Aneurysm Repair Research Articles

Primary decompressive craniectomy in patients with large intracerebral hematomas due to aneurysmal subarachnoid hemorrhage

BackgroundDecompressive craniectomy (DC) can alleviate increased intracranial pressure in aneurysmal subarachnoid hemorrhage patients with concomitant space-occupying intracerebral hemorrhage, but also carries a high risk for complications. We studied outcomes and complications of DC at time of ruptured aneurysm repair.MethodsOf 47 patients treated between 2010 and 2020, 30 underwent DC during aneurysm repair and hematoma evacuation and 17 did not. We calculated odds ratios (OR) for delayed cerebral ischemia (DCI), angiographic vasospasm, DCI-related infarction, and unfavorable functional outcome (extended Glasgow Outcome Scale 1–5) at three months. Complication rates after DC and cranioplasty in the aneurysmal subarachnoid hemorrhage patients were compared to those of all 107 patients undergoing DC for malignant cerebral infarction during the same period.ResultsIn DC versus no DC patients, proportions were for clinical DCI 37% versus 53% (OR = 0.5;95%CI:0.2–1.8), angiographic vasospasm 37% versus 47% (OR = 0.7;95%CI:0.2–2.2), DCI-related infarctions 17% versus 47% (OR = 0.2;95%CI:0.1–0.7) and unfavorable outcome 80% versus 88% (OR = 0.5;95%CI:0.1–3.0). ORs were similar after adjustment for baseline predictors for outcome. Complications related to DC and cranioplasty occurred in 18 (51%) of subarachnoid hemorrhage patients and 41 (38%) of cerebral infarction patients (OR = 1.7;95%CI:0.8–3.7).ConclusionsIn patients with aneurysmal subarachnoid hemorrhage and concomitant space-occupying intracerebral hemorrhage, early DC was not associated with improved functional outcomes, but with a reduced rate of DCI-related infarctions. This potential benefit has to be weighed against high complication rates of DC in subarachnoid hemorrhage patients.

Exoscopic Clipping of a Ruptured Posterior Communicating Artery Aneurysm Through a Minipterional Approach: 2-Dimensional Operative Video

Posterior communicating artery (PCoA) aneurysms represent approximately 15% to 25% of intracranial aneurysms and carry an estimated risk of rupture of 44%. 1-4 Surgical clipping of PCoA aneurysms bears notable challenges associated with operating in a confined space with limited visualization of deep structures. 1,5 We illustrate the case of a 54-year-old woman who presented with a seven-hour course of intense headaches, vomiting and loss of consciousness. Her neurological examination revealed she had a 4/5 left-sided hemiparesis, a Glasgow coma scale score of 12, and a Hunt and Hess score of 3. A head computed tomography scan without contrast showed subarachnoid hemorrhage in the basal cisterns and Sylvian fissures (Fisher grade 3). Digital subtraction angiography and three-dimensional reconstruction imaging revealed a right bilobed saccular PCoA aneurysm of 4.8 × 5.9 mm projecting anterior-inferiorly. After consideration of her clinical course and aneurysmal features, she underwent a right minipterional craniotomy for exoscopic clipping of the aneurysm neck. The patient tolerated the procedure well, her hemiparesis improved, and she was discharged with a modified Rankin scale score of 1 on postoperative day 3. Exoscopy offered high image quality and expanded 3-dimensional view with digital zoom during the aneurysm repair. 6,7 Although evidence suggests exoscopy is non-inferior to microscopy regarding surgery duration, safety, and outcomes, the capability of providing operator ergonomy during surgery is a worth-noting advantage. 8 IRB and patient consent declaration: This study was exempt from the Institution Review Board because patient consent was granted for the use of clinical information, images, and operative videos. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image.

International Collaborative Study Comparing Outcomes of Fenestrated Endovascular Aortic Repair in OCtogenarian vs Non-Octogenarian Patients: The FEVOC study.

