Small Pseudoaneurysms Research Articles

Delayed Presentation of Anterior Tibial Artery Pseudoaneurysm Causing Distal Ischemia – A Case Report with Review of Literature

A pseudoaneurysm is a rare complication involving the vasculature and may be limb threatening if not treated. Pseudoaneurysm typically occurs when there is a breach in the vessel wall such that the blood leaks through the inner wall but is contained by the adventitia or surrounding perivascular soft tissue. These may be caused due to trauma to the vessel (either due to fractures, bony fragments), following endovascular therapy, or infective etiology, or other causes. Tibial and pedal artery aneurysms occur in the setting of penetrating trauma, fractures, or iatrogenic injury during orthopaedic surgery or peripheral interventions. Those causing significant symptoms must be repaired with autologous vein bypass grafts if there is distal ischemia. If other tibial arteries are patent, a simple ligation will also suffice. Coil embolization and conservative management resulting in spontaneous thrombosis of small pseudoaneurysms, have also been reported. We report a case of a 51 year old male with right Anterior Tibial Artery pseudoaneurysm which had developed over several years after a trauma with the patient presenting to us only after he started having symptoms of distal ischemia.

S2601 Gastroepiploic Pseudoaneurysm: A Shocking Complication of PEG Tube Placement

Introduction: Percutaneous gastrostomy (PEG) tubes are commonly used for enteric feeds and medication administration. While considered safe and routine, PEG tube placement is not without its complications. Here we present a rare case of hemorrhagic shock secondary to traumatic pseudoaneurysm formation after PEG tube placement. Case Description/Methods: A 52-year-old male with atrial fibrillation on apixaban and a recent stroke with PEG tube placement 1 month prior to arrival presented to the hospital with multiple episodes of hematemesis. CT angiography of the abdomen was unremarkable and negative for signs of active bleeding. Antiplatelets were held and anticoagulation was reversed with prothrombin complex concentrate. Esophagogastroduodenoscopy showed signs of erosive esophagitis with proper PEG tube placement but without signs of active bleeding. Hematemesis re-occurred less than 24 hours after anticoagulation was resumed, with subsequent development of hemorrhagic shock. Visceral arteriogram revealed a right gastroepiploic artery pseudoaneurysm, which likely developed from trauma during recent PEG placement. The patient stabilized after coil embolization and blood transfusion. He was then safely resumed on anticoagulation without further bleeding. Discussion: GI bleeding associated with PEG placement occurs in 0.6-1.2% of cases, and usually occurs at the gastrostomy tract or from gastric ulceration. Bleeding related to pseudoaneurysm formation is exceedingly rare with only a handful of case reports documenting such occurrence. While contrast enhanced imaging may aid in the diagnosis, small pseudoaneurysms may not be detected with noninvasive angiographic studies (as was the case here). Given this potentially life-threatening complication, clinicians must consider pseudoaneurysm formation as part of their differential for GI bleed after recent PEG placement especially if endoscopic evaluation is unrevealing.

Radiological Spectrum of Pseudoaneurysms After Extracranial Internal Carotid Artery Dissection

Radiological Spectrum of Pseudoaneurysms After Extracranial Internal Carotid Artery Dissection

Enormous Articular Hemorrhage Following Arthroscopy, Total Joint Replacement and other Surgical Operations in Hemophilic Patients due to Arterial Pseudoaneurysms: Diagnosis and Treatment.

Pseudoaneurysms in hemophilic patients are unusual. We must have a suspicion when the patient has suffered an arterial trauma (following arthroscopy, total joint replacement and other surgical operations). Pseudoaneurysms may take place in any anatomical zone where there has been trauma. The diagnosis must be verified by duplex ultrasonography (US), standard angiogram, computed tomography angiogram or magnetic resonance angiography. There are diverse alternatives for the management of arterial pseudoaneurysms. Small pseudoaneurysms can be solved with conservative noninterventional management. It includes outside pressing, US probe pressing or US-guided thrombin injections. In larger pseudoaneurysms, endovascular methods, such as coil embolization, are now preferred. If the aforesaid methods are unsuccessful, standard surgical management with simple ligation or arterial reconstruction must be carried out. We must suspect a pseudoaneurysm when, following an arterial trauma, there is severe bleeding that does not stop with appropriate management with intravenous injection of the insufficient coagulation factor. The diagnosis has to be verified by imaging. Endovascular methods, such as coil embolization, are now preferred by the majority of physicians. The diagnosis and managment of an arterial pseudoaneurysm must be carried promptly to avert adverse events.

