Surgical Treatment Of Aneurysms Research Articles

Application of hybrid operating room in the surgical treatment for intracranial aneurysm

BackgroundIntracranial aneurysms are associated with a high mortality rate in the event of a rupture and significant morbidity during subsequent treatment. Hybrid treatment approaches for vascular diseases have been incorporated into modern operating rooms as guides for surgical interventions now. The current study evaluates the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment of intracranial aneurysms. AimsTo evaluate the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment for aneurysms. Methods76 patients with 84 intracranial aneurysms were surgically treated in Hybrid operating room with intraoperative angiography between March 2018 and March 2021. Aneurysm clipping was performed in 76 (94.7 %) cases; Aneurysm trapping with extracranial-intracranial (EC-IC) bypass in 4 (5.3 %) cases. Patient demographics, aneurysm size, location, Hunt and Hess score, were recorded. 69 (90.8 %) patients were followed up 6–12 months post operation. ResultsIntraoperative angiography demonstrated 5 (6.9%) unexpected aneurysm neck residuals leading to adjustment; 6 (8.3%) parent vessel stenosis in which 5 returned to normal after adjustment. Four giant paraclinoid aneurysms trapping with EC-IC bypass showed total successful vessel reconstruction and complete aneurysm exclusion (100%). The postoperative outcome was evaluated with the modified Rankin Scale (mRS). 53 (76.8%) patients showed good outcome (mRS 0), 11 (15.9%) showed mild neurological defect (mRS 1–2), 3 (4.3%) showed poor outcome (mRS 5), and 2 (2.9%) patients died (mRS 6, Hunt-Hess grade V before surgery). Conclusion: Hybrid operating room provides new concepts in the surgically treatment of intracranial aneurysms, especially valuable for the complex aneurysms. The combination of intraoperative imaging of angiography and clipping surgery may offer the opportunity of radical clipping and reduced complications for aneurysm patients.

TAK-242 protects against oxygen-glucose deprivation and reoxygenation-induced injury in brain microvascular endothelial cells and alters the expression pattern of lncRNAs.

Deep hypothermic circulatory arrest (DHCA) is a technique used during the surgical treatment of aneurysms of the thoracic aorta in adult patients, and complex congenital heart disease in neonates. And brain microvascular endothelial cells (BMECs) are essential components of the cerebrovascular network and participate in maintaining the blood-brain barrier (BBB) and brain function. In our previous study, we found that oxygen-glucose deprivation and reoxygenation (OGD/R) activated Toll-like receptor 4 (TLR4) signaling in BMECs, and induced pyroptosis and inflammation. In this study, we further investigated the potential mechanism of ethyl(6R)-6-[N-(2-Chloro-4-fluorophenyl) sulfamoyl] cyclohex-1-ene-1-carboxylate (TAK-242) on BMECs under OGD/R, as in patients with sepsis, the TAK-242 was tested in clinical trials. To confirm the function of TAK-242 on BMECs under OGD/R, cell viability, inflammatory factors, inflammation-associated pyroptosis, and nuclear factor-κB (NF-κB) signaling were determined using Cell Counting Kit-8 (CCK-8) assay, enzyme-linked immunosorbent assay (ELISA), and western blotting, respectively. To investigate the lncRNAs associated with TLR4 during OGD/R, long non-coding RNAs (lncRNAs) and messenger RNAs (mRNAs) expression patterns were profiled with RNA deep sequencing. Moreover, to confirm whether lncRNA-encoded short peptides, liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used. Relative control group, OGD/R inhibited the cell viability, increased the section of inflammatory factors secretion, including IL-1β, IL-6, and TNF-α, and promoted the pathways of TLR4/NLRP3/Caspase-1 and TLR4/NF-κB. However, TAK-242 + OGD/R group promoted OGD/R cell viability, decreased OGD/R-induced inflammatory factors secretion, and inhibited the pathways of TLR4/NLRP3/Caspase-1 and TLR4/NF-κB. In addition, AABR07000411.1, AABR070006957.1, and AABR070008256.1 were decreased in OGD/R cells compared with controls, but TAK-242 restored their expression under OGD/R condition. AABR07000473.1, AC130862.4, and LOC10254972.6 were induced by OGD/R, but were suppressed in TAK-242 + OGD/R cells compared with OGD/R. Moreover, AABR07049961.1, AC127076.2, AABR07066020.1, and AABR07025303.1-encoded short peptides were dysregulated in OGD/R cells, and TAK-242 attenuated the dysregulation of AABR07049961.1, AC127076.2, and AABR07066020.1-encoded short peptides. TAK-242 alters the expression pattern of lncRNAs in OGD/R cells, and differently expressed lncRNAs may exert a protective effect against OGD/R injury through a mechanism of competing endogenous RNA (ceRNA) and encoding short peptides. These findings maybe provide a new theory basis for the treatment of DHCA.