With an increasing life expectancy, more octogenarian patients are referred with complex aortic aneurysms (cAAA). The aim of this study was to evaluate short and mid-term outcomes following fenestrated aortic repair (FEVAR) in octogenarians. Few studies looking at octogenarian-specific outcomes with diverging results. Retrospective, multicentre cohort study including consecutive patients undergoing elective FEVAR for cAAAs or type IV thoracoabdominal aortic aneurysms between 2007-2022 in eight high-volume centres. Octogenarians vs. non-octogenarians were compared. The primary outcome was 30-day mortality. Secondary outcomes included 1, 2 and 5-year survival and reintervention rates. A total of 729 patients (median age of 74.8 years [IQR 69.2 - 79.14]) were included, 169 (23%) of which were octogenarians, with 316 (43.3%) patients undergoing juxta/pararenal aneurysm repair. Although octogenarians presented less complex but larger (61mm vs. 58mm) aneurysms, the number of fenestrations was similar across groups. No differences in in-hospital mortality (4.1 vs. 3.0%), MAE (16.6% vs 12.2%) or reintervention rates (11.2 vs. 10%) were found. Multivariable logistic regression of in-hospital mortality identified BMI (OR 0.66, 95% CI 0.51-0.95, P=0.003), chronic heart failure (OR 7.70, 95% CI 1.36-36.15, P=0.003) and GFR<45ml/min/1.73m2 (OR 5.25, 95% CI 1.20-22.86, P=0.027) as independent predictors. Median follow-up was 41 months. The 1, 2 and 5-year survival rates were 91.3%, 81.8% and 49.5% in octogenarians vs 90.6%, 86.5% and 68.8% in non-octogenarian patients (Log-rank: =0.001). Freedom from aortic-related death and freedom from reintervention at five-years were similar across groups (log-rank=0.94 and .76, respectively). Age>80 was not an independent predictor of 30-day or long-term mortality on multivariable and Cox regression analysis. Elective FEVAR in octogenarians appears to be safe, with similar outcomes as in younger patients. Future studies looking at improved patient selection methods to ensure long-term survival benefits in both octogenarians and younger patients are warranted.

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

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

Presentation and management of true aneurysms of the pancreaticoduodenal arcade with concomitant celiac artery stenosis using the endovascular approach

True aneurysms of the pancreaticoduodenal artery (PDA) arcade are rare but require intervention due to the high risk of rupture. Historically, these aneurysms have been managed with open surgical methods. In this study, we describe a contemporary series of aneurysms treated using a modern approach that includes endovascular and hybrid techniques. All the patients with aneurysms of the PDA arcade in an institutional database were identified between 2008 and 2022. Patients with history of pancreatic resection were excluded. Data on demographics, presenting symptoms, imaging findings, operative approach, and outcomes were collected and reviewed. There were nine patients diagnosed with a PDA aneurysm, and all nine underwent endovascular intervention. Most were men (n = 5; 55.6%) and White (n = 7; 77.8%) and had American Society of Anesthesiologists class II or III. The median aneurysm size was 21 mm (range, 6-42 mm), and five (55.5%) were symptomatic. Of the five symptomatic cases, two presented with rupture and were treated urgently. The median time to intervention for the nonurgent cases was 30 days. All but one patient had concomitant celiac artery stenosis and two of the eight cases (25%) were due to extrinsic compression from median arcuate ligament syndrome. Both patients underwent median arcuate ligament syndrome release before endovascular intervention. Another patient required open surgical bypass before endovascular repair from the supraceliac aorta to hepatic artery using a Dacron graft to maintain hepatic perfusion. Among the eight patients with celiac axis stenosis, five (62.5%) required celiac stent placement within the same operation. Coil embolization of the aneurysm was used for all except for two patients (n = 7 of 9; 77.8%), with one patient receiving embolic plugs and another receiving an 8 × 38-mm balloon-expandable covered stent for aneurysm exclusion. The median operating room time was 134 minutes. All repairs were technically successful without any intraoperative or postoperative complications. The mean follow-up was 30 months. There was no morbidity, mortality, or unplanned secondary reinterventions within 6 months after aneurysm repair. Stent patency and aneurysm size remained stable at 2 years of follow-up. True pancreaticoduodenal artery arcade aneurysms can be safely and effectively treated using endovascular and hybrid techniques. Because many of these aneurysms have concomitant celiac artery stenosis, the use of endovascular technology allows for simultaneous treatment of both the aneurysm and the stenosis with exceptional results.

