Resection Of Aneurysm Research Articles

Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity

The aim. To analyze the effectiveness of the developed algorithms for the perioperative management of high-risk cardiac surgery patients with coronary artery disease (CAD) and polymorbidity.
 Materials and methods. We analyzed perioperative management of 354 high-risk cardiac surgery patients with CAD with EuroSCORE II predicted mortality >5%, among which 194 (54.8%) underwent isolated coronary artery bypass grafting, and 160 (45.2%) had surgical myocardial revascularization with accompanying valvular pathology correction or left ventricular postinfarction aneurysm resection. All the patients were discharged after cardiac surgery performed at the Department of Surgical Treatment of CAD of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 2009 to 2019. As part of the study, general clinical examinations, electrocardiography, echocardiography, coronary angiography, cardiosurgical treatment were provided, and perioperative patient management protocols were developed and implemented.
 Results. Based on the conducted detailed analysis, it was established that the success of surgical revascularization of the myocardium depends not only on cardiac factors, but also on the compensation of concomitant diseases, the work of an experienced cardiac team consisting of a cardiologist, an interventionist, an anesthesiologist, a cardiac surgeon, and an intensivist. Treatment and prevention measures should be personalized and aimed at timely response to changes in laboratory and hemodynamic indicators of patients at all stages of their management, as well as stabilization of concomitant diseases. An important point in the preoperative preparation of cardiac surgery patients is verification of concomitant diseases with the aim of their timely compensation. The implemented algorithm for searching for comorbid conditions made it possible to improve the diagnosis of initial disorders of glucose metabolism, abnormal uric acid levels and cerebrovascular disease. Lowering the glucose level according to the developed algorithm of management of patients with impaired glucose metabolism in the perioperative period made it possible to reduce the number of postoperative wound infections by 3.4% and arrhythmological complications by 19.4%. Correction of drug therapy taking into account the glomerular filtration rate made it possible to avoid postoperative hemodialysis. Preventive prescription of therapeutic doses of proton pump inhibitors against the background of dual antiplatelet therapy, according to the developed protocol, led to a decrease in postoperative gastroduodenal complications from 5.1% to 0.3%.
 Conclusions. Implementation of the system of personalized treatment and preventive management of patients in the perioperative period made it possible to reduce postoperative complications from 16.7% to 4% (p=0.0190).

A Step-by-Step Dissection of Cerebral Pathologies for Neurosurgical Trainees: The Middle Cerebral Artery Bifurcation Aneurysm.

Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases. After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees. Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed. Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold.

25, 50 and 75 years ago.

25, 50 and 75 years ago.

Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella.

Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms. The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed. Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms. Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Reconstruction of both M2 blood flow with a "Y" fashion anastomosis after excision of a large M1 bifurcation aneurysm: advantages and challenges.

Middle cerebral artery (MCA) M1 aneurysms with M2 branches originating from the aneurysm neck are difficult to treat because of blood flow reconstruction method selection, graft blood volume matching and various anastomoses. We report a case of MCA M1 bifurcation aneurysm resection and reconstruction of the bifurcation using "Y" fashion anastomosis. Intraoperative DSA showed anastomotic stoma patency. This patient suffered transient left temporal ischemia and recovered well with a modified Rankin scale of 0 at discharge. This case demonstrates the application of "Y" fashion anastomosis after the excision of a large M1 bifurcation aneurysm. This bifurcation reconstruction method showed advantages and challenges in specific situations.