Screening of patients with cerebral aneurysms: mathematical analysis and economic justification

Demonstrate the clinical and economic feasibility of screening the population (including first-line relatives) for cerebral aneurysms using an economic and mathematical model of the RF virtual population. Mathematical modeling was carried out using an algorithm that implements a discrete Markov chain. The virtual population consisted of 145 million people (the population of the Russian Federation). Magnetic resonance angiography 3DTOF was chosen as a screening method. Virtual patients underwent preventive surgical treatment in case of detection of aneurysm during screening. The number of aneurysms in the population, the number of aneurysmal subarachnoid hemorrhage (aSAH), the cost and outcomes of treatment, and the risk of disability were calculated. In the case of screening and preventive surgical treatment of aneurysms, there is a decrease in the number of aSAH by 14.3% (37.5% in first-line relatives (RPLR), which affects the reduction in mortality due to aSAH by 14.4% (24.1% in The total number of disabled people is reduced by 1.5% (5.1% for the RPHR). A shift in the structure of disability towards greater labor and social adaptation of patients was noted. An economic analysis for the entire population showed that screening saves 7.7 billion annually rubles, including in the population consisting of RPLR - 4.9 billion rubles. The created mathematical model of the virtual population demonstrated that screening and prophylactic treatment of cerebral aneurysms makes it possible to reduce the number of aSAH and associated mortality among the entire population and in the RPLR group. The number of individuals with severe disabilities is decreasing. Thus, population screening for the detection of cerebral aneurysms may be clinically effective and cost-effective in the general population, especially in RPCR.

Simulator training in aneurysm clipping

Abstract Due to an increased number of patients with aneurysms treated endovascularly, a resident does not have enough opportunities to come across such a complex procedure as surgical clipping. There have been many types of training methods designed for traditional surgical aneurysm treatment so far. A brief report regarding the helpfulness of vascular simulator AneurysmBox at our Neurosurgical Department is presented.

A clinical case of surgical treatment of a rare left ventricular aneurysm in a patient with ischemic cardiomyopathy

One of the manifestations of ischemic cardiomyopathy is remodeling of left ventricular (LV), which can manifest itself both globally and as a result of an aneurysm. In the vast majority of cases, LV aneurysm location is the apex and the anterior septal region; very rarely, aneurysms are localized in the area of the posterior LV wall and are large. Due to the relative rarity of the given localization surgical treatment tactics of this pathology is not well-established and standardized. The work presents a clinical case of surgical treatment of an aneurysm of the LV posterior wall, demonstrates the stages of diagnosis, and also identifies the features of surgical intervention with the results of treatment in 6 months after surgery.

The teaching about arterial aneurysm by Professor I.F. Bush as the beginning of angiology and vascular surgery in Russia

The article introduced selected fragments of the "Manual for Teaching Surgery" by Professor of the St. Petersburg Medical and Surgical Academy I.F. Bush (1771-1843), devoted to the teaching about arterial aneurysm, into scientific circulation. For the first time in Russian literature, I.F. Bush defined aneurysm, divided aneurysm into true, false, mixed and arteriovenous, singled out spongy aneurysm (hemangioma), described the etiology, clinic, diagnosis, outcome, prognosis and surgical treatment of aneurysm, as well as indications and contraindications for surgery, possible complications and postoperative care. It should be noted that the teaching about arterial aneurysm is presented with a deep knowledge of the subject and literature about it at the beginning of the 19th century, which indicates the great personal clinical experience of the author and his students (V.V. Pelikan, I.V. Buyalsky, etc.) in this section of surgery. It was concluded that the teaching about arterial aneurysm, comprehensively presented by I.F. Bush in 1807-1831, should be considered the beginning of Russian angiology and vascular surgery.

