Iatrogenic Aneurysm Research Articles

An Institutional Experience and Literature Review on Iatrogenic Major Vascular Injury in Neurosurgery: Proposal of a Management Algorithm.

Major vessel injury is among the most dreaded complications of any neurosurgical procedure. Once intraoperatively tamponaded, it can present in the form of pseudoaneurysm, dissecting aneurysm or complete occlusion of vessel. These injuries are often associated with very high morbidity and mortality. The literature available on this topic is limited and our understanding remains limited. In this article, we present our surgical experience with iatrogenic aneurysms and present a review of literature. We conducted a retrospective analysis of all patients with major vessel injury during surgery from a prospectively maintained database from January 2012 to February 2020. A total of 15 patients developed iatrogenic aneurysms following a major vessel injury during various neurosurgical procedures. The most common vessel injured was vertebral artery (n = 9) in craniovertebral junction (CVJ) anomalies and ossification of posterior longitudinal ligament (OPLL) followed by internal carotid artery injury (n = 5) in sellar and parasellar pathologies. One patient developed basilar artery injury during endoscopic third ventriculostomy (ETV). Eight patients had pseudoaneurysm and seven had dissecting aneurysm with or without complete thrombosis of the involved artery. A total of two patients died after vascular injury and remaining thirteen patients survived and discharged. The adage "prevention is better than cure" applies most aptly in such cases. Any major vessel injury should be followed by immediate angiography and subsequent early management. The endovascular management is more favorable as these aneurysms are difficult to clip due to the absence of a neck and fragile wall.

Girişimsel işlemlere bağlı gelişen femoral psödoanevrizmanın primer onarımı

Objective: This study aimed to report our clinical experience with the treatment of iatrogenic femoral pseudoaneurysms with the primary suture technique. Materials-methods: Thirty patients treated with the diagnosis of femoral pseudoaneurysm in the femoral artery between September 2015 and August 2020 participated in the Non-iatrogenic pseudoaneurysms, iatrogenic aneurysms smaller than 4 cm, and thrombosed aneurysms were excluded. All pseudoaneurysms were diagnosed by ultrasonography and computed tomography. Results: Peripheral arterial thrombosis developed in 1 (4%) patients. All femoral pseudoaneurysms were repaired with primary suture without clamping. No early postoperative deaths occurred. Conclusion: Although cross-clamp surgical treatment modalities have been described as standard surgical treatment, surgical repair with primary suture technique without clamping is a good method for iatrogenic peripheral arterial pseudoaneurysms.

SUPPURATION OF IATROGENIC FEMORAL ARTERY ANEURYSM

The article describes the application of methods and methods of reconstructive surgery of iatrogenic false aneurysms of the left femoral artery. Experience shows the optimality of the choice and method of surgical treatment of iatrogenic aneurysms of the femoral artery by restoring prosthetic arteries. The article presents a clinical case of surgical treatment of iatrogenic aneurysm of the left femoral artery resulting from a puncture of the left femoral artery. The elimination of the aneurysm was accompanied by plastic surgery of the defect (5–6 cm) of the left femoral artery by applying prosthetics to the vessels. The rationale for the choice of surgical intervention is given.

Algorithm of actions in iatrogenic vascular aneurisms

Aim of the study was the development of treatment and diagnostic algorithm for iatrogenic vascular aneurysms and their surgical treatment. Material and methods. The paper presents an analysis of the treatment results of 19 patients (15 men – 78.9 % and 4 women – 21.1 %) with iatrogenic vascular damages and their consequences. The method of endovascular complete vascular occlusion was used for the patients treatment. Results. The following methods were used for surgical treatment: vascular ligation – 3 cases, side seam – 6; plastic surgery was performed on the vessels of 4 patients (autovenous, homovenous or synthetic prosthetics) with the use of endovascular full vascular occlusion. The following methods were used after the aneurysm removal: lateral suture – 6 (31.5 %); circular seam – 1 (5.2 %); dressing – 4 (21 %); autovenous shunting – 2 (10.5 %); extraanatomical shunting – 1 (5.2 %); homovenous bypass surgery – 1 (5.2 %); Z-shaped seams – 1 (5.2 %); Palm’s о peration – 1 (5.2 %). The following complications were observed after the operation: vascular thrombosis – 1, arrosive bleeding – 1 patient. There were no forced amputations and deceased patients. In the postoperative period of 16 (84.2 %) patients, wound healing was primary; 3 (15.8 %) healing occurred by secondary intention. Conclusion The proposed diagnostic and treatment algorithm improves the efficiency of surgical treatment of iatrogenic aneurysms by the method of endovascular complete vascular occlusion and obtains good results.

