Impending Rupture Research Articles

Diagnosis and management of acute aortic syndromes in the emergency department.

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60bpm and systolic blood pressure of 100-120mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

Single-Photon Emission Computed Tomography Imaging Using Formyl Peptide Receptor 1 Ligand Can Diagnose Aortic Aneurysms in a Mouse Model

BackgroundOur previous studies showed that neutrophil infiltration and activation plays an important role in the pathogenesis of abdominal aortic aneurysms (AAA). However, there is a lack of noninvasive, inflammatory cell-specific molecular imaging methods to provide early diagnosis of AAA formation. Formyl peptide receptor 1 (FPR1) is rapidly upregulated on neutrophils during inflammation. Therefore, it is hypothesized that the use of cinnamoyl-F-(D)L-F-(D)L-F-K (cFLFLF), a PEGylated peptide ligand that binds FPR1 on activated neutrophils, would permit accurate and noninvasive diagnosis of AAA via single-photon emission computed tomography (SPECT) imaging. Materials and methodsMale C57BL/6 (wild-type) mice were treated with topical elastase (0.4 U/mL type 1 porcine pancreatic elastase) or heat-inactivated elastase (control), and aortic diameter was measured by video micrometry. Comparative histology was performed on Day 14 to assess neutrophil infiltration in aortic tissue. We performed near-infrared fluorescence imaging using c-FLFLF-Cy7 probe on Days 7 and 14 postelastase treatment and measured fluorescence intensity ex vivo in excised aortic tissue. A separate group of animals were injected with 99mTc-c-FLFLF 2 h before SPECT imaging on Day 14 using a SPECT/computed tomography/positron emission tomography trimodal scanner. Coexpression of neutrophils with c-FLFLF was also performed on aortic tissue by immunostaining on Day 14. ResultsAortic diameter was significantly increased in the elastase group compared with controls on Days 7 and 14. Simultaneously, a marked increase in neutrophil infiltration and elastin degradation as well as decrease in smooth muscle integrity were observed in aortic tissue after elastase treatment compared with controls. Moreover, a significant increase in fluorescence intensity of c-FLFLF-Cy7 imaging probe was also observed in elastase-treated mice on Day 7 (approximately twofold increase) and Day 14 (approximately 2.5-fold increase) compared with respective controls. SPECT imaging demonstrated a multifold increase in signal intensity for 99mTc-cFLFLF radiolabel probe in mice with AAA compared with controls on Day 14. Immunostaining of aortic tissue with c-FLFLF-Cy5 demonstrated a marked increase in coexpression with neutrophils in AAA compared with controls. ConclusionscFLFLF, a novel FPR1 ligand, enables quantifiable, noninvasive diagnosis and progression of AAAs. Clinical application of this inflammatory, cell-specific molecular probe using SPECT imaging may permit early diagnosis of AAA formation, enabling targeted therapeutic interventions and preventing impending aortic rupture.

Impact of labor epidural analgesia on maternal and neonatal outcomes with trial of labor in previous caesarean delivery: A prospective, controlled, longitudinal study

Background: Labor outcome with regional anesthesia following previous cesarean section has been fraught with concerns regarding uterine rupture. There is sparse literature regarding the association between the impact of epidural analgesia and labor outcome in vaginal birth after cesarean section (VBAC). This study aims to evaluate the effect of labor epidural analgesia on labor outcome following TOL (Trial of labor) in previous cesarean or normal delivery with maternal and neonatal outcomes. Material and Methods: This is a prospective controlled longitudinal study in second-gravida patients in labor. A total of 132 patients were enrolled for the study out of which 101 were divided into three groups. Group A included 38 second-gravid women with a history of previous caesarean delivery and Group B included 32 second-gravid having previous normal vaginal delivery, both the groups received epidural analgesia during labor. Group C included 31 second-gravid with a history of previous cesarean section who did not receive epidural analgesia during labor. The aim of the study was to evaluate labor outcome in terms of successful vaginal delivery with or without epidural analgesia, along with visual analogue scale (VAS) pain scores during the conduction of delivery, hemodynamic parameters, and progress of trial of labor (TOL). Other obstetric and neonatal parameters were also evaluated. Results: Vaginal delivery was conducted in all patients in Group B (32/32; 100%) and Group C (31/31; 100%), whereas in Group A, two patients underwent emergency cesarean section as a result of impending uterine rupture in one case and acute fetal hypoxia in another. According to the intensity of pain on VAS, women having previous cesarean delivery experienced more severe pain before starting epidural analgesia (VAS in Groups A and C; 7.9 ± 0.2) as compared to previous vaginal delivery (VAS; Group B 6.4 ± 0.2) (P 0.05) Cervical dilatation on admission to the maternity ward was 4.1 ± 1.0 (Group A and C) and 4.0 ± 1.0 (Group B). The total consumption of ropivacaine in epidural analgesia was significantly high in Group A (previous CD) (29.6 ± 1.2 mg) as compared to Group B (previous vaginal delivery) (28.1 ± 1.6 mg) (P