Association of Onset-to-Treatment Time With Discharge Destination, Mortality, and Complications Among Patients With Aneurysmal Subarachnoid Hemorrhage

Rapid access to specialized care is recommended to improve outcomes after aneurysmal subarachnoid hemorrhage (SAH), but understanding of the optimal onset-to-treatment time for aneurysmal SAH is limited. To assess the optimal onset-to-treatment time for aneurysmal SAH that maximized patient outcomes after surgery. This cohort study assessed 575 retrospectively identified cases of first-ever aneurysmal SAH occurring within the referral networks of 2 major tertiary Australian hospitals from January 1, 2010, to December 31, 2016. Individual factors, prehospital factors, and hospital factors were extracted from the digital medical records of eligible cases. Data analysis was performed from March 1, 2020, to August 31, 2021. Main exposure was onset-to-treatment time (time between symptom onset and aneurysm surgical treatment in hours) derived from medical records. Clinical characteristics, complications, and discharge destination were extracted from medical records and 12-month survival obtained from data linkage. The associations of onset-to-treatment time (in hours) with (1) discharge destination of survivors (home vs rehabilitation), (2) 12-month survival, and (3) neurologic complications (rebleed, delayed cerebral ischemia, meningitis, seizure, hydrocephalus, and delayed cerebral injury) were investigated using natural cubic splines in multivariable Cox proportional hazards and logistic regression models. Of the 575 patients with aneurysmal SAH, 482 patients (mean [SD] age, 55.0 [14.5] years; 337 [69.9%] female) who received endovascular coiling or neurosurgical clipping were studied. A nonlinear association of treatment delay was found with the odds of being discharged home vs rehabilitation (effective df = 3.83 in the generalized additive model, χ2 test P = .002 for the 4-df cubic spline), with a similar nonlinear association remaining significant after adjustment for sex, treatment modality, severity, Charlson Comorbidity Index, history of hypertension, and hospital transfer (likelihood ratio test: df = 3, deviance = 9.57, χ2 test P = .02). Both unadjusted and adjusted cox regression models showed a nonlinear association between time to treatment and 12-month mortality with the lowest hazard of death with receipt of treatment at 12.5 hours after symptom onset, although the nonlinear term became nonsignificant upon adjustment. The odds of being discharged home were higher with treatment before 20 hours after onset, with the probability of being discharged home compared with rehabilitation or other hospital increased by approximately 10% when treatment was received within the first 12.5 hours after symptom onset and increased by an additional 5% from 12.5 to 20 hours. Time to treatment was not associated with any complications. This cohort study found evidence that more favorable outcomes (discharge home and survival at 12 months) were achieved when surgical treatment occurred at approximately 12.5 hours. These findings provide more clarity around optimal timelines of treatment with people with aneurysmal SAH; however, additional studies are needed to confirm the findings.

Surgical treatment of aneurysms of aortic arch branches and vessels of the upper extremities

Aneurysms of theaortic arch branches and vessels of the upper extremities are dangerous and there is a high probability of mortality due to rupture of the aneurysm or stroke. The indication is surgical treatment, regardless of the age and size of the aneurysms. The frequency of deaths and strokes that occurred during operations for carotid artery aneurysms is about 2%, which is associated with distal embolism of intracerebral vessels and the contents of the aneurysm cavity. One of the most common causes of aneurysms of the branches of the aortic arch and vessels of the upper extremities are atherosclerosis, nonspecific aortoarteritis and posttraumatic aneurysms. The study included 38 patients with aneurysms of the branches of the aortic arch and arteries of the upper extremities operated in the vascular surgery department over the past 10 years, whose total age ranged from 19 to 76 years. There were 84% men, 16% women. Aneurysms of the carotid arteries and its branches (temporal artery) were diagnosed in 58%, subclavian arteries in 16%, arteries of the upper extremities in 26%. The size of aneurysms of the branches of the aortic arch and arteries of the upper extremities ranged from 2.5 cm to 10 cm. The average size is 6.3±1.8 cm. When choosing the method of treatment of aneurysms of the branches of the aortic arch and arteries of the upper extremities, preference was given to performing reconstructive operations without the use of additional materials, which were performed in 52% cases), in 13 of these cases, excision of a false aneurysm with stitching of the defect was performed, in 6 of these cases, resections of aneurysms with end-to-end anastomosis were performed. In 48% cases, operations with the use of synthetic materials and autovenous plastic surgery were performed, and endovascular interventions were also performed in 4 cases. The most frequent type of surgery performed is resection of an aneurysm with a lateral suture – 34% cases. Resection of the anastomosis aneurysm at the end of the arteries – 16%, and prosthetics – in 8% cases (synthetic alloprosthetics in one and with autovenous prosthetics in two cases). After resection of subclavian artery aneurysm due to large diastasis of blood flow, reconstruction was performed by bypass surgery or prosthetics. Arterial aneurysm resection with autovenous patch was performed in 13% cases, and with allosunting – in 8% cases. Excision of an aneurysm of the axillary artery on the left with the restoration of a synthetic patch – in 5% cases. Ligation of an aneurysm in the temporal artery was performed in 2 cases (5%), this type of operation was performed with an aneurysm of non-main vessels, as well as in vessels with collateral blood flow in the distal area of the vessels. Implantation of a stentgraft into the right subclavian artery – in 3 cases (8%). X-ray endovascular embolization of aneurysm – in 3% case. Positive results in the postoperative period were observed in 92% patients. One (3%) patient developed complications in the form of hematomas after aneurysm resection. In 5% cases - lymphorrhea after excision of a false aneurysm