ENDOSCOPIC AND PERCUTANEOUS MANAGEMENT OF AN IATROGENIC DISTAL PANCREATIC FISTULA DURING VASCULAR SURGERY

Abstract Introduction Traumatic pancreatic fistulas are, normally, secondary to a partial or complete rupture of the pancreatic duct. Pancreatic surgery is associated with high morbidity and mortality, thus a step-up approach, with priorization of a conservative or endoscopic management, is useful in selected cases. Clinical case A 74-year-old man underwent resection of a thoraco-abdominal aneurysm with placement of a vascular graft and reimplantation of visceral arteries. In the immediate postoperative period, he presented with febrile syndrome and abdominal pain. Abdominal CT was performed, observing a retroperitoneal collection of 7cm. Ultrasound-guided percutaneous drainage of the collection was performed. Amylase levels in the drainage were analyzed, which were compatible with a pancreatic fistula. Pancreatomagnetic resonance imaging confirmed partial disruption of the pancreatic duct. In successive radiological studies, the persistence of the collection was observed, and the removal of the drain was prevented. ERCP was performed with insertion of a pancreatic stent (photo 1) and papillotomy with good clinical evolution. In subsequent ambulatory CT, the progressive decrease of the retroperitoneal collection was evident. The percutaneous drainage was removed. After 3 months, the pancreatic stent was removed. Discussion Diagnosis of iatrogenic traumatic pancreatic injury is difficult and requires a high degree of caution. Pancreatoresonance is the gold-standard for imaging. The transpapillary placement of pancreatic stents, in selected patients, has a high success rate.

Post-Operative Ischemia and Surgical Technique Affect Late Mortality of Femoral Artery Pseudoaneurysms Following Injection Drug Use

Surgical management of infected common femoral artery (CFA)1 pseudoaneurysms arising from intravenous drug use (IVDU)2 is clinically challenging with excellent perioperative outcomes reported for a number of techniques. Long-term outcomes after arterial ligation versus revascularization are not known. We report both short- and long-term comparison of lower extremity perfusion and outcomes for 25 patients that underwent simple or more extensive ligation, or revascularization treatment. A retrospective analysis of 25 consecutive patients presenting primarily with infected CFA pseudoaneurysms related to IVDU at one referral institution was performed to determine short- and long-term outcomes at time of discharge, 30-days, and 1-year, including intraoperative differences, post-operative and follow-up ankle brachial index (ABI)3, bacteriology, and post-operative mortality. In addition to a direct comparison between the revascularization patients (n=12) and simple ligation patients (n=13), a comparison within the simple ligation group was performed between those who underwent a ligation of the common femoral artery with preservation of the femoral bifurcation (double ligation) and those who underwent ligation of the common femoral, superficial femoral and profunda femoral artery individually, (triple ligation) RESULTS: All techniques resulted in similar mortality at 30 days. Lower extremity perfusion at discharge was highest in the revascularization group, and lowest in the triple ligation patients. One year mortality was significantly higher in the triple ligation cohort. This is the first report of long-term outcomes after surgery for infected CFA pseudoaneurysms, and demonstrates increased late mortality in patients treated with extensive (triple) ligation with persistent ischemia. We conclude that revascularization after resection of infected CFA aneurysms, or surgical techniques that preserve or recreate the femoral artery bifurcation cause less ischemia and late mortality in these challenging patients.

Features of Surgical Treatment of Patients with Splenic Artery Aneurysms (Case Report and Literature Review)

Despite the insigniϐicant prevalence, aneurysms of the splenicartery take a dominant share among all visceral aneurysms with a predominance of morbidity in women of childbearing age. Taking into account the mostly asymptomatic course and the high risk of mortality due to its rupture, timely diagnosis and correct treatment strategy remain extremely important. Questions regarding the choice of surgical treatment tactics for patients with this pathology remain debatable.
 The aim. Demonstration of a clinical case, improvement of diagnosis andsurgical treatment of patients with splenic artery aneurysms.
 Clinical case. Female patient G., 32 years old, with complaints of periodic pain in the left hypochondrium, signs of portal hypertension against the background of cavernous transformationof the portal vein, history of recurrent bleeding from the esophageal veins, hypersplenism admitted with a pre-diagnosed aneurysm of the splenic artery of giant dimensions (diameter 8x5 cm). The patient was qualified for open surgery and aneurysm resection with splenectomy and spleen autotransplantation by N. Roth. The postoperative period was complicated by the occurrence of reactive pancreatitis on day 7, which was successfully treated conservatively. In the future, the course was unremarkable. The remote follow-up lasted two years, and no recurrence of the aneurysm was detected. The performed immunogram showed normal results.
 Conclusion. The timely diagnosis makes it possible to establish the correct diagnosis, justify the treatment tactics and prevent fatal complications. Open surgical intervention in somecases remains the method of choice in the treatment of this pathology. Autotransplantation of the spleen has shown good long-term results and can be performed in patients of this category for the prevention of immunodeficiency states.