Perianeurysmal Edema:An Indirect Sign of a Minor Leak from an Intracranial Aneurysm

We report a rare case of perianeurysmal edema(PAE)around the dome of a usual intracranial aneurysm. A 79-year-old woman who presented with a dull headache that had become stronger from a month before was referred to our hospital for further examination of an aneurysm. MR angiogram had detected the aneurysm, having a dumbbell shape and arising from the M2 bifurcation of the right middle cerebral artery. Initial fluid attenuated inversion recovery and T2 weighed images revealed a slightly high intensity area in the brain around the dome of the aneurysm buried in the right temporal lobe, suggesting the presence of PAE possibly due to a preceding minor leak or partial thrombosis or impending rupture of the aneurysm. A CT angiogram revealed bleb formation of the aneurysm(size:10×6 to 4mm)without definite intraluminal thrombosis. The patient and her family consented to emergency craniotomy. During the microsurgical approach, thickening of the arachnoid membrane on the right sylvian fissure was observed. The subarachnoid space between the right frontal and temporal lobes was turbid/adhesive, and deposition of hemosiderin was observed around the aneurysm, indicating a preceding minor bleeding. The aneurysm was successfully clipped, and the postoperative course was uneventful. The present case showed that PAE could be observed even in a usual aneurysm. This finding might be an indirect sign of a preceding minor leak from the aneurysm, particularly when the dome is buried in brain parenchyma or is in close contact with the surrounding brain surface.

Impending Rupture of a Common Hepatic Artery Aneurysm Successfully Treated by Emergency Coil Embolization: A Case Report

Impending Rupture of a Common Hepatic Artery Aneurysm Successfully Treated by Emergency Coil Embolization: A Case Report

Arteriovenous fistula takedown in hemodialysis patients: our experience of 26 cases

IntroductionCreation of arteriovenous fistulas (AVF) for providing vascular access in patients dependent on hemodialysis is a very frequent type of surgery. One of the common complications of such a fistula is the formation of an aneurysm or a pseudoaneurysm and the risk of impending rupture. These are a few of the reasons why such surgically created AVF have to be taken down surgically. Some of these may be taken down for cosmetic reasons electively while some present in an emergency due to rupture of the aneurysm itself.AimThis is a retrospective study of 26 patients who underwent AVF takedown at our center over a period of 4 years.Material and methodsWe intended to study the patient profile, the surgery that they underwent and the post-operative course of these patients.ResultsWe found that aneurysm formation was the most common reason for a takedown, although we did see a good percentage of patients who presented to us with a ruptured AVF aneurysm. Our procedure was a ligation of the aneurysm with resection of the aneurysmal segment and maintaining arterial continuity. No attempt to preserve the fistula was made in any of these cases.ConclusionsThis article gives a brief overview of our experience in AVF takedown.

An Urgent Surgical Case of Open Repair for AAA Impending Rupture Due to a Residual Type II Endoleak Following EVAR: A Case Report and Literature Review

An Urgent Surgical Case of Open Repair for AAA Impending Rupture Due to a Residual Type II Endoleak Following EVAR: A Case Report and Literature Review

Initial Experience and Potential Advantages of AFX2 Bifurcated Endograft System: Comparative Case Series.