Immediate and Long-Term Results of Treatment of Aneurysms of Ascending Aorta and Aortic Arch and Substantiation of Tactical Approaches to the Treatment Based on the Obtained Results

Acute aortic dissection is a formidable disease. Its prevalence increases due to the population aging, as well as wider awareness of physicians about this pathology.
 The aim. To analyze immediate and long-term results of surgical treatment of aneurysms of ascending aorta and aortic arch and to determine optimal methods of correction of these lesions in order to improve the results of surgical treatment.
 Materials and methods. This was a comparative analysis of immediate and long-term treatment outcomes in 419 patients with aneurysms of ascending aorta and aortic arch. A comparative analysis of the results of treatment of two groups of patients was performed: the comparison group of 157 people operated before 2013, and the main group of 262 patients operated since 2013 using modified methods of aortic surgery.
 Results. The study showed significant reduction in the left ventricular dilatation according to echocardiography and satisfactory postoperative course in patients of both groups. Patients with valve-sparing aortic prosthetics had better results than those who underwent valve replacement surgery. Hospital mortality decreased from 17.2% to 5.3%.
 Analysis of long-term results showed that supracoronary aortic prosthetics with aortic valve plasty and elimination of the intimal tear zone make it possible to carry out effective aortic reconstruction. Due to events in the long run, regular lifelong monitoring is required.
 The analysis also showed that individualized approach to the choice of surgical tactics for the correction of aortic insufficiency in patients with aortic root and ascending aortic pathology allows to achieve comparable results in the immediate and long-term follow-up. Despite the complexity of the applied correction methods, the developed methods of surgical treatment of ascending aortic aneurysm (AAA) and aortic arch aneurysm and methods of protection of brain and visceral organs allowed to keep hospital mortality and the number of complications at the same level corresponding to one of the best world results. This gives hope for a good result in the long-term follow-up.
 Conclusions. Aneurysm of ascending aorta and aortic arch is a formidable life-threatening disease, and its only non-alternative treatment option is surgery. The optimized approach to the treatment of patients in the main group allowed to obtain better immediate and long-term results of surgical treatment and reduce postoperative complications from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%. Comparative analysis of long-term results in the studied groups showed more encouraging indicators of quality of life and life expectancy in patients when using modified surgical techniques, protection of the brain and visceral organs. We hope to get a final assessment of these data in the further study of the condition of these patients in the long-term follow-up.

Experimental evaluation of a hybrid thoracic aortic prosthesis in a pig model

Relevance. The frozen elephant trunk technique is recognized as a safe and effective method of surgical treatment for aneurysms and dissections of the thoracic aorta. The hybrid prostheses, available on the territory of the Russian Federation, are foreign-made, characterized by a high price, and, accordingly, unpopular. Due to unavailability of domestic hybrid prostheses in the home market, the development of domestic prosthesis is the key point to further progress in aortic surgery in the Russian Federation. Aim . The aim of the study was to evaluate the implantation characteristics of prototype hybrid thoracic aorta prosthesis in the pig model and the transformation of the prosthesis in the postoperative period. Material and Methods . The hybrid prosthesis consists of two parts including the vascular part and a stent graft. The prosthesis is made of Dacron and Z-shaped nitinol wire stents. A Landrace pig aged six months with body weight of 120 kg underwent open reconstruction of the descending aorta through the left-sided lateral thoracotomy, under conditions of extracorporeal bypass with a roller pump from the left subclavian artery to the descending aorta. The animal was removed from the experiment after six months as planned. The macro- and microscopic evaluation of the removed implant was performed. Results . The technical success of implantation of hybrid stent graft prototype was confirmed. Macroscopy of the stent graft, removed after six months, demonstrated a complete coverage of the neointimal inner surface of the synthetic prosthesis. The lumen of the product was patent. Histological examination revealed the neointima presented as a structured connective tissue without signs of inflammation. The luminal surface was lined with a single layer of evenly spaced endotheliocytes. The thickness of the neointima in the vascular part was significantly greater than in the stent-graft part ( p = 0.0121). Conclusion. The study demonstrated the technical feasibility of implantation of the prototype hybrid prosthesis developed by Angioline Research LLC. The effectiveness of sealing impregnation was confirmed by the absence of active signs of bleeding during the perioperative and early postoperative stages. The prosthesis demonstrated satisfactory bio- and hemocompatibility.