True Aneurysm of Temporal Superficial Artery Arise Spontaneously. Case Report

Abstract Aneurysms of the temporal superficial artery (TSA) are very rare clinical entity. From 1861 to the present day, is described less than 200 cases. The most common cause of these aneurysms is so called blunt head trauma but there are described many cases of iatrogenic aneurysms, very rarely, aneurysms arise spontaneously. We report a case of 17-yearold patient with spontaneously formatting aneurysm of TSA. Three months prior to admission, he noticed the existence of tumefaction localized frontotemporal on the right side. MSCT angiography of blood vessels of the scalp showed an aneurysm on the frontal branch of TSA diameter of 15 mm. The aneurysm was resected with uneventful postoperative course. PH findings pointed to a true aneurysm. Treatment protocol for the aneurysms of the TSA include clinical monitoring, compression of the aneurysm, the injection of thrombin, endovascular treatment and surgical resection. Surgical resection has proven to be a safe and effective treatment modality and still is the method of choice.

Extracranial internal carotid artery aneurysm: case illustration

Abstract Extracranial internal carotid artery aneurysms (EICAA) are uncommon lesion. These aneurysms can be classified as true or false aneurysms, atherosclerotic, dysplastic, infectious, posttraumatic and iatrogenic aneurysms. The most common presentation is central neurologic dysfunction, either a stroke or a transient ischemic attack. The rupture of these aneurysms can lead to severely impairment and can affect the quality of life of the patients or even may lead to death. Management of these lesions is required in most cases to prevent complications, however there is no treatment guideline or expert consensus for the management. We present a case of an unusual EICAA, associated with kinking of the affected vessel and review the literature.

Editor's Choice – Ex vivo Renal Artery Repair with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Long-term Results of Sixty-seven Procedures

To evaluate the long-term outcome of renal revascularization by exvivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). Between 1991 and 2015, 67 exvivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p<.05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93±29mL/minute, the immediate post-operative MDRD was 94±33mL/minute, and at the end of follow up it was 86±26mL/minute (p>.05). Exvivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.

Missed vascular injuries: presentation and outcome.

To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries. A case series. Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012. All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed. Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years (mean = 33.7 ± 15.4 years). Male to female ratio was 6:1. Twelve (42.8%) patients presented with pseudoaneurysm alone, 10 (35.7%) with traumatic arteriovenous fistulae, 4 (14.3%) with post-traumatic thrombosis and occlusion and 2 (7.1%) with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 (67.8%). The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks (mean 228 weeks). Lower limb vessels were affected in 20 (71.4%), the upper limb in 5 (17.8%) and neck vessels in 3 (10.7%). Superficial femoral artery was the most frequently involved artery in 9 (32.1%) cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One (3.5%) patient had amputation after secondary hemorrhage. Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation.

Iatrogenic intracranial aneurysms in childhood: case-based update

Iatrogenic aneurysms are very rare in children. Characteristic clinical manifestations are variable and asymptomatic course is possible especially for fusiform dilatation of internal carotid artery. Even though radiological diagnosis is easy, the management of iatrogenic intracranial aneurysm is still a subject for discussion. Fusiform dilatations of internal carotid artery were diagnosed on three pediatric patients during follow-up imaging after primary surgery for suprasellar-parasellar tumor. All patients were asymptomatic. Conservative treatment was proposed because the lesion did not show any progression in subsequent examinations. Patients are stable under conservative treatment. Iatrogenic aneurysm may have an unusual presentation and their therapy still remains unclear. Fusiform dilatation of internal carotid artery rarely causes symptoms and there is no published paper of subarachnoid bleeding. Treatment would be difficult, since the main arterial branches arise from the dilated carotid segment. Conservative treatment is a choice only if aneurysm has no progression or in case of spontaneous healing. Intervention should be performed only in case of progression or if the aneurysm becomes symptomatic.