PurposeThe AFX2 endograft is a unibody, bifurcated stent graft that can be used to lower complications in certain patients. In this study, we retrospectively reviewed consecutive cases in which the AFX2 system was used to overcome the challenges of narrow distal aorta, as well as to reduce procedure time and contrast medium dose. Furthermore, we compared the results with matched patients treated using the Endurant II endograft system.Materials and MethodsThis was a retrospective observational study of nine patients with abdominal aortic aneurysm (AAA) who underwent endovascular aneurysm repair (EVAR) using the AFX2 device between June 2017 and April 2018 at Seoul National University Hospital. The patients had narrow distal aorta (n=3), reversed tapered neck (n=1), iliac artery aneurysm (n=2), chronic kidney disease patients (n=2), and impending rupture (n=1). Seven matched patients were treated using the Endurant II graft.ResultsIn the AFX2 group, the mean procedure time was 87.2 minutes, mean blood loss volume was 157.7 mL, and mean volume of contrast medium used was 48.3 mL. In the Endurant II group, the mean procedure time was 140.0 minutes, mean blood loss volume was 175.0 mL, and mean volume of contrast medium used was 119.3 mL.ConclusionOur preliminary experiences with selected AAA patients treated using the AFX2 endovascular repair system showed good outcomes compared with similar patients treated using the Endurant II system. Therefore, the AFX2 may be a good option to perform EVAR in patients of advanced age who have chronic kidney failure or narrow distal aorta.

Anesthetic Management of Emergency Cesarean Delivery Followed Immediately by Thoracic Endovascular Aortic Repair for a Peripartum Dissecting Aorta Aneurysm With Impending Rupture (Stanford Type B Dissection) in a Pregnant Patient With Takayasu's Arteritis

Abstract TAKAYASU'S ARTERITIS (TA) is a rare clinical condition, with an incidence of 1-2 cases per million in Japan 1 . It is characterized by chronic panarteritis of the aorta and its primary branches, including the subclavian, common carotid, coronary and renal arteries, and may result in localized stenosis, vascular occlusion, dilatation and aneurysm formation 2 . The disease can cause various circulatory complications, such as hypertension, heart failure, aortic regurgitation, coronary stenosis and aortic aneurysm.Among these, aortic dissection is very rare, accounting for 0.87% of patients with TA 3 . Further, there are only few reports of peripartum aortic dissection in pregnant patients with TA requiring combined treatment with cesarean delivery and TEVAR at the same time 4 . If aortic dissection occurs during pregnancy, ensuring the safety of both mother and fetus is quite challenging in this potentially lethal situation. Here, the authors report successful anesthetic management of emergency cesarean delivery immediately followed by TEVAR for a dissecting aortic aneurysm with impending rupture in a pregnant patient with TA. Written informed consent was obtained from the patient for publication of this case report

Acute Type B dissection and Aortic Coarctation, Now What?

Introduction: Acute type B dissection is a rare complication in patients with aortic coarctation. Medical therapy is the standard therapy for an uncomplicated acute type B dissection. Nowadays aortic coarctation should be treated by endovascular means. We describe a case of a patient with an acute type B dissection and a silent coarctation. Methods: We describe a case of a patient with an acute type B dissection and an underlying coarctation treated with a thoracic endograft. Results: A 58-year old man was admitted to another hospital with acute interscapular thoracic pain radiating to the left shoulder. CT-scan revealed a Stanford type B dissection with secondary dilatation up to 6 cm and a hematoma in the adjacent fatty tissue suspect for impending rupture. Patient was referred to our centre for treatment. A new CT-scan did not show any evolution, there was no malperfusion and the pain was under control. He was admitted to the intensive care unit for observation and antihypertensive therapy. Further investigations with transthoracic echocardiography showed a bicuspid aortic valve, a dilated arch and descending aorta, and a suspicion of aortic coarctation. Because of the impending rupture, the dilated descending aorta and the persisting limited thoracic pain we decided to treat the dissection after 14 days. A thoracic endografting was successfully performed, covering the entry point of the dissection, the coarctation and the dilated part of the descending aorta. Conclusion: In this case we describe a rare case of a patient with an acute type B dissection and an underlying coarctation, treated with a thoracic endograft. We discuss the preoperative work-up and surgical decision making, the technical aspects of thoracic endografting and the results of the procedure.