Methods and Results of the Brain and Visceral Organs Protection During the Correction of the Ascending Aorta and Aortic Arch Aneurysm or Isolated Aortic Arch Aneurism

The ascending aorta and aortic arch aneurysm surgical correction is the most difficult problem of cardiovascular surgery due to the necessity of management of the main disease and adequate protection of the brain and visceral organs.
 The aim. To present the methods and results of protection of the central nervous system and visceral organs during the correction of the ascending aorta and aortic arch aneurysm or isolated aortic arch aneurism.
 Materials and methods. During 1994–2018, we operated 419 patients with the ascending aorta and aortic arch aneurysm (or isolated aortic arch aneurism).
 Diagnosis of aneurysms was based on clinical data, transthoracic and transesophageal echocardiography, computed tomography, X-ray examination, aortography.
 All operations were performed under general anesthesia, through the median sternotomy using cardiopulmonary bypass. Valve-sparing technique with aortic valve resuspension/aortic valve plasty and semi-arch/arch replacement was used in 288/9 (68.7%) patients. Bentall operation with semi-arch/arch replacement was used in 86/9 (20.5%) patients. Other operations accounted for 45 (10.7%) patients.
 Results. The history of the development of aortic aneurysms treatment options is briefly overviewed in the paper. Diagnostic methods are mentioned, but the main method today is computed tomography. Initial status of the patients was severe. All operations were performed through median sternotomy using cardiopulmonary bypass. The following techniques were used for surgical treatment of aneurysms: 1) valve-sparing technique with aortic valve resuspension/ plasty and semi-arc/arch replacement was used in 288/9 (68.7%) patients. In this group there were 8 Yacoub operations, 6 David operations. In 7 patients, plication of one of the leaflets was performed in case of aortic valve prolapse. 3 patients underwent strengthening of the free edge of the leaflets and 4 patients underwent plasty by the patch in case of leaflet fenestrations; 2) Bentall operation with semi-arch/arch replacement was used in 86/9 (20.5%); 3) others: isolated arch in 15 (3.6%); Wheat operation + arch in 9 (1.0%); aortic arch plasty in 4 (1.0%); Elephant trunk (conventional Elephant trunk) + TEVAR was used in 17 (4.1%) patients. The brain protection was performed differently at each of the two stages in our surgical experience. The best result was achieved at the last stage. The number of postoperative complications decreased from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%, respectively. Also, a modern endovascular method – hybrid operations Elephant trunk + TEVAR – was used in 17 (4.1%) patients with good immediate result.
 Conclusions.
 1. At type A aortic dissection (DeBakey type I) the operation of choice is supracoronary ascending aortic replacement with a semi-arch (arch) replacement of the aorta.
 2. Accumulation of surgical experience, team training, improvement of methods of protection of the brain and visceral organs allowed to reduce the number of postoperative complications from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%.

Surgical treatment of vertebral artery confluence aneurysms

Aneurysms of vertebral artery confluence and proximal parts of basilar artery are extremely rare. They are usually combined with proximal fenestration of basilar artery. No timely surgical treatment of these aneurysms is associated with high risk of adverse outcomes, and their treatment is a challenge for neurosurgeons. We analyzed postoperative outcomes in 17 patients with 21 aneurysms of vertebral artery confluence and proximal parts of basilar artery. Six patients with 10 aneurysms underwent microsurgical resection, 11 patients with 11 aneurysms - endovascular procedure. Persistent postoperative deterioration was observed in 5 (29.4%) patients: severe neurological symptoms (GOS grade 3) in 1 case (5.9%), minor bulbar disorders in 4 cases (23.53%). There were no lethal outcomes. According to our own and literature data, aneurysms of vertebral artery confluence are extremely rare. The risk of rupture of these aneurysms is extremely high. Endovascular approach is preferred in these patients. Microsurgical procedure is an acceptable alternative if endovascular surgery is impossible.