REBOA: A Device to Gain Time

The management of trauma and emergency procedures (i.e., aneurysm repair, visceral and pelvic bleeding, and others) has undergone considerable changes due to the presence of new endovascular and mini-invasive approaches, which have supplanted the surgical approach in some cases. The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been largely used to manage trauma patients, but it is, nowadays, increasingly also being used for other types of bleeding, such as vascular emergencies, post-partum hemorrhages, and gastrointestinal and iatrogenic or spontaneous bleeding. We present a case of an unexpected hemorrhagic shock in a patient with a locally advanced cervix neoplasm involving sacrum and pelvic vessels, where we used a REBOA to manage an intraprocedural massive bleed due to the rupture of the descending branch of the right hypogastric artery.

Early versus delayed mobilization after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of efficacy and safety.

A central tenet of Enhanced Recovery After Surgery (ERAS) is evidence-based medicine. Survivors of aneurysmal subarachnoid hemorrhage (aSAH) constitute a fragile patient population prone to prolonged hospitalization within neurointensive care units (NICUs), prolonged immobilization, and a range of nosocomial adverse events. Potentially, well-monitored early mobilization (EM) could constitute a beneficial element of ERAS protocols in this population. Therefore, the objective was to summarize the available evidence on EM strategies in patients with aSAH. The authors retrieved prospective and retrospective studies that reported efficacy or safety data on EM (defined as EM in the NICU starting ≤ 7 days after ictus) versus delayed mobilization (DM) (any strategy that comparatively delayed mobilization) after aSAH and were published after January 1, 2000, in PubMed/MEDLINE, Embase, and the Cochrane Library. Random-effects meta-analysis was performed. Ten studies analyzing 1292 patients were included for quantitative synthesis, including 1 randomized, 1 prospective nonrandomized, and 8 retrospective studies. Modified Rankin Scale scores at discharge were not different between the EM and DM groups (mean difference [MD] [95% CI] -0.86 [-2.93 to 1.20] points, p = 0.41). Hospital length of stay in days was markedly reduced in the EM group (MD [95% CI] -6.56 [-10.64 to -2.47] days, p = 0.002). Although there was a statistically significant reduction in radiological vasospasms (OR [95% CI] 0.65 [0.44-0.97], p = 0.03), the reduction in clinically relevant vasospasms was nonsignificant (OR [95% CI] 0.63 [0.31-1.26], p = 0.19). The odds of shunting were significantly lower in the EM group (OR [95% CI] 0.61 [0.39-0.95], p = 0.03). The rates of mortality, pneumonia, and thrombosis were similar among groups (p > 0.05). Due to a lack of high-quality studies, vastly varying protocols, and resulting statistical clinical and statistical heterogeneity, the level of evidence for recommendations regarding EM in patients with aSAH remains low. The currently available data indicated that mobilization within the first 5 days after aneurysm repair was feasible and safe without significant excessive adverse events, that neurological outcome with EM was almost certainly not worse than with prolonged immobilization, and that there was likely at least some reduction in length of hospital stay. Radiological and clinical vasospasms were not more frequent-with signals even trending toward a decrease-in patients who mobilized early. Higher-quality studies and implementation of full ERAS protocols are necessary to evaluate efficacy and safety with a higher level of evidence and to guide practical implementation through increased standardization. Clinical trial registration no.: CRD42023432828 (www.crd.york.ac.uk/prospero).

Abstract 172: Outcomes and Complications of Stent‐Assisted Aneurysm Repair in Acute Subarachnoid Hemorrhage