Altered Coiling with Stent Assistance for an Iatrogenic Traumatic Aneurysm of the Internal Carotid Artery

We report a rare case of a traumatic aneurysm which developed after clipping surgery with review of the relevant literature. Endovascular treatment using coiling and stent assistance taking into account technical considerations is described. Monitoring of the aneurysmal pressure showed marked decrease immediately after the stent emplacement.

N-Butyl-2-cyanoacrylate Use in Intraoperative Ruptured Aneurysms as a Salvage Rescue

The use of N-butyl-2-cyanoacrylate (n-BCA) acrylic glue as a salvage rescue in procedural ruptured aneurysm should be part of the neurointerventionalist's armamentarium. Two patients, age 44 and 60 years, presented with Hunt and Hess grade 3 subarachnoid hemorrhage from aneurysmal rupture. We report 2 cases in which n-BCA was used effectively as a salvage rescue in aneurysms that ruptured during coil embolization. These 2 cases demonstrate a feasible technique for the salvage of iatrogenic aneurysm perforation during coil embolization, which, to our knowledge, has not been previously reported.

Endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery

Traumatic intracranial aneurysms are rare complications of closed and penetrating head injuries and may also be related to a variety of neurosurgical procedures. The primary goals in the treatment of patients harboring these lesions are early identification and intervention to prevent bleeding. Traumatic aneurysms are fragile, prone to rupture, and represent a challenging subset of vascular lesions for either surgery or endovascular therapy. Surgical approaches to aneurysms located at the pericallosal arteries are associated with higher rates of morbidity and mortality than approaches to other supratentorial aneurysms. Current endovascular treatment most often involves occlusion of the parent artery with the potential of added morbidity. The authors present their experience in the endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery achieved by primary coil embolization with parent vessel preservation. For patients harboring traumatic pericallosal aneurysms with favorable anatomical characteristics, in which the morbidity caused by parent vessel occlusion is not acceptable, endosaccular coil placement may be a valuable option.

Intradural Aneurysm Caused by Arterial Injury during Surgery

We described a patient with subarachnoid hemorrhage due to a ruptured intradural aneurysm caused by arterial injury during surgery and severe symptomatic vasospasm. The iatrogenic posttraumatic aneurysm was occluded by using GDC with preservation of parent artery followed by intraarterial infusion of papaverine to treat vasospasm as an one-stage procedure. This resulted in significant angiographic resolution of the vasospasm and the patient's clinical outcome was excellent. Endovascular approach to posttraumatic intracranial aneurysms and endosaccular GDC embolization of aneurysm with concomitant intraarterial papaverine infusion to treat vasospasm are discussed.

False aneurysms of the intracavernous carotid artery — Report of 7 cases

We present 7 cases of false intracavernous carotid artery aneurysms. Four occurred after trauma and three were caused iatrogenically. Two of the latter occurred in patients with pituitary adenomas, one after transsphenoidal microsurgery and the other after yttrium [YI90] seed implantation into the sella. The third iatrogenic aneurysm was seen shortly after transcavernous tumour surgery. In five of our seven patients massive, delayed, life-threatening epistaxis was the leading symptom. All traumatic cases were associated with immediate unilateral blindness or blurred vision and with skull base fractures. One of these had a concomitant carotid cavernous fistula. Treatment of choice of our 5 recent cases was permanent balloon occlusion of the intracavernous carotid artery at the level of the lesion. Collateral circulation was evaluated prior to definitive carotid occlusion using a balloon test occlusion. During the balloon test adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. Awake patients were neurologically examined continuously. In unconscious patients transcranial Doppler sonography, electroencephalographic and somatosensory evoked potential monitoring was used in addition. Intra-operative heparin administration was not reversed with protamin. A postoperative continuous heparin infusion was not found necessary. In our two early cases this technique was not available: In the first case we accomplished aneurysm occlusion by a surgically introduced Fogarty balloon catheter. Our second patient needed surgical trapping of the involved carotid after early unsuccessful attempts of selective aneurysm occlusion. After treatment no further epistaxis occurred. Follow-up angiography showed persistent aneurysm occlusion. The results were excellent in 5 cases and good in 1 case. One patient with bilateral lesions suffered a stroke after occlusion of the second, remaining carotid artery, despite functioning bilateral extra-intracranial bypasses. Four years later there is a mild dysphasia still present in this patient. The mean follow-up time was 75.6 months.

