False Aneurysm Formation Research Articles

False Aneurysm Formation Following Cutting Balloon Angioplasty in the Renal Artery of a Child

To report the fortuitous discovery of a false aneurysm 7 years after cutting balloon angioplasty for severe renal artery fibromuscular dysplasia in a child. A 3-year-old girl with neurofibromatosis was referred to our institution because of high blood pressure (220/160 mmHg). Computed tomography identified coarctation of the aorta and severe bilateral renal artery stenoses. The coarctation was successfully resected. One month later, bilateral renal artery angioplasty with a 3-mm balloon was unsatisfactory, so a second angioplasty one month later was done with a 3.25-mm cutting balloon. This procedure was complicated by a minimal arterial rupture, which resolved spontaneously after inflation of a regular balloon. Normal blood pressure was restored. The child was lost to follow-up until 7 years later, when recurrent hypertension (200 mmHg systolic) prompted referral again. Arteriography showed a very severe stenosis on the right side and a 30-mm false aneurysm of the left renal artery at the rupture site. Due to her age, the patient underwent surgery, which brought the blood pressure under control. False aneurysm of the renal arteries is a rare complication of percutaneous angioplasty. In a child, the cutting balloon would appear to be contraindicated for concentric dysplastic stenoses that are resistant to regular balloon angioplasty.

Long-term outcome after surgical treatment of arterial lesions in Behçet disease

Surgical treatment of arterial lesions associated with Behçet disease (BD) is often complicated by graft occlusion and recurrence of aneurysms. The purpose of this study was to clarify the long-term outcome of surgical intervention for arterial involvement in BD. Ten patients with BD (9 men, 1 woman) who underwent surgical treatment for arterial aneurysms between 1980 and 2004 were included in the study. The age of patients at the first operation ranged from 36 to 69 years (mean, 50.4 +/- 9.0 years). The mean period between the onset of BD and that of arterial manifestations was 8.0 +/- 5.0 years. We retrospectively reviewed their postoperative courses, including survival, graft occlusion, formation of anastomotic false aneurysms, and the development of aneurysms at different sites. The Kaplan-Meier method was used to calculate the chronologic incidence of complications after surgery. The mean follow-up period was 133 +/- 92 months, ranging from 5 to 285 months. One patient died of rupture of a dissecting aortic aneurysm after undergoing several surgical interventions for multiple aneurysms. There were five graft occlusions among 21 grafts. The cumulative primary graft patency rate in the infrainguinal region was 83.9% at 3 years. Five anastomotic false aneurysms formed among 49 anastomoses between grafts and host arteries. The overall cumulative incidence of formation of anastomotic pseudoaneurysm was 12.9% at 5 and 10 years. All of them formed within 18 months after surgery. Development of new aneurysms in different arteries was observed in two patients. Early occurrence of anastomotic false aneurysm is characteristic of BD. Further investigation is necessary to establish effective postoperative treatment.

Arteriovenous Access: Managing Common Problems

The creation and maintenance of hemoaccess occupies a significant portion of most vascular and general surgery practices. In this article, the methods used to detect hemoaccess at risk for failure and the endovascular and surgical techniques used to prolong or restore their patency are reviewed. Also, the management of hemoaccess infection, aneurysmal degeneration, false aneurysm formation, and symptomatic arterial steal syndrome are described.

Transesophageal Echocardiography and Therapeutic Management of Patients Sustaining Blunt Aortic Injuries

No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation. We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up. All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4). Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.

Critical appraisal of femorofemoral crossover grafts

The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention. All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied. Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0.7 per cent). Complications occurred within 30 days in 32 patients (22.2 per cent), including graft occlusion in three (2.1 per cent); six patients (4.2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0.034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two). When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

False aneurysm of the thoracic aorta due to hydatid cyst rupture

Hydatid disease is a parasitic infection, which generally occurs in the liver and lung. Localization of hydatid cyst in the thoracic aorta and false aneurysm formation are extremely rare in the endemic countries. We report a rare case of hydatid cyst invading the wall of thoracic aorta resulting in a false aneurysm, which was clearly demonstrated by contrast enhanced computed tomography (CT).