Introduction The use of detachable coils for endovascular embolization of cerebral aneurysms has become a safe and effective alternative to direct surgical clipping in patients with ruptured aneurysmal subarachnoid hemorrhage. However, endovascular treatment of wide‐necked, large (&gt;10 mm), and complex ruptured aneurysms continues to remain challenging despite multiple technical advancements in recent years. In order to improve treatment outcomes in these difficult cases, the use of stent‐assisted embolization has been attempted in endovascular treatment of intracranial aneurysms. In order to avoid thromboembolic complications in these cases, patients require treatment with antiplatelet therapy. Previous studies have shown that antiplatelet therapy poses an increased risk of hemorrhagic complications; this risk might be further heightened in the setting of acute subarachnoid hemorrhage (SAH), as these patients can develop an abnormal coagulation status. The purpose of this study was to retrospectively analyze the results and complications associated with stent‐assisted embolization of intracranial aneurysms in the acute treatment of subarachnoid hemorrhage at Dell Seton Medical Center. Methods Data from patients with acutely‐ruptured intracranial aneurysm treated with stent‐assisted embolization at Dell Seton Medical Center in the period between 2021 and 2022 were retrospectively assessed, with the focus of addressing aneurysm occlusion, clinical outcomes and complications. Results Fifteen patients with ruptured intracranial aneurysms were included in the analysis. Post‐procedural re‐rupture and hemorrhagic complications were observed in three patients, leading to death in two patients. Thromboembolic complications were observed in one patient, with the clinical outcome of death due to basilar stent thrombosis. Immediate complete occlusion and occlusion with residual neck was achieved in 66.7% of cases. Conclusion In the case of ruptured intracranial aneurysms with large and complex morphology and a wide neck, the use of stent‐assisted repair may be necessary compared to simpler and smaller aneurysms that can be treated with coils alone. The use of stent‐assisted repair in acutely‐ruptured aneurysms in this series of cases demonstrated rapid and good aneurysmal occlusion. The post‐procedural complication rate proved to be higher than in non‐ruptured stent‐assisted coiling. However, the overall resulting morbidity and mortality rates in this cohort of patients is lower than could have been expected; furthermore, the complication rates found in this study are in line with those reported in similar studies. In most cases in the emergency setting, it is not possible to appropriately prepare a patient with antiplatelet therapy pre‐procedurally. As a result, the proper antiplatelet medication regimen and its appropriate timing continue to remain a significant topic of investigation. In addition, there continues to be further investigation into the optimal timing of intervention to minimize risk of peri‐procedural and post‐procedural complications. Further retrospective analysis of patient data over multiple years and across multiple centers is needed to better assess outcomes and complications of stent‐assisted aneurysm repair in acute subarachnoid hemorrhage.

Abstract 250: Radial vs femoral access for neuroendovascular diagnostic and therapeutic procedures. A systematic review and Meta‐analysis

Introduction Transradial access (TRA) has become increasingly utilized among neurointerventionalists. There is evidence of reduced complications and higher patient satisfaction compared to transfemoral access (TFA), but more data directly comparing the safety and efficacy of the two approaches is needed. To assess the proportion of technical success and complications with TRA versus TFA in patients who underwent neuroendovascular diagnostic and therapeutic procedures. Methods PRISMA guidelines were used to conduct a systematic review of the literature with PubMed/Medline, Scopus, Embase, and Cochrane databases up to February 2023. Randomized clinical trials (RCT) and observational studies that compared TRA and TFA were included. Studies reporting results of patients who underwent diagnostic angiograms, endovascular management of acute stroke, aneurysm repair, and carotid or vertebral stenting were included. Our primary outcome was technical success, defined as successful arterial access and completion of the intended procedure without crossover. Secondary safety outcomes were rate of complications including access site and non‐access site related, and other efficacy measures such as procedure duration, fluoroscopy time, and radiation exposure. Random effects model was used to perform a meta‐analysis. The Mantel‐Haenszel method was used to calculate risk ratio (RR) and 95% confidence intervals (CI) for each outcome. Heterogeneity was evaluated using I2 and considered high if over 70%. Results Twenty‐nine studies comprising 14,523 patients met inclusion criteria. TRA was attempted in 5,865 (40.38%) patients and TFA in 8,658 (59.62%). Baseline characteristics were similar between groups. The rate of technical success was 95.46% (95% CI: 93.59 – 96.81; p &lt; 0.01) in the TRA group compared with 98.43% (95% CI: 97.60 – 98.97; p = 0.02) in the TFA group. Patients who underwent a diagnostic or therapeutic angiogram via TRA had a slightly lower chance of achieving technical success (RR = 0.98; 95% CI: 0.96 – 0.99; p &lt; 0.01) compared to TFA, with substantial heterogeneity (I2 = 68%). Major access site complications were non‐significantly lower in the TRA group (RR = 0.64; 95% CI: 0.29 – 1.41; p = 0.81) with null heterogenicity (I2 = 0%) between groups. Minor access site complications were significantly lower in the TRA group (RR = 0.43; 95% CI 0.28 – 0.67; p &lt; 0.01), with moderate heterogeneity (I2 = 57%). Non‐access site related complications (including mortality) were lower in the TRA group (RR = 0.69; 95% CI 0.51 – 0.94; p = 0.14) with low heterogeneity (I2 = 26%) between groups; for this outcome, the TRA approach shows a protective but not statistically significant result. Conclusion Our study suggests TRA is feasible and safe for diagnostic and therapeutic neuroendovascular procedures with low certainty of evidence. Minor complications were lower in the TRA group. RCTs directly comparing TRA vs TFA for these procedures are needed to confirm these results.