The Initial Aortic Diameter as the Predictors of Aortic Events in Uncomplicated Type B Aortic Dissection

Introduction: Several past studies investigated to detect the risk factors of late aortic events for patients with uncomplicated acute Type B aortic dissection. The initial aortic diameter was reported as a risk factor for late aortic events. However, it remains controversial about the cut off values; 40mm or 45mm. We evaluate the optimal initial aortic diameter for a risk factor. Methods: We conducted a retrospective cohort study reviewing 216 consecutive patients underwent initial treatment for uncomplicated acute type B aortic dissection between 2004 and 2018. We excluded 50 complicated cases (rupture, impending rupture and malperfusion). We evaluated the incidences of aortic events (operation for dissected aorta or operative indication for dissected aorta) after initial therapy. Follow up rates was 90.7% with median follow-up of 42 months. The largest minor and major axes diameters were measured on computed tomography at admission, before discharge. Logistic regression was used to examine whether aortic diameter was useful in predicting late aortic events. Cox regression was carried out to assess the prognostic effect of aortic diameter after allowing for significant covariates and receiver operating characteristic (ROC) analyses were used to determine test reliability. Moreover, patients were categorized into 3 groups based on the largest minor axis aortic diameter at admission; 40mm > Group A, 45mm > Group B ≥ 40mm, Group C ≥ 45mm, and Kaplan-Meier analyses detected the incidences of aortic events among these three groups. Results: In hospital mortality was 1 (0.5%). Long-term mortality was 40 (18.6%). Aortic events were 82 (38.1%). ROC analyses showed the cut-off values 40mm of minor axis diameter at initial CT (Area under the curve, 0.77, p< 0.01). In the multivariate analysis, risk factors of aortic events were initial aortic diameter ≥ 40mm (HR 4.21, 95% CI 2.54-6.98, p< 0.01), the false lumen diameter > the true lumen diameter (HR 3.73, 95%CI 1.88-7.41, p< 0.01), ulcer like projection (HR 1.83, 95%CI 1.04-3.22, p=0.04) and age ≥ 70 (HR 2.01, 95%CI 1.22-3.33, p= 0.01) were shown to be independent risk factors of late aortic events. The 3-years incidences rates of aortic events were 22.3% in Group A, 47.5% in Group B, and 87.9% in Group C, respectively (p< 0.01). Conclusion: We identify the optimal aortic diameter for predictor of aortic events was 40mm at admission. The larger initial aortic diameter, the more likely patients were to experience aortic events. We should closely monitor them and consider intervention at appropriate time. Disclosure: Nothing to disclose

Establishment of the First Mobile Telemedicine for Aortic Emergencies in Japan

Introduction - Quick and adequate decision-making is crucial to save patients with aortic emergencies including aortic dissection and aneurysm rupture. Preparing the devices to adapt to each patient’s anatomy is another crucial componet in the era of endovascular treatment. Surgical teams for aortic emergencies and special facilities, such as a hybrid operation room, are limited resources in rural areas. Telemedicine with high-resolution graphic data is thought to play significant roles in emergency medicine for cardiovascular emergencies, especially acute aortic syndrome. Methods - Asahikawa Medical University Hospital, which is locates in the centre of Hokkaido, introduced a mobile telemedicine system named JOIN, and created a cloud network of telemedicine that connects 6 local core hospitals, covering a 150 km range from Asahikawa. The JOIN application can transmit PACS (picture archiving and communication system) images such as CT scan and MRI as high-definition graphic data. Users can magnify an interesting area of the images and measure the length or angle of subjects appearing on users’ smartphones or tablet devices(Figure). We have been testing this mobile telemedicine system for acute cardiovascular emergency since October 2016. Results - Over 18 months, we have performed 63 consultations using this JOIN system, including 15 acute aortic dissections, 7 impending ruptures of thoracic aortic aneurysms, 4 ruptured abdominal aortic aneurysms(AAAs), 7 impending ruptures of AAAs, 5 cases of acute limb ischaemia, 3 cases of thrombosis or dissection of superior mesenteric artery, and other conditions. Among the 63 cases, 32 cases underwent emergency treatment and 16 cases were treated by endovascular treatment or hybrid therapy. Focusing on ruptured AAA, all four patients in the telemedicine system (TM group) were treated by endovascular aneurysm repair (EVAR), whereas 83% of the 18 AAA ruptures patients who were admitted without use of telemedicine (non-TM group; years 2011 Jan∼2018 March) were treated by EVAR. The door to operation time was 6∼70 min (median 11 min) in the TM group and 39∼211 min (median 88 min) in the non-TM group (p<0.05). The hospital death rate in the TM and non-TM groups were 0% and 16.7%, respectively. The questionnaire completed by medical staff revealed that communications among surgeons, anaesthesiologists, clinical engineers, and nurses have improved. Conclusion - Preliminary results suggest the following benefits:1)This telemedicine system can create time not only to prepare the devices and operating room but also to discuss and decide the treatment strategy before patient arrival.2)This telemedicine system reduces the door to operation time, which may contribute to improved clinical outcomes.3)The communication among medical staff is improving through the use of this system, which positively impacts the surgeon’ education and medical safety.