Cephalic Vein for Carotid Patching

Objective To assess the effectiveness of cephalic vein patch (CVP) closure following carotid endarterectomy (CEA). Material and methods We reviewed 121 patients who underwent CEA using CVP closure. Patch-rupture, re-exploration, false aneurysm formation, re-stenosis requiring surgery, 30-day-mortality, donor site complications, stroke and TIA were noted. A small cohort of patients were reviewed at 5-years and rescanned. Results No patient suffered patch rupture or re-stenosis requiring surgery. One patient developed false aneurysm at 1 year but at the time of repair the patch was found to be intact. There were two cardiac deaths. Three patients suffered strokes of whom two made a full recovery. There were three cases of TIA. All wrist wounds healed primarily without complications. None of the 10 patients recalled for scanning at 5 years showed re-stenosis or late aneurysmal dilatation at the site of surgery. Conclusion Cephalic-vein can be harvested at the wrist without donor site complications and our experience shows it to be a convenient and safe means of closure following CEA. Compared to prosthetics it is cheaper and less susceptible to bacterial contamination. The use of CVP preserves leg veins for future cardio-vascular interventions. Long term function of CVP appears satisfactory.

Cephalic Vein for Carotid Patching

ObjectiveTo assess the effectiveness of cephalic vein patch (CVP) closure following carotid endarterectomy (CEA). Material and methodsWe reviewed 121 patients who underwent CEA using CVP closure. Patch-rupture, re-exploration, false aneurysm formation, re-stenosis requiring surgery, 30-day-mortality, donor site complications, stroke and TIA were noted. A small cohort of patients was reviewed at 5 years and rescanned. ResultsNo patient suffered patch rupture or re-stenosis requiring surgery. One patient developed false aneurysm at 1 year but at the time of repair the patch was found to be intact. There were two cardiac deaths. Three patients suffered strokes of whom two made a full recovery. There were three cases of TIA. All wrist wounds healed primarily without complications. None of the 10 patients recalled for scanning at 5 years showed re-stenosis or late aneurysmal dilatation at the site of surgery. ConclusionCephalic-vein can be harvested at the wrist without donor site complications and our experience shows it to be a convenient and safe means of closure following CEA. Compared to prosthetics it is cheaper and less susceptible to bacterial contamination. The use of CVP preserves leg veins for future cardio-vascular interventions. Long term function of CVP appears satisfactory.

Patch Corrugation on Duplex Ultrasonography may be an Early Warning of Prosthetic Patch Infection

Four of 10 patients presenting with prosthetic patch infection after carotid endarterectomy (CEA) were noted to have Duplex evidence of ‘corrugation’ of the prosthetic patch, without false aneurysm formation. In three, corrugation preceded diagnosis of overt patch infection by up to 11 months. In the fourth patient, awareness of the potential significance of patch corrugation enabled timely treatment of an otherwise unrecognized patch infection. Even if other imaging modalities are normal, the presence of patch corrugation on Duplex should prompt the surgeon to (at least) consider the possibility of patch infection.

Repair of aortic false aneurysm using deep hypothermia and circulatory arrest

BackgroundAortic false aneurysms are a rare complication of surgery of the aorta that can occur several months to years after the initial operation. We reviewed our results with false aneurysm repair using deep hypothermia and circulatory arrest. MethodsEleven patients were reoperated on for false aneurysm of either the ascending or descending thoracic aorta. Femorofemoral cardiopulmonary bypass with full-dose aprotinin and a heparinized system was used in all patients. Hypothermic circulatory arrest at an average of 20°C was instituted in all patients for repair. Six patients had a patch repair with either polyethylene terephthalate fiber (Dacron) or bovine pericardium, 4 had tube replacement of the aorta, and 1 had primary repair of the defect. ResultsThree patients had false aneurysm formation at a site of coarctation repair in the descending aorta, and the 8 others had false aneurysms in the ascending aorta at the site of a previous aortotomy. Six patients had proven infection as the cause; the causative agent was Staphylococcus species in all cases. Mean cardiopulmonary bypass time was 178 ± 51 minutes, and circulatory arrest time averaged 39 ± 18 minutes. Operative mortality was 18% (2 of 11); the cause of death was cardiogenic shock in both patients. The mean time to extubation in survivors was 5 days, and the average time to discharge was 16 days. ConclusionsAlthough mediastinal infection is a common cause, aortic false aneurysms can be safely approached using femorofemoral cardiopulmonary bypass, hypothermic circulatory arrest, and patch repair with acceptable operative mortality and long-term survival.

