fluoroscopy. The navigation technology was based on three-dimensional visualization of computed tomography data and electromagnetic tracking of microposition sensors. The stent graft had integrated position sensors in side branch and introducer and was guided into proper position with the aid of three-dimensional images. Control trials were performed with fluoroscopy alone. Results: It was feasible to insert a side-branched stent graft using three-dimensional navigation technology. The navigation-guided trials had a significantly lower X-ray load (p < 0.001), but showed no difference in the duration of the procedures (p = 0.34) as compared with controls. Conclusions: Inserting a side-branched stent graft in an artificial AAA using navigation technology is feasible. Side-branched stent grafts and navigation systems may become useful in the endovascular treatment of complicated aortic aneurysms.

High incidence of renal failure in patients with aortic aneurysms

Renal failure (RF) is a well-recognized complication of aortic aneurysms (AA) although its incidence has been poorly documented previously. The purpose of this study is to examine the incidence of RF in patients with AA and prognosis of AA patients with RF. Renal function, complications and prognosis of AA patients with RF were retrospectively reviewed in 350 AA patients (median age 69.8+/-10.7 years) in the International Medical Center of Japan from 1989 to 1999. Among 350 patients with AA, 90 patients (25.7%) had chronic renal failure (CRF) at the initiation of follow-up. The number of CRF patients increased to 117 (33.4%) at 30 months of follow-up. Forty-four out of 160 patients (27.5%) who had aortic surgery developed postoperative acute renal failure (ARF). Stepwise logistic regression analysis revealed that age (>or=65 years), hypertension and multiple aneurysms were independent risk factors for CRF, whereas dissecting aneurysms, preoperative serum creatinine (sCr) levels and duration of surgery were independent risk factors for postoperative ARF in AA patients. In the 5-year follow-up of AA patients with CRF, the mean slopes of 1/serum-creatinine did not significantly differ between conservative treatment and surgical treatment. The survival rates were 49.5% in the conservative treatment group and 67.3% in the surgical treatment group. Our data suggest that the management of renal function including blood pressure from an early stage in AA patients is important since CRF is highly prevalent in AA patients and affects their prognosis and mortality.

Subcutaneous Injection of Heparin Calcium Controls Chronic Disseminated Intravascular Coagulation Associated with Inoperable Dissecting Aortic Aneurysm in an Outpatient Clinic

Chronic disseminated intravascular coagulation (DIC) is a rare but critical complication of aortic aneurysm, and can represent a difficult long-term management problem. Although surgical correction is the treatment of choice, alternative therapy is required for inoperable patients. We report herein a case of acute exacerbation of chronic DIC with inoperable dissecting aortic aneurysm, which was recurrent and resistant to regular treatment. Intermittent subcutaneous self-injection of heparin calcium 15,000 units per day achieved stabilization of coagulation and fibrinolytic parameters and relief of the bleeding tendency. Subcutaneous heparin injection can be an alternative treatment for long-term management of chronic DIC associated with inoperable aortic dissection, beneficial for providing good symptomatic control on an outpatient basis.