Acute Blood Products Within the Wall of an Intracranial Aneurysm: A Sign of Impending Rupture.

Acute Blood Products Within the Wall of an Intracranial Aneurysm: A Sign of Impending Rupture.

Aortic Remodeling After Extended PETTICOAT Technique in Acute Aortic Dissection Type III B.

The aim of this paper was to evaluate a new technique called an "extended" provisional extension to induce complete attachment (e-PETTICOAT) technique. In this prospective single-center clinical study, the primary safety end mid-term remodeling is evaluated for the new endovascular technique. It was based on a standard Petticoat and limited Stabilize technique, extended by the placement of 2 covered stents within the abdominal bare metal stent as parallel iliac stent grafts down to the iliac bifurcations. Computed tomographic angiography was performed postoperatively to assess aortic remodeling after 12 and 24months. Changes in aortic size and volumes of the false and true lumen were assessed. Between January 2014 and December 2015, 17 patients were treated due to acute, complicated aortic dissection type III B, according to the DaBekey classification. All patients presented with branch vessel obstruction/compromise, including six cases with aortic impending rupture. A 100% technical success rate was recorded regarding the resolution of complications. Favorable remodeling was achieved in 100% of the cases. Complete false lumen thrombosis in the thoracic, infra-renal aorta and the iliac artery was noted. A small volume (9.51±6.9mL) contrast-enhanced false lumen in the abdominal aorta was observed in 76% of cases with stable aortic size after 1 and 2years. No visceral branch occlusion, type I endo-leak, renal insufficiency or paraplegia was recorded in follow-up. The expanded PETTICOAT technique was feasible in achieving favorable remodeling in acute extensive aortic dissection. Extended followup is needed to ascertain long-term results. This article presents a series of 17 cases of a new endovascular method called E-PETTICOAT (EJVES 2018 https://doi.org/10.1016/j.ejvs.2018.07.038) used in complicated acute and extensive type IIIB dissections. Favorable remodeling was achieved in 100% cases with stable aorta diameter after 1 and 2years. It was shown that the extended PETTICOAT technique gives good remodeling in acute and extensive aortic dissection. This method can potentially provide a one-step solution and an easier alternative to FEVAR/BEVAR procedures. In order to ensure favorable results, further research is needed on a wider scale with long-term followup.

Contemporary Early and Long-Term Results of Open Repair for Ruptured and Symptomatic Unruptured Infrarenal AAA. Single Center Experience