Small Intestinal Submucosa for Vascular Reconstruction in the Presence of Gastrointestinal Contamination

Surgical options for vascular reconstruction in a contaminated field are limited and include prosthetic reconstruction or ligation with extra-anatomic bypass. With prosthetic insertion, rates of graft infection and failures (pseudoaneurysms and thrombosis) are high. In the emergent situations, extra-anatomic bypass is time-consuming and complex, and it produces marginal long-term results. Small intestinal submucosa (SIS) is a cell-free collagen matrix derived from porcine small intestine. Preliminary studies have demonstrated its ability to be remodeled into host tissue. In this study, we compared SIS to polytetrafluoroethylene (PTFE) as a vascular patch for arterial repair in the presence of massive gastrointestinal contamination to evaluate graft patency, incorporation, infection, and aneurysm formation. Adult mongrel pigs underwent general anesthesia with Isoflurane and were then randomized to 1 of 3 groups: control, contamination (colon puncture with stool contamination of the pelvis), or shock + contamination (40% blood volume for 1 hour, then resuscitation with shed blood and crystalloid, plus contamination). All groups then underwent a left common iliac arteriotomy and further randomized to a 1 x 3-cm patch angioplasty with either SIS or PTFE. All received cefotetan for 24 hours. All animals were sacrificed between 2 and 4 weeks, and necropsy was performed. Grafts were cultured, and microscopic analysis with hematoxylin and eosin and trichrome was performed. Outcomes included pulse quality (normal or diminished) compared with opposite side, graft infection, and pseudoaneurysm; all were determined by a blinded investigator. Forty animals were randomized, and 1 died of abdominal sepsis. All control animals had normal distal pulses, no pseudoaneurysms, and no patch infections. The pseudoaneurysm rate for the contaminated PTFE patches was 25% compared with 0% in the SIS group (P = 0.09). Patch infection occurred in 73% of all PTFE patches compared with 8% of SIS patches (P < 0.03). Organisms present in the infected grafts included Escherichia coli, Bacteroides species, and other Gram-negative enterics. Histopathology demonstrated the presence of neointima in both SIS and PTFE. Only SIS was completely incorporated, with infiltration of collagen fibrils and lymphocytes. SIS was associated with improved graft patency, less infection, complete incorporation, and no false aneurysm formation when compared with PTFE. This may be due to its ability to provide a durable scaffold for cellularization and tissue remodeling. This material may offer a superior alternative to more complex vascular reconstruction techniques in contaminated fields.

