Rare Complication of non-Treated Abdominal Aortic Aneurysm: Extensive Thrombus in Right Cardiac Chambers / Complicação Rara de Aneurisma da Aorta Abdominal não Tratado: Trombo Extenso em Câmaras Cardíacas Direitas

Abstract A 78-year-old patient presented with shortness of breath after falling down. Transthoracic echocardiogram showed an extensive thrombus in the right atrium (RA), extensive thrombosis of the inferior vena cava (IVC), and abdominal aortic aneurysm (AAA). A magnetic resonance confirmed the thrombosis of the RA extending to the IVC, which was apparently fused to the abdominal aortic aneurysm (compression? erosion?). This case illustrates a severe and rare complication of a non-treated AAA. There probably was IVC erosion by the aortic aneurysm, leading to blood stasis and extensive thrombosis of the IVC and right cardiac chambers.

Resumo Uma paciente de 78 anos procurou o serviço de emergência apresentando dispneia após sofrer queda da própria altura. O ecocardiograma transtorácico mostrou um extenso trombo no átrio direito (AD), trombose extensa da veia cava inferior (VCI), e aneurisma de aorta abdominal (AAA). A ressonância magnética confirmou a trombose do AD estendendo-se até a VCI, a qual aparentemente apresentava fusão ao aneurisma da aorta abdominal (compressão? erosão?). Este caso ilustra uma complicação grave e rara de um AAA não tratado. Provavelmente houve uma erosão da VCI pelo aneurisma da aorta resultando em estase sanguínea e trombose extensa da veia cava inferior e cavidades cardíacas direitas.

Alterations of blood flow pattern after triple stent endovascular treatment of saccular abdominal aortic aneurysm: a porcine model / Alterações do padrão do fluxo sanguíneo após tratamento endovascular do aneurisma sacular da aorta abdominal com triplo stent: modelo em suínos

ABSTRACT Objective: to determine the blood flow pattern changes after endovascular treatment of saccular abdominal aortic aneurysm with triple stent. Methods: we conducted a hemodynamic study of seven Landrace and Large White pigs with saccular aneurysms of the infrarenal abdominal aorta artificially produced according to the technique described. The animals were subjected to triple stenting for endovascular aneurysm. We evaluated the pattern of blood flow by duplex scan before and after stent implantation. We used the non-paired Mann-Whitney test for statistical analysis. Results: there was a significant decrease in the average systolic velocity, from 127.4cm/s in the pre-stent period to 69.81cm/s in the post-stent phase. There was also change in the flow pattern from turbulent in the aneurysmal sac to laminate intra-stent. Conclusion: there were changes in the blood flow pattern of saccular abdominal aortic aneurysm after endovascular treatment with triple stent.

RESUMO Objetivo: determinar as alterações do padrão do fluxo sanguíneo após tratamento endovascular do aneurisma sacular de aorta abdominal com triplo stent. Métodos: estudo hemodinâmico de sete suínos das raças Landrace e Large White portadores de aneurismas saculares de aorta abdominal infrarrenal artificialmente produzidos segundo técnica descrita. Os animais foram submetidos a implante de triplo stent para correção endovascular do aneurisma e reavaliados por duplex scan quanto ao padrão do fluxo sanguíneo antes e após o implante dos stents. A análise estatística foi realizada com o teste Mann-Whitney não pareado. Resultados: verificou-se uma queda significativa da velocidade sistólica média de 127,4cm/s na fase pré-stent para 69,81cm/s na fase pós-stent. Houve ainda mudança no padrão do fluxo de turbilhonar no saco aneurismático para laminar intrastent. Conclusão: o estudo demonstrou alterações do padrão do fluxo sanguíneo do aneurisma sacular de aorta abdominal após tratamento endovascular com triplo stent.