A dual-plane approach for surgical treatment of pseudoaneurysm with arteriovenous fistula in hemodialysis patients.

BackgroundWe report the efficacy of a dual-plane approach using a Dufourmentel skin flap with a purse-string suture of the de-epithelized dermis to manage pseudoaneurysm at the vascular access site for hemodialysis.MethodsA retrospective analysis was conducted of 61 patients from 2013 to 2018 with pseudoaneurysms at the arteriovenous fistula or graft who were treated with rhomboid excision, vessel repair with a purse-string suture, and a full-thickness Dufourmentel skin flap. The success rate was defined as the probability of complete wound closure and intact vascular access patency without infection or other complications.ResultsThe success rate was 93.4% at 6 months postoperatively. Complications included newly occurring pseudoaneurysms (n=2), wound dehiscence (n=1) and bleeding (n=1). There were no complications such as stenosis or thrombosis from the procedure.ConclusionsA dual-plane approach using a Dufourmentel skin flap with a purse-string suture for vessel repair was shown to be a favorable option for managing stable, small (diameter <2 cm) pseudoaneurysms without infection, rapid expansion, or patency issues of the vascular access.

Hemosuccus pancreaticus due to a small arterial pseudoaneurysm detected by CE-EUS and successfully treated with angiographic coiling (with video).

In hemosuccus pancreaticus,[1] potentially life-threatening bleeding into the pancreatic duct is usually caused by a large arterial pseudoaneurysm (average size of 52 mm) in chronic pancreatitis.[2] Bleeding from the papilla can be seen by endoscopy, and pseudoaneurysm can be detected by standard cross-sectional imaging. In this case report, a small pseudoaneurysm of the splenic artery with a fistula to the pancreatic duct could only be discovered by contrast-enhanced EUS (CE-EUS). A 54-year-old man with nonsteroidal anti-inflammatory drug intake and history of chronic alcohol pancreatitis was admitted for tarry stools. A cause for bleeding could not be identified by gastroscopy, ileocolonoscopy, abdominal ultrasound, and computed tomography [Figure 1]. However, the gastrointestinal bleeding continued. Small bowel video capsule endoscopy was performed and showed traces of blood in the duodenum. Repeated duodenoscopy presented a slight hemobilia from the papilla [Figure 2]. Therefore, hemosuccus pancreaticus was assumed, and CE-EUS indeed detected an arterial fistula to the pancreatic duct [Figure 3 and Video 1]. In the following, angiography showed a small pseudoaneurysm of the splenic artery [Figure 4], which was successfully treated by angiographic coiling [Figure 5] according to common guidelines.[3] Bleeding stopped after transfusion of summed up 9 units of blood. In some cases, EUS combined with Doppler ultrasound might be sufficient for the detection of the fistula[4] but failed in this patient. The useful application of CE-EUS in hemosuccus pancreaticus was previously shown in only one case report, in which the feeding vessel of a large pseudoaneurysm (42 mm) could not have been detected by angiography.[5] In conclusion, CE-EUS might be useful to detect hemosuccus pancreaticus due to small arterial pseudoaneurysms in patients with occult gastrointestinal bleeding.Figure 1: Computed tomography of the abdomen showing chronic pancreatitis with calcifications but cannot identify the source of gastrointestinal bleedingFigure 2: Slight hemobilia from the papilla is shown in repeated duodenoscopyFigure 3: Selected image from Video 1 showing the fistula from the arterial pseudoaneurysm to the pancreatic ductFigure 4: Selective angiography showing a small pseudoaneurysm (<20 mm) of the splenic artery. Fistula from the pseudoaneurysm to the pancreatic duct is not demonstratedFigure 5: Successfully treated pseudoaneurysm of the splenic artery by angiographic coiling. Direct application of the coils into the pseudoaneurysm had to be avoidedBRIEF DESCRIPTION CE-EUS was helpful to detect hemosuccus pancreaticus due to a small arterial pseudoaneurysm of the splenic artery in a patient with chronic pancreatitis and on-going occult gastrointestinal bleeding. Hemosuccus pancreaticus was successfully treated by angiographic coiling. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Empirical coil embolization of splenic artery as a salvage life saving procedure in post pancreatectomy hemorrhage and hemosuccus pancreaticus