Massive False Aneurysm of the Peroneal Artery Treated by Endovascular Stenting

We report a patient with alarge false aneurysm of the peroneal artery arising as adelayed complication of an orthopaedic procedureand treated by endoluminal stenting.Case ReportA 62-year-old man was referred to the vascular clinicwith sudden onset of swelling associated withdiscomfort within a tender right calf. The patient’spast medical history included a right tibial osteotomypreformed 7 years previously for osteoarthritis, aorticvalve replacement, chronic renal failure and a familyhistory of Marfan’s syndrome. He had originallypresented to his GP who arranged an ultrasoundscan that demonstrated a large arterial aneurysmwithin the calf.Examination of the right calf confirmed swellingand tenderness on gentle palpation. A small scar wasvisible on the anterior surface of the leg from the tibialosteotomy. The leg was warm and well perfused, andall pulses were easily palpable. An angiogram wasarranged, which demonstrated a large false peronealartery aneurysm at the level of the mid calf, adjacent toa reunited spiral fracture of the middle of the fibula(Fig. 1). Due to the patient’s significant medical co-morbidity and the small calibre of the peroneal arteryin a grossly swollen leg, the treatment of choice wasfelt to be occlusion of the false aneurysm withthrombin injections. A catheter was thereforeadvanced into the aneurysm and it was successfullythrombosed.At 6 weeks, a duplex scan revealed recurrence of thefalse aneurysm. A repeat angiogram was performed toconfirm this and a decision was made to stent theperoneal artery. Due to the small diameter of theaffected artery, a 12 mm long 3.5 French PTFE coveredcoronary artery stent (JOMED) was deployed acrossthe defect. This successfully occluded the tear in thevessel and completion angiography demonstrated nofilling of the false aneurysm with good distal runoff(Fig. 1(B)). He was reassured and discharged on lowdose aspirin 150 mg once a day.The patient has been followed-up for 1-year afterthe insertion of the stent. Duplex scanning confirms apatent peroneal artery with no false aneurysm.DiscussionPeroneal artery false aneurysm formation has onlybeen reported once.

Neodymium:yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion

Purpose To describe a patient with central retinal artery occlusion successfully treated with neodymium:yttrium-aluminum-garnet laser arteriotomy and embolectomy. Design Interventional case report. Methods A 77-year-old woman noted sudden loss of vision after vigorous coughing. A central retinal artery occlusion was diagnosed. Four hours after symptoms appeared, arteriotomy and embolectomy with neodymium:yttrium-aluminum-garnet laser was performed. Results Displacement of embolus outside the artery with return of retinal perfusion and recovery of vision. Laser treatment also resulted in vitreous hemorrhage and false aneurysm formation of the central retinal artery. Conclusions Neodymium:yttrium-aluminum-garnet laser arteriotomy in a patient with central retinal artery occlusion resulted in extrusion of the embolus, reopening of the central retinal artery, and return of vision. This technique warrants further study as a primary treatment for this blinding disorder.

Formation and Rupture of a Large False Femoral Aneurysm: An Unusual Golf Handicap

Spontaneous femoral artery pseudoaneurysms are extremely rare. We report what is apparently the second documented case in the literature (Medline Access as of May 2003, search method on request) precipitated by acute hip torsion whilst playing golf. The case report aims to reinforce the fact that a femoral artery pseudoaneurysm can arise spontaneously following this type of repetitive physical activity and highlights the importance of prompt assessment and treatment of this condition.

Treatment of iatrogenic false aneurysms.

The incidence of iatrogenic false aneurysms has risen exponentially in recent years. Although this growth in peripheral vascular injuries likely is multifactorial in origin, the increasing complexity of percutaneous techniques combined with public demand for minimally invasive procedures has probably contributed. Periprocedural complications secondary to vascular interventions include false aneurysms, hematomas, thromboemboli, AV fistulae, and lacerations. False aneurysms, or pseudoaneurysms, account for more than 60% of these iatrogenic complications. Historically, the incidence of procedure-related vascular injury has been estimated as 0.05% to 0.1%. Today the incidence is estimated to range from 0.2% to 9.0%. Although percutaneous vascular access was once primarily used for diagnostic purposes, a transfemoral approach is now used for a wide variety of both diagnostic and therapeutic modalities. The femoral route is generally preferred for ease and reliability of access to the arterial and venous systems. Consequently, iatrogenic vascular injuries and false aneurysms are frequently located in the groin. The terms false aneurysm, pseudoaneurysm, and pulsatile or communicating hematoma are synonymous and may be used interchangeably. True aneurysms are defined as a circumscribed dilation of the artery; pseudoaneurysms involve dilation of an artery with actual disruption of one or more layers of its walls. The etiology of true and false aneurysms also differs: true aneurysms are typically caused by degenerative factors and false aneurysms are generally traumatic in origin. Iatrogenic pseudoaneurysms are most commonly produced by cardiac catherization, and these diagnostic and interventional procedures account for 70% to 80% of the incidence. Peripheral angiography or angioplasty, or both, are responsible for 10% to 15% of pseudoaneurysms. Additional causes of iatrogenic false aneurysms include percutaneous hemodialysis access, percutaneous intraaortic balloon pump placement, and other interventional techniques. Risk factors for the development of iatrogenic pseudoaneurysms include age greater than 60 years, female gender, catheter size greater than 8F, cannulation of both artery and vein, and concurrent anticoagulation. Operator inexperience, catherization of an artery other than the common femoral artery, and underlying peripheral vascular disease are also positively correlated with increased risk of false aneurysm formation. The natural history of peripheral vascular injuries is uncertain and surgical dictum previously mandated prompt operative repair. Recently, the focus has shifted from open surgical repair to a vast array of management options, including observation, compression therapies, thrombin injection, and embolization procedures. The remainder of this review focuses on the diagnosis, natural history, and treatment options for iatrogenic false aneurysms.