Hemothorax Due to Aneurysm of the Left Pulmonary Vein in a Pregnant Patient. Case Report

Pulmonary venous aneurysm often presents as a mediastinal mass, in most cases patients are asymptomatic and surgical treatment is not required unless there are complications. We present the case of a 34-year-old woman, with a normal evolutionary pregnancy of 36 weeks of gestation, with dyspnea on small to medium efforts, to which was added pleuritic pain in the left hemithorax, evidence of left pleural effusion greater than 80%, with drainage of 700 ml of hematic fluid. The gynecology and obstetrics service identified anhydramnios, deciding to terminate the pregnancy through the abdomen. A simple and contrast- enhanced chest tomography was performed, as well as papanicolaou staining of pleural fluid with a negative report for malignancy. The angiotomography reported an aneurysm of the left lobar vein with a fistulous tract, so cardiothoracic surgery performed resection of the saccular aneurysm by thoracotomy without complications. Pulmonary vein aneurysms are such rare lesions that there are no data in the literature to predict their natural history or pathogenesis. During pregnancy, cardiovascular causes of mortality predominate; on this spectrum, hemothorax could be a true surgical emergency.

RELATO DE CASO DE INFARTO AGUDO DO MIOCÁRDIO DE PAREDE INFERIOR DECORRENTE DE COMPRESSÃO DE TERÇO MÉDIO DA CORONÁRIA DIREITA POR ANEURISMA GIGANTE DE PORÇÃO PROXIMAL DA CORONÁRIA DIREITA

Giant coronary aneurysms are defined as dilatation greater than 4.0 cm in diameter, or 4 times the normal diameter of the coronary artery. It is a rare pathology in the general popula-tion and most commonly affects the right coronary artery. The most common etiology of this aneurysm subtype is atherosclerosis. The clinical presentation varies, from asymptomatic to acute myocardial infarction with ST-segment elevation. The present case report describes a patient with acute myocardial infarction that underwent coronary cineangiography, which revealed a giant coronary aneurysm in the right coronary ostium, between the aorta and the superior vena cava, measuring 55 mm in diameter. It was compressing the middle portion of the coronary artery. Subsequently, resection of the coronary aneurysm, correction of the aortic defect resulting from the resection, and right coronary artery bypass graft surgery, using an aortovenous graft, were prescribed.

Fourteen-Year Patency of an Anterior Tibial Artery-Saphenous Vein Fistula in an Ambulatory Patient

Ankle arteriovenous fistulas are the rarest vascular access type among lower extremity fistulas for hemodialysis patients with end-stage renal disease. Here, we present a case of a tibial-saphenous fistula that remained open for a long time despite a recurrent anastomotic aneurysm. Case Presentation. A 43-year-old female patient who had been undergoing hemodialysis via a right femoral tunnel catheter for six months was referred for recurrent catheter infection and a 4 cm pulsatile mass in the anterior aspect of the ankle. While she had been undergoing hemodialysis through a right tibial-saphenous fistula for fourteen years, hemodialysis continued after the fistula's closure due to total occlusion of the great saphenous vein through the tunneled catheter. After balloon angioplasty to the right subclavian vein, we performed right upper extremity basilic vein transposition. Later, after starting adequate dialysis from the basilic vein fistula and removing the femoral catheter, we performed a resection of the anastomotic aneurysm in the right ankle and repaired the anterior tibial artery. Because this is the only ambulatory patient and the one with the longest patency of ankle arteriovenous fistulas in the literature and the only case in which the anterior tibial artery was used, the case is presented and discussed in light of the literature. Despite many complications and low patency rates reported in the literature, ankle vessels should be considered for autogenous vascular access in selected patients.