Efficacy and safety of surgical treatment for middle cerebral artery aneurysms: A retrospective case series

ObjectiveThe purpose of this study was to evaluate the efficacy and safety of surgical treatment for aneurysms of the middle cerebral artery at a Brazilian Vascular Neurosurgical Center. MethodsA retrospective review was conducted of the medical records of 194 patients (213 aneurysms) operated on by the primary author at the Santa Casa Neurosurgery service in Belo Horizonte, Minas Gerais, Brazil. This study evaluated clinical outcome, treatment efficacy and mortality. ResultsOverall analysis showed that 146 patients (75.2%) demonstrated ago od outcome. Evaluation of patient evolution showed that 78 patients (69.0%) with a ruptured aneurysm had a good outcome, and among patients with unrupture aneurysms, 68 (88.3%) had a good outcome at discharge (p = 0.005). Among patients with unruptured aneurysms, noneof the factors analyzed had statistically significant differences in terms of outcome.Among patients with ruptured aneurysms, the HH on admission, Fisher grade and presence of hematoma were significantly associated with clinical outcome. Multivariate analysis showed that only HH on admission was associated with prognosis. Postoperative arteriography demonstrated complete occlusion in 177 cases (83.1%). ConclusionThis study demonstrated that surgical treatment for middle cerebral artery aneurysms is safe and effective. In the overall analysis, ruptured aneurysms predicted poor outcome. None of the variables studied predicted poor outcome among patients with unruptured aneurysms. In univariate analysis, patients with ruptured aneurysms, HH on admission, Fisher grade and presence of hematoma were associated with outcome; in multivariate analysis, only HH on admission was associated with prognosis.

Autologous pericardium used for reconstruction of left innominate vein in patient with mediastinal venous aneurysm:a case report

BackgroundMediastinal venous aneurysm is a very rare disease and can be easily misdiagnosed. Patients are often asymptomatic while venous aneurysm of large size with adjacent structures oppressed can lead to discomfort. The surgical treatment for aneurysm of large vessels is often complex and challenging.Case presentationWe reported a 52-year-old man with mediastinal mass who received operation on July 2019 in our hospital. Left innominate vein aneurysm was diagnosed during operation with superior vena cava involved. The aneurysm was resected and pericardium was taken to repair part wall of superior vena cava and reconstruct left innominate vein. The patient’s postoperative course was uneventful.ConclusionsVenous aneurysm should be considered when mediastinal mass has no clear boundary with large veins or even seems to connect with them. Magnetic resonance imaging, computed tomographic angiography and invasive venography can be performed to further evaluate the mass once diagnosis of venous aneurysm was suspected. Using pericardium to repair large veins is a good choice which is safe and costless.

Aspect ratio as a factor predicting rupture of cerebral aneurysms

Cerebral vascular aneurysms are abnormalities present in 2–5% of the population. Aneurysm rupture often leads to the development of a hemorrhagic stroke. Among its consequences are disability and death. Despite this, preventive surgical treatment of aneurysms is not always justified, since it leads to serious postoperative complications. In this regard, there is the problem of developing and justifying reliable and convenient criteria for assessing the risk of aneurysm rupture. Aspect ratio (the ratio of the height of the aneurysm to the diameter of the neck) is the relative size of the aneurysms used to classify them as prone to rupture and not prone to rupture. This characteristic is also used as predictor of aneurysm rupture. In this paper, we carried out a series of numerical biomechanical calculations aimed at substantiating the critical value of the aspect ratio characterizing aneurysms prone to rupture. In the simulation, the average shear stresses on the aneurysm wall were compared for different aspect ratios from 0.5 to 2.25 with a step of 0.25 for asymmetric models and for aspect ratios from 0.5 to 2.1 with a step of 0.2 for symmetrical models. It was revealed that average wall shear stresses on the aneurysm significantly decrease when the aspect ratio is greater than critical. An abrupt decrease in the average wall shear stresses on the aneurysm with aspect ratio greater than the critical value was revealed.

Size-Dependent Distribution of Patient-Specific Hemodynamic Factors in Unruptured Cerebral Aneurysms Using Computational Fluid Dynamics.

Purpose: To analyze size-dependent hemodynamic factors [velocity, shear rate, blood viscosity, wall shear stress (WSS)] in unruptured cerebral aneurysms using computational fluid dynamics (CFD) based on the measured non-Newtonian model of viscosity. Methods: Twenty-one patients with unruptured aneurysms formed the study cohort. Patient-specific geometric models were reconstructed for CFD analyses. Aneurysms were divided into small and large groups based on a cutoff size of 5 mm. For comparison between small and large aneurysms, 5 morphologic variables were measured. Patient-specific non-Newtonian blood viscosity was applied for more detailed CFD simulation. Quantitative and qualitative analyses of velocity, shear rate, blood viscosity, and WSS were conducted to compare small and large aneurysms. Results: Complex flow patterns were found in large aneurysms. Large aneurysms had a significantly lower shear rate (235 ± 341 s−1) than small aneurysms (915 ± 432 s−1) at peak-systole. Two times higher blood viscosity was observed in large aneurysms compared with small aneurysms. Lower WSS was found in large aneurysms (1.38 ± 1.36 Pa) than in small aneurysms (3.53 ± 1.22 Pa). All the differences in hemodynamic factors between small and large aneurysms were statistically significant. Conclusions: Large aneurysms tended to have complex flow patterns, low shear rate, high blood viscosity, and low WSS. The hemodynamic factors that we analyzed might be useful for decision making before surgical treatment of aneurysms.