Observational studies have shown a reduced short-term mortality and increased long-term survival of EVAR over OR in the treatment of ruptured Infrarenal Abdominal Aortic Aneurysm (IAAA). Until now, none of the RCT has gained the result to demonstrate this superiority. Moreover, contemporary reports about results of OR of rIAAA are poor. The study is observational and retrospective according to STROBE statement. The patients, unselected and strictly consecutive, were operated in urgency/emergency between 2007 and 2012. All had a preoperative CT angiography. Patients' characteristics, presentation, intraoperative and postoperative details were analyzed to identify factors that can affect the outcome. Considering the small number of events and the exploratory nature of the analyses, only univariate models were fit. One hundred five patients were treated in urgency/emergency setting because of symptomatic. The patients have been divided into two subgroups, based on lesion findings: 75 patients had ruptured IAAA (group A) and 30 patients had unruptured symptomatic IAAA, with CT findings of impending rupture (group B). Intraoperative, perioperative, and in-hospital mortality was respectively 0.9%, 8.6%, and 15.2%, with no difference between the groups. Unique predictors of 30-day mortality were transfusions, major and minor complications. Cumulative follow-up time was 455 person-years. Overall survival was not different between the groups. Predictors of late mortality were: age, creatinine at presentation, adjunctive procedures, length of in-hospital stay, any intraoperative complications, any perioperative complications, any major complication, and postoperative AKI. An experienced vascular team can achieve very good results in OR of ruptured IAAA, entirely comparable to EVAR. We are still far from a scientifically robust demonstration of the superiority of EVAR over OR in the treatment of ruptured IAAA.

36. All headaches are not GCA

IntroductionVasculitis is a heterogeneous group of autoimmune disorders having multisystem involvement. In many cases, the neurological disorders have an atypical clinical course or even an early onset, and the healthcare professionals should be aware of them.Case descriptionWe report a case of 57-year-old Asian male without any significant past medical history admitted under the urology department. He had presented with abdominal pain and fever and was being treated for presumptive pyelonephritis (on antibiotics). He was referred to rheumatology when he developed severe unilateral headache on right side with significant scalp tenderness. Headache involved temporal and fronto-parietal-occipital area with no jaw claudication or any significant visual disturbance. There was no limb claudication or polymyalgia symptoms. On examination he had new onset hypertension (BP:174/94mmHg), rest of the systemic examination was normal with no bruit. Musculoskeletal and skin examination was normal.Investigations included CRP of 204, hemoglobin 133, white cell count 15.2 (neutrophils: 12.06), creatinine 118 (eGFR 59). Liver function: normal. Urine dip: Normal and blood/urine culture: negative. Immunological profile and viral screen was negative. Urgent CT head was done for severe headache which was normal. Patient was referred to rheumatology with provisional diagnosis of giant cell arteritis due to headache and raised inflammatory markers. On reviewing his CT abdomen, the renal parenchyma showed symmetrical well demarcated bilateral involvement which was more in favor of renal infarct rather than pyelonephritis. CT angiography of abdomen was requested which showed multiple vessel involvement including mesenteric artery and bilateral renal arteries with beaded appearance and stenosis. MR angiogram showed 6mm aneurysm of PICA with stenosis of P1 segment of PCA. Currently he is being screened for ADA2 deficiency. During his stay his renal function deteriorated, not responding previously to antibiotics. He was started on methylprednisolone pulse and antibiotics stopped in view of worsening liver function. On day 3 of methylprednisolone pulse he had significant improvement of his headache with stabilization of renal and liver function. Our plan is to start him on steroid sparing therapy based on the ADA2 levels.DiscussionThe classification of vasculitis is still unsatisfactory as the patho-genetic mechanisms have not been fully understood. Existing criteria classify based on predominant vessel involvement but there is still some overlap between them. The prevalence of CNS involvement in medium vessel vasculitis ranges as widely as 2-10% and does not usually occur until late in the course of the disease. The most commonly reported CNS manifestation is diffuse encephalopathy, followed in frequency by focal deficits and seizures. Intracranial aneurysms are rare with around 15 reported cases usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. Treatment guidelines are still not clear and most are treated conservatively by medical management. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported Deficiency of ADA2 (DADA2) has been recently recognized first molecularly described monogenic vasculitis having biallelic hypomorphic mutation in ADA2 gene. CNS involvement is one of the main features of DADA2 which presents with a wide spectrum of clinical manifestations ranging from systemic inflammation to cutaneous or visceral PAN like vasculopathy and early onset stroke.Our patient had presented with primary CNS and renal involvement with impending rupture aneurysm. Timely control of inflammation is pertinent in such cases with remission induction and maintenance to prevent stroke. Although cyclophosphamide is still used in such cases DADA2 usually require anti-TNF therapy. Our patient had good response to primary steroid therapy.Key learning pointsAcute GCA-like neurological presentation of medium vessel vasculitis with cerebral involvement is rare. If not recognised in a timely fashion, it can lead to sub-arachnoid haemorrhage which is the most common presentation of such cases. DADA2 is a recently recognised entity that presents with stroke and vasculitis/vasculopathy and responds to anti-TNF therapy.Conflicts of interestThe authors have declared no conflicts of interest.