Large Carotid Aneurysm: An Illustrative Case of Open Surgical Repair

Abstract Background Extracranial carotid artery aneurysms are rare and are often localized at the level of the carotid bulb or in the distal internal carotid artery. Generally asymptomatic until an embolic event or a local compression reveals their presence, the rupture is rare. Case Report We presented a case of a 68-year-old female referred to our hospital for a pulsatile mass on the right side of her neck with no other symptoms. The patient had a history of hypertension that was medically controlled. The duplex ultrasound confirmed the presence of a large internal carotid aneurysm. Angiotomography shows a large 5 cm diameter type 1 aneurysm of the right internal carotid artery and a type 1 2.7 cm diameter of the left carotid artery. Open surgery with aneurysmal resection and direct end-to-end anastomosis was performed with an uneventful course. Conclusion This is an illustrative case of managing large carotid aneurysms by open surgery.

Unusual presentation of aneurysmal bone cyst with scoliosis: a case report

BackgroundAneurysmal bone cysts are benign bone tumors that not uncommonly involves the spine. However, this involvement can cause scoliosis, albeit rarely. This report focuses on the importance of proper management for complete tumor resection to prevent recurrence and spinal deformity.Case presentationA 12-year-old Middle Eastern boy, with a history of T11 aneurysmal bone cyst resection and bone grafting carried out at another hospital, presented with spine deformity of 4 months’ duration. The deformity was not associated with pain or neurological deficit. A whole-spine magnetic resonance imaging with contrast confirmed the recurrence of the aneurysmal bone cyst. Posterior spinal instrumentation with corpectomy of T11 was then performed, and confirmed with histopathology the recurrence of aneurysmal bone cyst. Two years post-corpectomy, deformity correction was done from T5–L4.ConclusionManagement of aneurysmal bone cysts requires meticulous planning and full excision to prevent recurrence, especially in the growing spine. If neglected, it can cause major spinal deformities and cord compression, which places a medical burden on the patient and family. To avoid such complications, treating aneurysmal bone cysts along with scoliosis correction can prevent deformity progression.

Abstract 14581: Massive Sinus of Valsalva Aneurysm With Rupture Into the Right Atrium

Case Presentation: A 40-year-old male presented with decompensated heart failure and severe pulmonary hypertension (echo-predicted right ventricular systolic pressure 60 mmHg). Right heart catheterization revealed high output heart failure (cardiac index 7.3 L/min/m 2 ), left to right shunt (Qp:Qs 3.6:1), pulmonary hypertension (mean 38 mmHg), and normal pulmonary resistance (1.53 Wood units). Transesophageal echocardiogram revealed a large non-coronary sinus of Valsalva aneurysm with communication to the right atrium (Figure 1a and b). Percutaneous transcatheter closure of the aneurysm was deferred due to large size (3.3 x 4.3 cm), proximity to the right coronary artery, and risk of aneurysm rupture with catheter manipulation (Figure 1c). The patient underwent surgical aneurysm resection and aortic root replacement and recovered well. Discussion: Sinus of Valsalva aneurysms (SVAs) are rare pathologies characterized by expansion of the aortic root wall between the sinotubular junction and the aortic valve annulus and are often associated with connective tissue disorders. SVAs are often diagnosed incidentally on imaging but can present with symptoms if they rupture into nearby cardiac structures, such as an aorto-atrial fistula with left to right shunting, high output heart failure and hemodynamic compromise, as in this case. While transthoracic echocardiogram is the diagnostic modality of choice for most SVAs, multimodality imaging, catheterization, and advanced imaging may also be needed. Surgical repair remains the gold standard of therapy, however treatment with transcatheter device placement has also been successfully performed.