Introduction: Computerised Tomography Angiogram (CTA) is the diagnostic modality in Post pancreatectomy Haemorrhage (PPH) and Hemosuccus Pancreaticus (HP). However, occasionally, the offending aneurysm or the source of bleed may not be evident by CTA or conventional angiography. Intraluminal bleeds, especially after Dunking Pancreaticojejunostomy, may be from small pseudoaneurysms in the territory of splenic artery or from cut end of pancreas that are difficult to pick up by CTA. We evaluated the efficacy of empirical segmental Coil embolisation of pancreatic segment of splenic artery in the setting of intraluminal PPH as well as HP following Acute /Chronic pancreatitis. Methods: A cross sectional study was done by analysing the prospectively held pancreatic database from January 2009-december 2018. All consecutive patients with PPH following any type of Pancreatectomy as well as Hemosuccus Pancreaticus (in Acute and chronic pancreatitis) who underwent empirical coil embolization of splenic artery were included. Those who showed blush on CTA or conventional angiography and those who were managed primarily with surgery for PPH were excluded. The rebleeding and mortality rates were assessed at 72-hour and 30-days respectively. Results: There were 137 Pancreaticoduodenectomies, 68 Distal Pancreatectomies, 11 median pancreatectomies and 134 admissions for Acute pancreatitis/ exacerbation of Chronic pancreatitis during the period. Overall, 6/7 (85.7%) with negative CTA had successful coil embolization. No re-intervention/ continued bleed/ splenic infarcts/ no requirement of transfusion or abscess were seen in any of these six patients. Conclusion: Empirical coil embolization of splenic artery in pancreatic bleed holds promise as a salvage life-saving procedure.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management.

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.

POCUS and POCDUS: essential tools for the evaluation and management of carotid artery pseudoaneurysms after a gunshot wound

BackgroundEvaluation of asymptomatic penetrating vascular injuries can be done with Point-of-care ultrasound (POCUS) and Point-of-care Doppler ultrasound (POCDUS).Case presentationA 21-year-old woman was admitted to the Emergency Department with a small wound and pain on the left side of her neck. The patient stated she was standing outside her home and suddenly felt acute pain in the neck. She denied trauma or being assaulted and reported no significant past medical or surgical history. On physical exam the only positive finding was a small gunshot entry wound on the left side of her neck without hard signs of vascular injury. Bedside POCUS demonstrated soft tissue swelling and a hematoma next to the left carotid artery. A round in shape bullet was visualized in contact with the posterior left common carotid artery wall and two small saccular pseudoaneurysms were seen at left common carotid artery wall. POCDUS showed a patent left carotid artery and turbulent flow in the two saccular aneurysms. A computed tomography angiogram (CTA) was performed confirming the findings and a stent in left carotid artery was placed. The patient tolerated the procedure well and was discharged 4 days after the procedure. At the sixth month follow-up, Doppler ultrasound showed patent stent and resolution of the muscular hematoma.ConclusionsPenetrating trauma-related vascular injuries are complex cases to handle within an acute setting. POCUS and POCDUS are increasingly being used for the workup and decision-making process of gunshot-related vascular injuries to the neck and are a fundamental part of the follow-up after definitive therapy.

Transforming Growth Factor-β1 Inhibits Pseudoaneurysm Formation After Aortic Patch Angioplasty.