Handmade fenestrated stent grafts to preserve all supra-aortic branches in thoracic endovascular aortic repair

ObjectiveTo evaluate the efficacy and safety of a zone 0 landing aortic stent graft with handmade fenestrations for the preservation of all supra-aortic branches in thoracic endovascular aortic repair (TEVAR). MethodsThis study included 13 consecutive patients who underwent TEVAR using zone 0 landing handmade fenestrated stent grafts to preserve all supra-aortic branches from July 2016 to April 2017. Technical success was defined as the resolution of the primary aortic pathology as well as the preservation of all supra-aortic branches through the accurate alignment of the fenestration. Outcomes including technical success, perioperative morbidity and mortality, requirement of secondary interventions, and graft patency were analyzed. ResultsIn this study, 11 patients presented with aortic dissection, 1 presented with thoracic aortic aneurysm with impending rupture, and 1 presented with penetrating aortic ulcer of the thoracic aorta. The technical success rate of the primary procedure was 100%. Over a mean follow-up of 20 months, secondary endovascular procedures were performed in 6 patients to resolve 3 cases of stent graft-induced new entry, 2 cases of type Ib endoleak, and 1 case of new false lumen formation. During the study period, no complication resulting from proximal landing and fenestration occurred. ConclusionsOur experience of using handmade fenestrated stent grafts revealed preliminary results of using the grafts to preserve all supra-aortic branches in TEVAR, and results demonstrated the feasibility of this technique for achieving total arch replacement endovascularly in selective patients. Further technical advancement is anticipated, and larger studies with long-term follow-up are required.

Effects of source model variations on Coulomb stress analyses of a multi-fault intraplate earthquake sequence

Fault models are quickly produced and iteratively improved over weeks to years following a major earthquake, to characterise the dynamics of rupture, evaluate the role of stress transfer, and contribute to earthquake forecasting. We model Coulomb stress transfer (ΔCFS) between the largest foreshock (Mw 5.4; 1 year prior to first mainshock) and three Mw 6.1 to 6.5 earthquakes that occurred in a 12-hour period on January 22, 1988 in central Australia (Tennant Creek earthquake sequence) to investigate the role of static stress transfer in earthquake triggering relative to progressive source model development. The effects of fault model variance are studied using ΔCFS modelling of five different fault source model sequences (27 total models) using different inputs from seismic and geospatial data. Some initial models do not yield positive ΔCFS changes proximal to hypocentres but in all models, preceding earthquakes generate positive ΔCFS (≥0.1 bar) on ≥10 to 30% of the forthcoming receiver fault rupture areas. The most refined and data-integrative model reveals ΔCFS ≥ +0.7 to +13 bars within 2 km of impending hypocentres and large (≥30 to 99%) areas of positive ΔCFS. When compared to global compilations of threshold ΔCFS prior to impending ruptures (average = 3.71 bar, median = 1 bar), this suggests that Coulomb stress change theory adequately explains the Tennant Creek rupture sequence. In the most-refined model, earthquake inter-event times decrease as ΔCFS increases, suggesting that higher stress magnitudes may have more rapidly (within hours) triggered successive events, thus accounting for some temporal aspects of this sequence. ΔCFS analyses provide a useful framework for understanding the spatiotemporal aspects of some intraplate earthquakes. The progressive refinement of source models using emergent data may reduce epistemic uncertainties in the role of stress transfer that result from different model inputs, approaches, and results.