VASCULAR TUMORS IN CHILDREN

Tumors with a vascular component are the most common masses seen in children. Malformations and hemangiomas predominate. Hemangiomas have a biphasic natural history consisting of initial proliferation followed by spontaneous involution; these tumors rarely require surgical intervention. Malformations present at birth or shortly after birth and have a wide spectrum of clinical presentations depending upon their predominant cell type and rheology. Physical examination and MR imaging will effectively define most of these anomalies. Surgery is reserved for very symptomatic lesions and is effective in all but the fast-flow, Type C group of malformations. Glomus tumors, pyogenic granulomas and both traumatic and iatrogenic aneurysms are also seen in the pediatric age group. All are benign and effectively treated surgically. Malignant vascular tumors are rare in this age group.

Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature.

We report four pediatric traumatic intracranial aneurysms occurring before the age of 10 years. Two of these aneurysms were the result of closed head injury. The remaining two were iatrogenic aneurysms which occurred in unusual circumstances. These four children represent 33% of the pediatric intracranial aneurysms seen at the Children's Hospital of Eastern Ontario from 1974 to 1992. Diagnosis of traumatic intracranial aneurysms requires a high index of suspicion: any head-injured or postoperative child who experiences delayed neurologic deterioration, or who fails to improve as expected following treatment, should promptly undergo diagnostic intracranial imaging. Documented subarachnoid hemorrhage, intracerebral or intraventricular hemorrhage, or subdural haematoma in this clinical setting should be further investigated by cerebral angiography to exclude a traumatic aneurysm or other vascular lesion. Traumatic aneurysms typically arise at the skull base or from distal anterior or middle cerebral arteries or branches consequent to direct mural injury or to acceleration-induced shear. Reported traumatic aneurysms account for 14%-39% of all pediatric aneurysms. Iatrogenic aneurysms also occur with unexpected frequency during childhood and adolescence. Pediatric traumatic cerebral aneurysms may present early or late. Most present early with intracranial hemorrhage. Late presentation occurs infrequently, typically as an aneurysmal mass. Once diagnosed, these aneurysms should be promptly treated by craniotomy employing routine microsurgical techniques, or in some cases, by endovascular detachable balloon techniques. Delay in operative treatment entails significant risks of repeated hemorrhage and death. Outcome in these children is primarily determined by the extent of traumatic cerebral injury and the preoperative clinical status. The latter directly depends upon diagnosis of the aneurysm prior to either initial or repeated hemorrhage.

Temporary clip部に発生したiatrogenic aneurysmの治療および直角型fenestrated clip使用時のpitfall

Temporary clip部に発生したiatrogenic aneurysmの治療および直角型fenestrated clip使用時のpitfall

Aneurysm of the gastroduodenal artery as a cause of hemobilia

One case of iatrogenic aneurysm of the gastroduodenal artery with hemobilia is reported. Surgical treatment consisted of ligature and resection after arteriographic diagnosis. The literature is reviewed.

Iatrogenic Intracranial Aneurysms

Intracranial aneurysms following head trauma are not uncommon. Few cases of iatrogenic intracranial aneurysm have been reported however. This type of lesion is illustrated by three cases. If these lesions have the same poor prognosis as that proposed for the usual traumatic aneurysm, their early diagnosis and treatment is important.