Two cases of left ventricular apical aneurysm associated with severe aortic stenosis: case report

BackgroundLeft ventricular (LV) apical aneurysm associated with aortic valve stenosis (AS) is very rare. We herein report two cases of this entity.Case presentationCase 1 was a 75-year-old woman admitted for surgery for severe AS and enlargement of the ascending aorta. Preoperative routine echocardiography and cardiac computed tomography (CT) revealed an unexpected local aneurysm of the LV apex. The patient underwent aortic valve replacement (AVR), LV aneurysm resection, and ascending aorta replacement. Case 2 was a 71-year-old woman diagnosed with severe AS. Preoperative cardiac CT detected LV apical aneurysm that could not be detected by echocardiography. Cardiac catheterization showed a coronary ventricular fistula. The patient underwent AVR and LV aneurysm resection. Given that neither of the two cases had a history of myocardial infarction or obstructive hypertrophic cardiomyopathy, the cause of the local aneurysm of the LV apex was thought to be relative ischemia at the apex due to myocardial hypertrophy and LV pressure overload due to long-term AS. In addition, a coronary artery fistula was suggested to be involved in the relative ischemia of the apex in Case 2.ConclusionsEchocardiography alone is not sufficient to exclude apical aneurysm, and cardiac CT may be useful. Regarding the surgical indication, it is necessary to consider further cases in the future.

Midterm Performance of the Autologous Adventitial Overlay Method in Aortic Surgery

BackgroundWe developed an adventitial overlay method for reinforcing aortic anastomoses. This study evaluated the midterm morphologic and clinical outcomes of this method. MethodsWe harvested and prepared adventitia from a resected aneurysm or dissected aortic wall and performed aortic repair using the adventitial overlay method. At the midterm follow-up, we examined the differences between overlay, inversion, and felt sandwich methods by evaluating the morphologic features of the anastomosis on computed tomography scans. Moreover, we performed macroscopic evaluation of 1 patient who required a second operation. ResultsBetween May 2009 and April 2020, 160 consecutive patients (104 men, 56 women; mean age, 68.6 ± 11 years; range, 39-88 years) underwent thoracic aortic surgery. The overlay technique was successfully performed in 84 cases. The anastomosis sites of the overlay method maintained their morphologic appearance without any clinical complications. The inner diameter ratio of anastomosis/graft was measured by computed tomography, which revealed that the overlay method was not significantly different from inversion and was significantly larger than the felt sandwich method. There was no anastomotic stenosis in the proximal or distal overlay anastomosis. Only 1 patient required a second operation for an enlarged aneurysm of the distal false lumen. We observed that the proximal overlaid adventitia was smoothly attached to the native lumen and was macroscopically indistinguishable from the original intima. ConclusionsThis study showed the midterm stability of the overlay technique. The midterm outcome was clinically acceptable. No anastomotic stenosis or pseudoaneurysm formation in either the true aortic aneurysm or dissection cases was observed.

Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters

Aneurysmal arteriovenous fistulas (AVF) can pose a difficult treatment dilemma for the vascular surgeons. Prolonged tunneled dialysis catheters (TDCs) in patients requiring long-term dialysis are associated with significantly increased mortality compared to AVF. We aimed to elucidate the outcomes of aneurysmal arteriovenous (AV) access revision with aneurysm resection and Artegraft® (LeMaitre, New Brunswick, NJ) Collage Vascular Graft placement to avoid prolonged use of TDCs. We reviewed all patients with aneurysmal AV access in whom the access was revised with aneurysm resection and jump graft placement at a single institution from 2018 to 2021. Outcomes were time to cannulation, reintervention rates, time to reintervention, and patency (primary, primary assisted, and secondary). Patency rates were estimated with Kaplan-Meier Survival analysis. A total of 51 revised aneurysmal AV accesses in 51 patients were studied, of which 23.5% (n=12) had perioperative TDC placement. Three patients were done for emergent bleeding. The cohort was 62.8% male (n=32) with a median age of 58years (interquartile range: 49-67). Most patients had brachiocephalic AVF (n=37 [72.6%]). The median follow-up time was 280days. The median time to cannulation was 2days. Time to cannulation was significantly longer in patients with perioperative TDC as compared with those without TDC (24days vs. 2days, P<0.001). Reintervention was required in 41.2% of patients (n=21), at median time of 47days. At 30, 90, 180, and 365days, primary patency rates were 84.3%, 78.3%, 66.6%, and 54.9%; primary assisted patency rates were 94.1%, 88.1%, 79.4%, and 79.4%; and secondary patency rates were 100%, 97.8%, 91.6%, and 91.6%, respectively. The revision of aneurysmal AV access (urgent or elective) with Artegraft as jump graft is safe, with acceptable short- and mid-term patency results. This allows dialysis patients to continue to have a functional access, decreasing the need for a tunneled catheter and reducing the associated risk of sepsis and increased mortality. This should be considered for all patients with aneurysmal, dysfunctional fistulas to maintain AV access and avoid TDC placement.

A CASE REPORT OF CONGENITAL GIANT LEFT ATRIAL APPENDAGE ANEURYSM WITH THROMBUS PRESENTING AS ATRIAL ARRHYTHMIA.

Congenital left atrial appendage aneurysm are a rare entities and are caused by congenital dysplasia of the atrial muscle. Less than 100 cases have been reported in literature so far. Patients usually present with dyspnoea ,palpitations ,thromboembolic phenomenon in their 3rd decade with slight higher preponderance in females.In asymptomatic individuals the condition is often diagnosed incidentally during cardiac imaging . We hereby report a case of 30 year old male with a giant LAAA containing thrombus presenting with palpitations diagnosed with echocardiography and cardiac MRI. The patient successfully underwent aneurysmal resection sugery, post which atrial arrhthias stopped and symptoms relieved. Therefore,even though rare,if a young patient presents with atrial tachyarrthymia with no other associated cardiac pathologies, a LAAA should be ruled out. Since this condition has been shown to be associated with increased morbidity and mortality. A transthoracic echocardiogram or even better,a TEE colour Doppler echocardiogram may suggest the diagnosis by demonstrating the exchange of blood between LA and LAAA. Surgical resection is the standard modalitiy of treatment even in asymptomatic individuals to reduce risk of associated complications. Learning objectives : It is a rare case of giant left atrial appendage aneurysm, few cases have been reported, LA appendage aneurysm usually present as atrial arrhythmias ,stroke or as incidental diagnosis on imaging.Though patients may be asymptomatic it still requires operative intervention since it has very high risk of atrial arrhythmias and thrombus formation which result into stroke.Therefore, if a young patient presents with atrial tachyarrthymia with no other cardiac pathologies, LAAA should be ruled out.

Resection of an internal carotid artery aneurysm with extreme cranial exposure maneuvers

A 63-year-old woman presented with an enlarging lump below the angle of her left mandible. Neck computed tomography angiography revealed a 5 × 3 cm left internal carotid artery (ICA) aneurysm, arising 3 cm cranial to the carotid bifurcation and extending to the top of the second cervical vertebral body (Supplementary Video 1, online only), and this was confirmed on cervical angiography (Supplementary Video 2, online only). Initially, two overlapping flow-diverting stents were deployed leading to stagnant flow within the aneurysm sac (Supplementary Video 2, online only).

Soleal Venous Aneurysm in a Patient With a History of Pulmonary Embolism

A lower extremity venous aneurysm is an uncommon disease process known to increase the risk for pulmonary embolism. While most are popliteal venous aneurysms, crural aneurysms are rarely documented. We present a rare case of a soleal venous aneurysm in a patient with a history of pulmonary embolism. A risk-reducing open aneurysm resection with lateral venorrhaphy was performed.