Predisposing Factors for Migration of the Iliac Limb and Reintervention after Endovascular Abdominal Aortic Aneurysm Repair

Migration of the iliac limb after endovascular abdominal aortic aneurysm repair (EVAR) can result in type 1b and 3 endoleaks, which are relatively common causes of reintervention after EVAR. The aim of the present study was to investigate the factors influencing migration of the iliac limb and methods of treatment. From April 2012 to September 2017, 4 patients experienced migration of the iliac limb, requiring additional iliac stent graft implantation intraoperatively or at follow-up at our institute. Patient 1 was a 74-year-old man in whom preoperative computed tomography angiography (CTA) revealed a large aneurysm. The patient underwent EVAR with a bifurcated stent graft, and the left iliac stent graft migrated into the aneurysm sac. Patient 2 was a 53-year-old man in whom CTA revealed a large abdominal aortic aneurysm (AAA) involving the bilateral common iliac artery (CIA), with occlusion of the left hypogastric artery. An iliac stent graft was deployed to the right CIA to preserve the hypogastric artery. CTA, at 5 years of follow-up, showed migration of the right iliac limb and impending rupture. Patient 3 was a 61-year-old man with a ruptured AAA, and CTA revealed a large AAA and dilated CIA. The patient underwent EVAR with a bifurcated stent graft. Three years after EVAR, CTA showed that the right iliac limb migrated and kinked, with rupture of the stent graft. Patient 4 was an 80-year-old man with a ruptured AAA and aortocaval fistula. CTA revealed a large aneurysm involving the bilateral CIA. The patient underwent urgent EVAR with a bifurcated stent graft, and a cuff was deployed to seal the landing zone of the left CIA to preserve the hypogastric artery. Type 3 endoleak occurred because of the migration and detachment of the left iliac limb. All 4 patients underwent additional iliac stent graft implantation to connect or reline the iliac limb. The mean diameter of the aneurysms was 85.3±18.9mm, and 2 patients were diagnosed with ruptured AAAs. The mean diameter, length, and proportional engagement rate of the CIA that experienced migration of the iliac limb were 25.50±11.1mm, 32.8±6.6mm, and 72.75%±17.88%, respectively. Oversizing of the iliac stent graft was 10-20% in 2 patients and was less than 10% in the other 2 patients. The migrated iliac limbs were bell-bottom stent grafts. All patients underwent additional iliac stent graft implantation successfully, and there were no deaths or complications perioperatively. The patients were followed up from 7 months to 3 years and remained in good condition. Migration of the iliac limb after EVAR was influenced by a complex combination of several factors including a large aneurysm (>60mm in diameter), dilated or aneurysmal CIA (>18mm in diameter), short length of fixation (<70%), lower degree of iliac limb oversizing (<10-20%), and bell-bottom of the iliac limb. Patients with these factors require more vigorous surveillance after EVAR. The implantation of an additional stent graft is effective and is the most common reintervention procedure.

A tale of four valves: outcome of Brucella endocarditis: a case series.

BackgroundBrucellosis is a zoonotic infection. Humans contract brucellosis through inhalation of aerosolized infected particles, or when they come in direct contact with infected animal parts, or on consuming unpasteurised dairy products. It can affect multiple organs and systems. Endocarditis is diagnosed late in the course of the disease with mostly aortic valve involvement with serious morbidity and mortality.Case summaryWe report a case series of four patients with Brucella endocarditis. The first patient presented with fever, malaise, and exertional breathlessness. He underwent aortic valve replacement for refractory heart failure and bulky vegetations after failed medical therapy. The second patient presented with fever, breathlessness New York Heart Association (NYHA) III, with arthralgia, myalgia, anorexia, and weight loss. In view of aortic abscess with impending rupture and compression of left main coronary artery, aortic valve replacement was performed on the 4th day of antibiotic treatment. The third patient presented with fever, fatigue, NYHA II, and developed peripheral embolization but responded to medical treatment alone. The fourth patient presented with intermittent fever for 7 months. During hospitalization, he suffered acute limb ischaemia and stroke with absence of left dorsalis pedis and posterior tibial pulsation. Brucella IgG ELISA was positive. Mitral valve replacement was done subsequently with unremarkable hospital course.DiscussionBrucellosis is a challenging diagnosis to make. The diagnosis and treatment is often delayed as it presents with non-specific symptoms and signs. Cardiac involvement occurs in only 2% of the cases, but accounts for 80% of the mortality due to brucellosis. Brucella endocarditis should be suspected in cases of endocarditis with negative blood cultures and a risk of exposure. The most accepted treatment for Brucella endocarditis is a combination of antimicrobial therapy with surgery.