False Aneurysm of the Peroneal Artery: An Unusual Complication of Femoro-Peroneal Bypass Grafting

Non-traumatic false aneurysm formation involving the native crural vessels is rare. We present the case of a false aneurysm of the native peroneal artery, which complicated femoro-peroneal bypass grafting. It seemed most likely to be of an infective aetiology, arising as a consequence of contiguous methicillin resistant Staphylococcus aureus wound infection. This was previously unreported in the literature. Successful management was achieved by primary suture, local wound debridement, excision of the distal graft and replacement with an interposition vein graft through uninfected tissue planes.

False aneurysm of the peroneal artery: an unusual complication of femoro-peroneal bypass grafting

Non-traumatic false aneurysm formation involving the native crural vessels is rare. We present the case of a false aneurysm of the native peroneal artery, which complicated femoro-peroneal bypass grafting. It seemed most likely to be of an infective aetiology, arising as a consequence of contiguous methicillin resistant Staphylococcus aureus wound infection. This was previously unreported in the literature. Successful management was achieved by primary suture, local wound debridement, excision of the distal graft and replacement with an interposition vein graft through uninfected tissue planes.

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement

Background. Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement. Methods. One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%). Results. Global actuarial survival was 76.1% ± 4.3% for group 1 and 73.7% ± 3.9% for group 2 at 10 years ( p = 0.22). Freedom from reoperation excluding early deaths was 81% ± 3% for group 1 and 86% ± 2.2% for group 2 at 10 years ( p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 ( p = 0.04). Conclusions. Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.

Endovascular Treatment of type B Aortic Dissections

The purpose is to describe our experience with endovascular treatment of type B aortic dissections. Five patients were treated for complications following type B dissections like, false channel aneurysm formation, rupture and arterial obstruction. They were treated in general anaesthesia using a ‘homemade’ endoprosthesis or a commercially available endoprosthesis (Excluder®) deployed during fluoroscopy. The patients have been followed at regular intervals with a median observation time of 18 months (range 12–36). One patient needed a secondary intervention due to dislodgement of the proximal stentgraft with haemorrhage into both the false and the true lumen. Otherwise there have been no early or late mortality or major complications in this series. Even if our experience with endovascular treatment of type B dissections is rather limited, the results so far are promising. Open surgery in many of these cases is complicated with high morbidity and mortality rate and the endovascular technique offers great advantages. A longer follow-up period is necessary to define the place of endovascular treatment.

Endovascular treatment of type B aortic dissections

The purpose is to describe our experience with endovascular treatment of type B aortic dissections. Five patients were treated for complications following type B dissections like, false channel aneurysm formation, rupture and arterial obstruction. They were treated in general anaesthesia using a ‘homemade’ endoprosthesis or a commercially available endoprosthesis (Excluder®) deployed during fluoroscopy.The patients have been followed at regular intervals with a median observation time of 18 months (range 12–36). One patient needed a secondary intervention due to dislodgement of the proximal stentgraft with haemorrhage into both the false and the true lumen. Otherwise there have been no early or late mortality or major complications in this series.Even if our experience with endovascular treatment of type B dissections is rather limited, the results so far are promising. Open surgery in many of these cases is complicated with high morbidity and mortality rate and the endovascular technique offers great advantages. A longer follow-up period is necessary to define the place of endovascular treatment.