Adenosine-Induced Transient Asystole During Surgical Treatment of Basilar Artery Aneurysms

To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Respiratory Rehabilitation in Patients with Abdominal Aortic Aneurysm Submitted to OPEN and EVAR Treatment: Predictive Factors of Postoperative Pulmonary Complications and Clinical Implications

Background: In the conventional surgical treatment of aneurysms, the respiratory physiotherapy is one of the cornerstones of patient rehabilitation. The endovascular technique, with less invasiveness, has significantly changed the rehabilitative approach to the operated subject. Objective of the study: to evaluate and compare the effectiveness of the pre and post-operative rehabilitation treatment associated with the conventional OPEN surgery compared to the EVAR procedure and their incidence in preventing postoperative respiratory complications. Design: Longitudinal case control study to compare patients who have open surgery with patients who do not have the laparotomy, as in ENDO technique, to look how frequently the postoperative pneumonia and the risk factor was present in each group to determine the relationship between the risk factor, the type of operation and the pneumonia incidence. Setting Data were collected from patients admitted consecutively at the Tor Vergata Hospital with diagnosis of an abdominal aortic aneurysm. Risk factors, type of intervention, pneumonia incidence in postoperative period was evaluted at 30 days. Population: Three hundred and twenty patient were enrolled. Materials and methods: From 2005 to 2016, 320 patients suffering from an abdominal aortic aneurysm were treated consecutively. One hundred eighty one patients were treated using the open technique (group A) and 139 using the EVAR technique (group B). All patients in OPEN group were submitted to respiratory rehabilitation protocol. Risk factors, type of intervention, anesthesia and results of treatment with complications, observed mortality, mean hospital stay were studied. Pre and postoperative respiratory rehabilitation treatment protocol was performed in all of the patients. The data were analyzed with descriptive statistics and inferential statistics using SPSS 18.0 for Windows. Results: From 2005-2010, the postoperative stay (days) was significant shorter for EVAR compared to open (6.47 vs. 10.48; P 0.001). From 2011-2016, the postoperative stay (days) was significant shorter EVAR compared open (4.07 vs. 11.41; P 0.001). The patients treated from 2011 to 2016 for both OPEN and EVAR groups presented an average age 3 years lower compared to the patients treated in the period from 2005-2011 (75.5 to 72.8 for EVAR and from 71,2 to 68,2). The patients treated from 2011 to 2016 for EVAR group presented an average reduction in post-operative hospitalization of 2.4 days (-37.09%) compared to 2005-2011 period. There was a significant higher incidence of pneumonia in the open group (P=0.001). The reduction of the incidence of pneumonia in group A and B during the two different periods from 2005 to 2010 and from 2011 to 2016 was observed. There wasn’t a significant difference in the incidence of pneumonia in patients treated from 2005 to 2010 (P-value=0.1). In patients treated from 2011 to2016 there was a significant increasing the incidence of pneumonia in OPEN group (P=0.001). Conclusion: Rehabilitation physiotherapy plays a fundamental role in the prevention of postoperative complications of patients undergoing OPEN treatment. Despite of the excellent results obteined in patients undergoing OPEN treatment, the lower rate of complications in EVAR group showed better results of this treatment.

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil.

Background:The aim of the study was to characterize the clinical profile of patients with anterior communicating artery (ACoA) aneurysms and examine potential correlations between clinical findings, aneurysm morphology, and outcome.Methods:A review of medical records and diagnostic neuroimaging reports of patients treated at a neurosurgical service in Porto Alegre, Brazil, between August 2008 and January 2015 was performed.Results:During the period, 100 patients underwent surgery for ACoA aneurysms. Fifteen had unruptured aneurysms and 85 had ruptured aneurysms. Ruptured aneurysms had a higher aspect ratio than unruptured ones (2.37 ± 0.71 vs. 1.93 ± 0.51, P = 0.02). Intraoperative rupture occurred in 3%, and temporary clipping was performed in 15%. Clinical vasospasm occurred in 43 patients with ruptured aneurysms (50.6%). Overall, mortality was 26%; 25 patients in the ruptured group (29.4%) and one in the unruptured group (6%). The Glasgow Outcome Scale (GOS) was favorable (GOS 4 or 5) in 54% of patients, significantly more so in those with unruptured aneurysms (P = 0.01). In patients with ruptured aneurysms, mortality was associated with preoperative Hunt and Hess (HH) score (P < 0.001), hydrocephalus (P < 0.001), and clinical complications (P < 0.001). Unfavorable outcomes were associated with HH score (P < 0.001), Fisher grade (P = 0.015), clinical vasospasm (P = 0.012), external ventricular drain (P = 0.015), hydrocephalus (P < 0.001), and presence of clinical complications (P = 0.001). In patients with unruptured aneurysms, presence of clinical complications was the only factor associated with mortality (P < 0.001).Conclusion:Despite advances in the management of subarachnoid hemorrhage and surgical treatment of aneurysms, mortality is still high, especially due to clinical complications.