Pseudoaneurysms remain a significant complication after vascular procedures. We hypothesized that TGF-β (transforming growth factor-β) signaling plays a mechanistic role in the development of pseudoaneurysms. Rat aortic pericardial patch angioplasty was associated with a high incidence (88%) of pseudoaneurysms at 30 days, with increased smad2 phosphorylation in small pseudoaneurysms but not in large pseudoaneurysms; TGF-β1 receptors were increased in small pseudoaneurysms and preserved in large pseudoaneurysms. Delivery of TGF-β1 via nanoparticles covalently bonded to the patch stimulated smad2 phosphorylation both in vitro and in vivo and significantly decreased pseudoaneurysm formation (6.7%). Inhibition of TGF-β1 signaling with SB431542 decreased smad2 phosphorylation both in vitro and in vivo and significantly induced pseudoaneurysm formation by day 7 (66.7%). Normal healing after aortic patch angioplasty is associated with increased TGF-β1 signaling, and recruitment of smad2 signaling may limit pseudoaneurysm formation; loss of TGF-β1 signaling is associated with the formation of large pseudoaneurysms. Enhancement of TGF-β1 signaling may be a potential mechanism to limit pseudoaneurysm formation after vascular intervention.

A Case of Conservative Treatment of Postsurgical Aortic False Aneurysm

&lt;p&gt;A 51-year-old male underwent replacement of the ascending aorta for acute type A dissection. The post-operative course was uncomplicated, and he was discharged home. Approximately a month later, control CT revealed an enlarging pseudoaneurysm of the proximal anastomosis. The patient was re-operated, and a Bentall operation with mechanical prosthesis was performed. Again, surgery was uncomplicated, but follow-up CT scan revealed a recurrent small pseudoaneurysm of the proximal suture line. He was managed with close observation, and control CT at four months showed complete resolution. Conservative treatment of small postsurgical pseudoaneurysms is discussed. &lt;/p&gt;

Radiologic Assessment of Native Renal Vasculature: A Multimodality Review.

A wide range of clinically important anatomic variants and pathologic conditions may affect the renal vasculature, and radiologists have a pivotal role in the diagnosis and management of these processes. Because many of these entities may not be suspected clinically, renal artery and vein assessment is an essential application of all imaging modalities. An understanding of the normal vascular anatomy is essential for recognizing clinically important anatomic variants. An understanding of the protocols used to optimize imaging modalities also is necessary. Renal artery stenosis is the most common cause of secondary hypertension and is diagnosed by using both direct ultrasonographic (US) findings at the site of stenosis and indirect US findings distal to the stenosis. Fibromuscular dysplasia, while not as common as atherosclerosis, remains an important cause of renal artery hypertension, especially among young female individuals. Fibromuscular dysplasia also predisposes individuals to renal artery aneurysms and dissection. Although most renal artery dissections are extensions of aortic dissections, on rare occasion they occur in isolation. Renal artery aneurysms often are not suspected clinically before imaging, but they can lead to catastrophic outcomes if they are overlooked. Unlike true aneurysms, pseudoaneurysms are typically iatrogenic or posttraumatic. However, multiple small pseudoaneurysms may be seen with underlying vasculitis. Arteriovenous fistulas also are commonly iatrogenic, whereas arteriovenous malformations are developmental (ie, congenital). Both of these conditions involve a prominent feeding artery and draining vein; however, arteriovenous malformations contain a nidus of tangled vessels. Nutcracker syndrome should be suspected when there is distention of the left renal vein with abrupt narrowing as it passes posterior to the superior mesenteric artery. Filling defects in a renal vein can be due to a bland or tumor thrombus. A tumor thrombus is most commonly an extension of renal cell carcinoma. When an enhancing mass is located predominantly within a renal vein, leiomyosarcoma of the renal vein should be suspected. ©RSNA, 2017.