Endovascular Management for an Aberrant Right Subclavian Aneurysm

Introduction: Aberrant right subclavian artery (ARSA) aneurysm repair is usually performed surgically. Case Presentation: We report the case of an endovascular exclusion of ARSA aneurysm using a degressive covered endograft via axillary access. This technique can avoid classical complications of an open surgical repair and the complexity of hybrid techniques, especially in patients of advanced age with multiple comorbidities.

Two Methods, One Story? Comparing Results of a Choice Experiment and Multidimensional Thresholding From a Clinician Preference Study in Aneurysmal Subarachnoid Hemorrhage

ObjectivesAn increasing number of methods are used to elicit health preference information. It is unclear whether different elicitation methods produce similar results and policy advice. Here, we compared the results from a discrete choice experiment (DCE) and multidimensional thresholding (MDT) that were conducted in the same sample. MethodsClinicians (N = 350) completed a DCE and MDT to elicit their preferences for 4 attributes related to the medical management of subarachnoid hemorrhage after aneurysm repair. Preference weights were compared between the DCE and MDT using a complete combinatorial convolution test. Additionally, data from the DCE and MDT were used to compute preference-based net treatment values for 16 hypothetical treatment profiles versus 1000 simulated comparators. The implied treatment recommendations were compared between the DCE and MDT. ResultsPreference weight distributions and median weights did not differ significantly between the DCE and MDT for any attribute: likelihood of delayed cerebral ischemia (medians 0.48 vs 0.40; P = .41), risk of lung complications (medians 0.27 vs 0.30; P = .52), risk of hypotension (medians 0.10 vs 0.11; P = .55), and risk of anemia (medians 0.07 vs 0.07; P = .50). The DCE and MDT produced similar treatment net value distributions (P > .05) and implied the same treatment recommendations in 82.3% of cases. ConclusionsThe DCE and MDT elicited similar preference distributions and produced the same treatment recommendations for most tested cases. However, the share of people supporting the average treatment recommendation differed. More research is needed to determine how these findings would compare with those in other populations (in particular, patients) and applications.

Changes in Surgical Volume in Military Medical Treatment Facilities and Military Surgeon Clinical Combat Readiness During the COVID-19 Pandemic.

Mini-abstract In this retrospective study, we evaluated changes in measures of surgeon clinical combat readiness within the military health system during the COVID-19 pandemic. We found a 36% reduction in surgical knowledge and skills as compared to pre-COVID. Sizable reductions were encountered for surgery for colectomy (-50%) and aneurysm repair (-61%).

Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage.

Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO2), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.

Analysis of Repair Type and Hypogastric Artery Antegrade Perfusion and Erectile Function following Repair of Abdominal Aortic Aneurysms