Invited Commentary

Dr Coselli discloses a financial relationship with Terumo Aortic, Medtronic, and W.L. Gore & Associates.For more than 30 years, Nicholas Kouchoukos has worked to reduce the life-altering complications of thoracoabdominal aortic aneurysm (TAAA) repair.1Laschinger J.C. Izumoto H. Kouchoukos N.T. Evolving concepts in prevention of spinal cord injury during operations on the descending thoracic and thoracoabdominal aorta.Ann Thorac Surg. 1987; 44: 667-674Abstract Full Text PDF PubMed Scopus (89) Google Scholar Specifically, he has focused on the use of hypothermia to protect the spinal cord and kidneys during the ischemic conditions necessitated by extensive aortic repair.2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Kouchoukos was present at the dawn of contemporary distal aortic replacement. In his early years, he used temporary shunts, as well as left heart bypass, to provide downstream perfusion of the aorta after noting the risk of substantial spinal cord and kidney injury when using a clamp-and-sew approach.3Carlson D.E. Karp R.B. Kouchoukos N.T. Surgical treatment of aneurysms of the descending thoracic aorta: an analysis of 85 patients.Ann Thorac Surg. 1983; 35: 58-69Abstract Full Text PDF PubMed Scopus (79) Google Scholar Unsatisfied, he was led to the routine use of hypothermic circulatory arrest during descending thoracic aortic aneurysm and TAAA repair because of the protection it provides to highly sensitive spinal cord and renal tissue.4Kouchoukos N.T. Wareing T.H. Izumoto H. Klausing W. Abboud N. Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta.J Thorac Cardiovasc Surg. 1990; 99: 659-664Abstract Full Text PDF PubMed Google Scholar Dr Coselli discloses a financial relationship with Terumo Aortic, Medtronic, and W.L. Gore & Associates. In his most recent description of the use of hypothermia during open TAAA repair, Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar report their experience with 285 such repairs, including 104 Crawford extent II TAAA repairs. Most of these repairs were in patients with degenerative aneurysms (73%), which typically carry a higher operative risk than repair of chronic aortic dissection. In addition to the use of hypothermic circulatory arrest, cerebrospinal fluid drainage and select reimplantation of intercostal and lumbar arteries were used to reduce the likelihood of postoperative spinal cord deficit further. Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar sagely point out that in their series, cerebrospinal fluid drainage had no favorable impact on spinal cord injury when it was used in combination with hypothermic circulatory arrest, even in the most extensive TAAA repairs—Crawford extent II TAAA repairs. In contrast, the reimplantation of intercostal and lumbar arteries proved beneficial during extent II TAAA repair. Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar make the point that cerebrospinal fluid drainage is clearly not an innocuous procedure and poses an occasional but significant risk, which may be exacerbated by full heparinization. Further, its use may be entirely unnecessary in patients undergoing extensive TAAA repair while using the protection of cardiopulmonary bypass with hypothermic circulatory arrest. In conclusion, the results of Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar speak for themselves and are among the best possibly achieved: a 6% rate of renal failure requiring dialysis, a 5% rate of permanent paraplegia or paraparesis, and a 7% rate of 30-day death. No doubt, many surgeons sweat during TAAA repair, but Kouchoukos and colleagues keep their cool as they keep it cold. Dr Coselli receives a departmental educational grant from Terumo Aortic and serves as a co-investigator for CytoSorbents. Dr Coselli's work is partly supported by the Cullen Foundation. Early Outcomes After Thoracoabdominal Aortic Aneurysm Repair With Hypothermic Circulatory ArrestThe Annals of Thoracic SurgeryVol. 108Issue 5PreviewA variety of intraoperative strategies are currently used for organ protection during open operations on the thoracoabdominal aorta. We report our experience with cardiopulmonary bypass and hypothermic circulatory arrest as the primary modality for organ protection, focusing on the early outcomes. Full-Text PDF