Observation May Be Safe in Selected Cases of Blunt Traumatic Abdominal Aortic Injury

Blunt traumatic abdominal aortic injury (BTAAI) is a rare lesion, often associated with extensive intraperitoneal injuries. Optimal management remains unclear, including the role of prosthetic aortic graft replacement with concomitant bowel injury and the management of small pseudoaneurysms. We reviewed BTAAI cases occurring between 2000 and 2014. Thoracic and isolated iliac artery injuries were excluded. We included patient demographics, mechanism of injury, admission physiology, and reviewed available imaging to characterize aortic injury type and severity. BTAAI was noted in 16 of 8,751 (0.2%) blunt abdominal trauma patients admitted during the study period. Of these, 56% were males and the median age was 47 years (range, 5-80). Aortic repair was attempted in 7 patients, including 3 open prosthetic aortobi-iliac bypass grafts, 1 endovascular repair, and 2 primary repairs. One patient died before repair. The remaining patients were medically managed for their aortic injury, including 3 with pseudoaneurysm and 3 with large intimal flaps. There were 5 in-hospital deaths (31%) but only 1 attributed to aortic injury. Among patients surviving to discharge, there were no readmissions or delayed deaths. All nonoperative and surgically repaired patients seen in follow-up had stable aortic lesions. No patient with graft or endograft repair had evidence of graft infection on follow-up (median, 52 months; range, 21-121). BTAAI is a rare entity and is associated with high in-hospital mortality, primarily due to associated injuries. Observation of selected small pseudoaneurysms and intimal flaps appear safe. Survival after hospital discharge is excellent, and aortic-related complications are rare. The indications for repair and the role of revascularization with in situ prosthetic graft in the setting of concomitant bowel injuries are not well defined.

Abstract No. 356 - Vascular urologic emergencies: image-guided interventions

Modern imaging studies such as computerized topography (CT) and ultrasound (US) provide an advantage for the detection of vascular urological injuries because of their speed, while digital subtraction angiography (DSA) allows for the precision needed for effective intervention. Minimally invasive techniques offer potentially lower complication rates and faster recovery times than traditional methods. This study demonstrates the role of image-guided percutaneous angiography (PCA) in such emergencies through five cases that cover the scope of neoplastic, iatrogenic, post-operative, and traumatic hemorrhages as well as priapism. PCA has revolutionized vascular interventions. DSA provides both a detailed diagnosis and an avenue for precise interventions. Embolization of pathologic vessels or hemorrhage sites can be achieved using embospheres, microcoils or gel foam. These techniques are easily extrapolated in the context of vascular urologic emergencies. One such case was a 57 year-old woman with an acute hemorrhage following surgical resectioning for renal cellular carcinoma (RCC). The postoperative period was complicated by a difficult extubation followed by acute hemorrhagic shock. The patient’s hemoglobin dropped to 6.5 as her surgical drain emptied serosanguineous fluid. After requiring 6 units of PRBC, 4 units FFP and 1 unit of platelets, IR was consulted and emergent renal DSA was performed of the left main renal artery. Subselective left inferior renal segmental branch angiography showed two small pseudoaneurysms peripheral to the site of resectioning. Microcoil embolization of the left inferior segmental branch was performed, successfully occluding perfusion to the pseudoaneurysms. The patient’s hemodynamic status soon stabilized and she was transferred out of the ICU in the following days. The case above demonstrates the application of interventional radiologic techniques in just one urologic vascular emergency. Furthermore, the methods used in the above case are not dissimilar to those used in the following case reviews, which illustrate the unique treatment options image-guided interventions can offer in the urologic setting.

Arterial Pseudoaneurysm in Neonates with Hemophilia: Successful Treatment with Noninvasive Clotting Factor Replacement and Ultrasound-guided Compression