Published reports suggest that exclusion of antegrade hypogastric artery flow may have deleterious effects on erectile function after abdominal aortic aneurysm (AAA) repair. Off-label and open surgical hybrid procedures and, more recently, purpose-built branched devices have been developed to maintain antegrade pelvic perfusion in patients undergoing endovascular repair. Maintaining antegrade perfusion may reduce a spectrum of risks, including buttock claudication, colorectal ischemia, and spinal cord ischemia when patients undergo subsequent thoracic aortic procedures, as well as erectile dysfunction (ED). This project specifically focuses on erectile function, and analyzes baseline associations and relationships of hypogastric artery exclusion on changes in erectile function following aneurysm repair. Male patients in the Veterans Affairs Open Versus Endovascular Repair (CSP#498; OVER) Trial had erectile function assessed preoperatively and postoperatively by administration of the International Index of Erectile Function-5 questionnaire. Bayesian mixed-effects regression models were created with the outcome variable (erectile function) treated as a latent variable. Primary effects of differences in erectile function between groups with and without preservation of bilateral antegrade hypogastric flow were compared. 876 men (442 randomized to endovascular repair) were enrolled in the trial and included in the analysis comparing treatment assignment. There is significant ED in elderly men with aortic aneurysm at baseline. Over 5years of follow-up, there is modest decrease in erectile function and the endovascular group has improved function compared to open repair (0.082; 95% credible interval (CI) 0.008 and 0.155). A fifth of patients did not have bilateral preservation of antegrade hypogastric artery perfusion, with no difference in erectile function by univariate analysis. A more detailed regression analysis was applied--and after adjustment for baseline score, age, beta blocker use, diabetes, activity level, ejection fraction, preoperative ankle-brachial indices and time--preservation of both antegrade hypogastric arteries' perfusion showed transient improvement in survey scores compared to occlusion of at least 1 hypogastric artery at 6months and 12months after treatment, although this was not sustained at 60months (score change: 0.046; 95% CI: -0.123, 0.215). Retesting this model in the cohort with complete data as a sensitivity analysis did not meaningfully change the conclusions. In this large prospective aneurysm treatment trial with systematic measurement of erectile function with a validated instrument, endovascular repair is associated with improved erectile function. Preservation of antegrade hypogastric flow with any repair is associated with early improved erectile function; however, it is not a sustained benefit. There is limited benefit of maintaining bilateral hypogastric artery perfusion for this specific indication in unselected men undergoing AAA repair.

A STUDY OF BRANCHING PATTERN OF EXTERNAL CAROTID ARTERY IN THE CAROTID TRIANGLE – A CADAVERIC STUDY

Background Carotid triangle is an important neurovascular area located in the anterior cervical region of the neck. Variations in the external carotid artery in carotid triangle may complicate surgeries like radical neck dissection, aneurysm repair in the carotid triangle To study the branching pattern and variations of external c Aim and Objective arotid artery in carotid triangle This study includes 30 formalin xed cadavers from the Department of Ana Method tomy, Sri lakshmi Narayana institute of medical sciences Puducherry . This study includes all the cadavers during routine anatomical dissection by the students. In this present study Results both sides of the neck regions , a total of 60 sides were dissected. External carotid artery branches in the carotid triangle were traced. In the study period we found 3% of superior thyroid artery arising from common carotid artery and common unilateral linguofacial trunk in 6% of cadavers. Other branches of external carotid artery in the carotid triangle were traced. Ca Discussion And Conclusion rotid triangle is a vascular area contains common carotid artery and its terminal branches, important area for auscultation and palpation of vessels. With in the carotid triangle common carotid artery divides into internal and external carotid arteries at the level of upper border of thyroid cartilage. External carotid artery gives eight branches with in this ve branches arises from carotid triangle. The study of branches of external carotid artery in the carotid triangle was paramount important to avoid iatrogenic injury during neck dissection.

A case report: A severe juxta-ductal coarctation of aorta with post coarctation aortic aneurysm

Objective: Coarctation of aorta with post coarctation aneurysm is a congenital malformation of the aorta which usually occurs in undiagnosed and long standing coarctation and present in third to fifth decade of life. In this case, we present technique of differential hypothermia used to repair coarctation and post coarctation aneurysm: meticulous repair of coarctation segment and aneurysm without compromising blood flow to the vital organs distal to the coarctation segment. Case report: A 44-year old male patient with severe juxtaductal coarctation of aorta with post coarctation aortic aneurysm who was relatively asymptomatic until he presented with hypertension since 6 months in his fifth decade of life was admitted to our hospital. The patient was managed with surgery of coarctation of aorta and aneurysm repair using dual arterial cannulation and maintaining selective antegrade cerebral perfusion. Conclusion: Differential hypothermia allows meticulous repair of coarctation segment and post coarctation aneurysm without compromising blood flow to vital organs and and better neurological recovery. Key words: Aortic coarctation, aortic surgery, post coarctation aneurysm, ventral repair

Clinicians' preferences for managing aneurysmal subarachnoid hemorrhage using endothelin receptor antagonists.

The endothelin receptor antagonist (ERA) clazosentan is being investigated for the medical prevention of cerebral vasospasm and associated complications, such as delayed cerebral ischemia (DCI), after aneurysmal subarachnoid hemorrhage (aSAH). This study quantified how clinicians weigh the benefits and risks of ERAs for DCI prevention to better understand their treatment needs and expectations. An online choice experiment was conducted to elicit preferences of neurologists, intensivists, and neurosurgeons treating aSAH in the US and UK for the use of ERAs. The design of the choice experiment was informed by a feasibility assessment (N = 100), one-on-one interviews with clinicians (N = 10), a qualitative pilot (N = 13), and a quantitative pilot (N = 50). Selected treatment attributes included in the choice experiment were: one benefit (likelihood of DCI); and three risks (lung complications, hypotension, and anemia). In the choice experiment, clinicians repeatedly chose best and worst treatment options based on a scenario of a patient being treated in the ICU after aneurism repair. A correlated mixed logit model determined the relative attribute importance (RAI) and associated highest density interval (HDI) as well as acceptable benefit-risk trade-offs. The final choice experiment was completed by 350 clinicians (116 neurologists, 129 intensivists/intensive care clinicians, and 105 neurosurgeons; mean age, 47.4 years). Reducing the likelihood of DCI (RAI = 56.5% [HDI, 53.6-59.5%]) had the largest impact on clinicians' treatment choices, followed by avoiding the risks of lung complications (RAI = 29.6% [HDI, 27.1-32.3%]), hypotension (RAI = 9.2% [HDI, 7.5-10.8%]), and anemia (RAI = 4.7% [HDI, 3.7-5.8%]). Clinicians expected the likelihood of DCI to decrease by ≥8.1% for a 20% increase in the risk of lung complications, ≥2.4% for a 20% increase in the risk of hypotension, and ≥1.2% for a 20% increase in the risk of anemia. Clinicians were willing to accept certain increased risks of adverse events for a reduced risk of DCI after aSAH. The likelihood of DCI occurring after aSAH can therefore be considered a clinically relevant endpoint in aSAH treatment development. Thus, evaluations of ERAs might focus on whether improvements (i.e., reductions) in the likelihood of DCI justify the risks of adverse events.

Abstract Number ‐ 132: Stent‐assisted repair of the intracranial aneurysms with loading dose of antiplanets and perioperative events.

Introduction Introduction: Thromboemboembolic event (TEE) remains the mail perioperative challenge in addition to the potential intracranial hemorrhage (IH) in stent‐assisted repair of intracranial aneurysms (IA), and there are no standard antiplatelet strategies. Bases on the data, antiplatelets effects are more pronounce in first 4 hours after administration of antiplatelets. Objectives: To evaluate the effect of acute loading doses of aspirin and clopidogrel (LDAC) in TEE and hemorrhagic events associate with stent‐assisted repair of intracranial aneurysm. Additionally, to review the outcome of those patient who underwent stent‐assisted coiling using LDAC. Methods Consecutive patients underwent stent‐assisted repair of aneurysm using loading doses of aspirin 324 mg (4 baby aspirin) and clopidogrel 300 mg 2 to 4 hours before the procedure were enrolled from 2011 to 2022. Patients demographics including intra‐operative and post operative events were recorded. Outcome was measured using modified Rankin Scale (mRS) score. Results 96 patients (6 had baseline mRS 2) with mean age of 53 ± 13 underwent 98 stent‐assisted procedures including two Y‐stent neck reconstructions to treat 98 (6 ruptured and 41 symptomatic aneurysms) IA. Aneurysms are Right internal carotid artery (ICA) 25, left ICA 30, middle cerebral artery (MCA) 22, basilar artery 17 and anterior communicating artery 2.Stent deployment was achieved in all cases. Coil prolapsed and stretching occurred in one right ICA case, required deployment of additional 3 intracranial stents and one carotid artery stent with no clinical events. There was no intra‐operative rupture or IH. A small perioperative left hemispheric subarachnoid hemorrhage was observed on a right MCA aneurysm on day 3 after discharged, which resolved spontaneously without stopping antiplatelet. Intra‐operative stent thrombosis developed in one who had two aneurysms in right ICA with significant cerebrovascular risk factors; resolved with intraarterial integrilin followed by intravenous for infusion with no clinical consequences immediately and 12 months follow‐up; was resistant to clopidrogel and placed on ticagrelor.Post‐operative TEE were observed in 2 cases (2%); first event was observed on day 2 in a 42 years old woman with a giant right ICA giant aneurysm with NIHSS 6 and who recovered completely (NIHSS 0, mRS 1) in 90 days. The second event was visual distortion and diplopia (NIHSS 0) developed on day 2 in a 66 years old woman with basilar artery aneurysm. Her symptoms resolved completely and return to nursing job. All ruptured and symptomatic aneurysms were secure immediately and there are no subarachnoid hemorrhages during follow‐up. TEE was associated withperiorerative smoking. Immediate complete and near complete obliteration of aneurysm was observed in 66% and subtotal in 34%. There was no mortality or permanent disability in our series. 90 days mRankins 0 and 1 was observed in 96% and mRS 2 in 7% (baseline mRS) Conclusions Our study revealed that LDAC in stent‐assisted repair of IA is associated with a low TEE without added risk of IH with clinical good outcome. Our antiplatelets loading regimen may be an option in stent‐assisted repair of IA, especially when patients are unreliable and aneurysms are symptomatic. Further studies are required.