Vascular cannulation is an invasive procedure that carries the risk of complications such as pseudoaneurysms. Hemophilia, the most common severe bleeding disorder of inheritance, increases the risk of such complications through underlying hypocoagulability. Although surgical ligation has been considered the gold standard treatment, less invasive options are currently available. Here we present 2 hemophiliac neonates for whom clotting factor replacement and ultrasound (US)-guided compression were successfully used. A 3-week-old male infant and a 4-week-old male infant presented with masses in the left antecubital area and the radial aspects of both wrists, respectively, after arterial punctures. The US confirmed the presence of pseudoaneurysms located at the left brachial artery and right radial artery. US-guided compressions with clotting factor administration initially attempted while confirming a thrombus inside the pseudoaneurysm sac indicated successful management. Arterial cannulation and other procedures in hemophiliac neonates must be attempted with caution because pseudoaneurysms or uncontrolled bleeding may occur. If laboratory analyses or invasive procedures are needed for neonates with a bleeding tendency or a suspected hemophiliac disorder, arterial or venous cannulation requires more caution or should be avoided if possible. This case report suggests that US-guided compression and clotting factor administration are suitable modalities for the treatment of small pseudoaneurysms in hemophilia patients.

Treatment for femoral pseudoaneurysms.

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006. To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection. For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9). Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review. Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors. Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group. The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Child With Painful Palmar Mass

Child With Painful Palmar Mass

Femoral Artery Complications Associated with the Mynx Closure Device

Devices to close a femoral arteriotomy are frequently used after catheterization for interventional radiology and cardiac procedures to decrease the time to hemostasis and ambulation and, potentially, to decrease local complications. The Mynx vascular closure device uses a sealant designed to occlude the access tract, resulting in hemostasis. We retrospectively reviewed all cases in which the Mynx device was used and for which follow-up angiography was available. A total of 146 devices were deployed in 135 patients. A follow-up vascular study visualizing the femoral artery was performed in 26 patients (27 studies). There were 5 (5/27, 18%) cases of intravascular Mynx sealant on follow-up vascular imaging. Three pseudoaneurysms (3/27, 11%) were identified. In this small study, intravascular sealant and pseudoaneurysms were found frequently after femoral arterial closure with the Mynx vascular closure device.

Acute gastrointestinal bleeding: CT angiography with multi-planar reformatting

Acute gastrointestinal bleeding is a common medical emergency, which carries a significant mortality. CT Angiography is an important non-invasive diagnostic tool, which can be used to plan subsequent endovascular or surgical management. The cases presented demonstrate that a meticulous and systematic approach to image interpretation is necessary, in particular, to detect focal sites of contrast extravasation and small pseudoaneurysms.

Composite Freestyle Stentless Xenograft With Dacron Graft Extension for Ascending Aortic Replacement

The present study was undertaken to evaluate clinical, hemodynamic, and morphologic results of composite stentless xenograft with polyethylene terephthalate fiber (Dacron; DuPont, Wilmington, DE) graft extension for combined replacement of the aortic valve, root, and ascending aorta. Between 1997 and 2008, 55 consecutive patients (33 men, 71 +/- 11 years) underwent ascending aortic replacement using Medtronic Freestyle with Dacron graft extension (DuPont). Indications included aneurysm (n = 31, 56%), dissection (n = 16, 29%), and endocarditis (n = 8, 15%). Associated procedures were performed in 25 patients (46%). Preoperative logistic EuroSCORE averaged 34% +/- 28%. Mean cardiopulmonary bypass and aortic cross-clamp times were 244 +/- 134 minutes and 162 +/- 69 minutes, respectively. Clinical follow-up was 100% complete and averaged 2 +/- 3 years. Early mortality was 0% (n = 0) in patients with a preoperative EuroSCORE of less than 20 (n = 26, mean expected mortality, 13% +/- 5%) and 31% (n = 9) in those with preoperative logistic EuroSCORE of at least 20 (n = 29, mean expected mortality, 52% +/- 28%). One- and 3-year survival rates were 83% +/- 5% and 78% +/- 7%, respectively. No major thromboembolic or spontaneous bleeding events were recorded. One patient (2%) required late reoperation for prosthetic valve endocarditis. Echocardiographic follow-up showed no valve dysfunction and low mean transvalvular gradients (7 +/- 5 mm Hg). A 64-channel computed tomographic scan was performed in 33 patients at 32.4 +/- 34 months and revealed two small pseudoaneurysms in a single patient. Composite Freestyle with Dacron graft extension appears to be a safe option for bioprosthetic replacement of the aortic root and tubular ascending aorta. However, long-term results using this composite graft will have to be determined.