Acceptable Intra-aortic Balloon Occlusion Duration Affecting the Regional Saturation Oxygen of Lower Limbs Using Near-infrared Spectroscopy for Abnormally Adherent Placentation

Objective: To investigate the utility of regional saturation oxygen (rSO2) using near-infrared spectroscopy (NIRS) in the lower limbs and to estimate the safe occlusion duration in patients with abnormally adherent placentation who underwent intra-aortic balloon occlusion (IABO) during a cesarean hysterectomy by comparing them with infrarenal aortic clamping. Methods: The researchers classified 15 lower limbs of patients with abnormally adherent placentation with IABO during a cesarean hysterectomy as the balloon group and 20 lower limbs of patients with cross-clamping on the infrarenal aorta during the aneurysmal repair as the clamping group. The rSO2 measurement of the limbs was performed using a near-infrared spectrometer. In addition, the aortic occlusion duration, rSO2 before and during occlusion, and after blood resumption were analyzed. Results: Continuous rSO2 measurement was possible in all patients. The median aortic occlusion durations in the balloon and clamping groups were 68 and 92.5 min, and the median minimum rSO2 during occlusion was 60% and 17.5%, respectively. The clamping group was found to have stronger occlusion for a longer time than the balloon group. No complications associated with aortic occlusion were observed in both groups. Conclusions: rSO2 measurement using a near-infrared spectrometer effectively monitors lower-limb blood flow during IABO in patients with abnormally adherent placentation. An IABO duration of approximately 90 min was believed to be relatively acceptable in a cesarean hysterectomy under heparin administration.

Impact of Bifidobacterium adolescentis in patients with abdominal aortic aneurysm: a cross-sectional study.

The relationships between various diseases and the human gut microbiota (GM) have been revealed. However, the relationships between the human abdominal aortic aneurysm (AAA) and GM remains unknown. The aim of this cross-sectional study was to clarify the association between the human AAA and GM. Stool samples from 30 consecutive patients with AAA before aneurysm repair and those of 30 controls without vascular diseases were analyzed by 16S rRNA gene (V3-4) sequencing using an Illumina MiSeq system and QIIME 2. There was no significant difference in age (75 vs. 75 years) or gender (80% vs. 87% males) between the groups. No significant difference in GM composition was observed in principal coordinate analysis between the two groups, whereas the AAA group showed a significantly lower abundance of Bifidobacterium adolescentis (p<0.01) at the species level than the controls. This study demonstrated that the abundance of B. adolescentis decreased in patients with AAA. This is the first study to show the characteristics of the GM in patients with AAA. Studies are needed to reveal if causal relationships exists between the human AAA and GM.