Retroperitoneal fibrosis: case series of five patients and review of the literature / Fibrose retroperitoneal: série de cinco casos e revisão da literatura

ABSTRACT Chronic periaortitis (CP) is an umbrella term used to describe a group of nosologically allied conditions that include idiopathic retroperitoneal fibrosis (Ormond's disease), inflammatory abdominal aortic aneurysm, and perianeurysmal retroperitoneal fibrosis. Retroperitoneal fibrosis encompasses a range of diseases characterized by the presence of a fibro-inflammatory tissue, which usually surrounds the abdominal aorta and the iliac arteries and extends into the retroperitoneum to envelop neighboring structures-ureters. Retroperitoneal fibrosis is generally idiopathic, but can also be secondary to the use of certain drugs, malignant diseases, infections, and surgery. Here we describe a 5 years follow up (2006-2011) of 5 patients admitted to our hospital with symptoms, laboratory, imaging and pathologic finding compatible with retroperitoneal fibrosis. We review our clinical course of our patient with respect to the literature.

RESUMO Periaortite crônica (PC) é um termo genérico usado para descrever um grupo de condições nosologicamente ligadas que incluem a fibrose idiopática retroperitoneal (doença de Ormond), o aneurisma da aorta abdominal inflamatório e a fibrose retroperitoneal perianeurismática. O termo fibrose retroperitoneal engloba uma gama de doenças que se caracterizam pela presença de um tecido fibroinflamatório que geralmente envolve a aorta abdominal e as artérias ilíacas, se estende ao retroperitôneo e envolve estruturas ureterais vizinhas. A fibrose retroperitoneal geralmente é idiopática, mas pode também ser secundária ao uso de determinados fármacos, doenças malignas, infecções e cirurgia. Este estudo descreve o seguimento por cinco anos (2006-2011) de cinco pacientes internados em nosso hospital que apresentavam sintomas e achados laboratoriais, de imagem e patológicos compatíveis com a fibrose retroperitoneal. Revisou-se a evolução clínica dos pacientes, que foi comparada com os achados da literatura.

Uso combinado de endoprótese GORE TAG® e Gore Exculder® para tratamento de aneurisma de aorta abdominal com angulação extrema / Combined use of GORE TAG® and Gore Exculder® endografts for treatment of abdominal aortic aneurysm with severe angulation

O avanço tecnológico da cirurgia endovascular no tratamento de aneurismas de aorta vem permitindo que uma maior quantidade de pacientes, antes considerados inaptos para essa abordagem, beneficie-se dessa modalidade terapêutica. Apesar da atual disponibilidade de endopróteses com alta conformabilidade, casos com anatomia desfavorável permanecem um desafio para os cirurgiões. Descrevemos um caso anatomicamente desfavorável, resolvido com sucesso pela técnica endovascular, utilizando-se uma manobra não convencional.

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.

Proposta de correção virtual geométrica da projeção ostial da artéria renal no estudo operatório de aneurismas infrarrenais: resultados iniciais de um estudo piloto / Proposal of renal artery's ostial projection under virtual geometric correction in infrarenal aneurysms: initial results of a pilot study

Introdução: Para o preparo pré-operatório endovascular dos aneurismas infrarrenais é necessária a mensuração acurada de suas características anatômicas e morfológicas, alcançada com o uso de softwares avançados em manipulação de imagens de tomografias multicanais. Este processo permite também o estudo acurado das relações anatômicas das demais artérias do eixo aorto-ilíaco. Uma visualização perpendicular à origem da artéria renal mais baixa possibilita o uso de toda a extensão do colo para fixação da endoprótese e selamento proximal, o que pode ser previsto durante o estudo da tomografia, impedindo um posicionamento subótimo e a sobreposição das estruturas vasculares no intraoperatório. Expõem-se aqui os resultados iniciais de um projeto piloto, envolvendo manipulação de imagens tomográficas, na correção ortogonal da artéria renal aplicada à orientação radioscópica no intraoperatório. Métodos: Por meio de reconstrução multiplanar de imagens tomográficas em software obtém-se um corte axial em ângulo reto. Conceitos geométricos de triangulação virtual promovem a correção ortogonal em três dimensões da visualização ostial da artéria renal, que pode ser reproduzida intraoperatoriamente, através do reposicionamento do arco cirúrgico. Resultados/Discussão: Embora alguns autores argumentem que a anatomia do vaso observada na tomografia possa mudar durante o intraoperatório, sabe-se que o posicionamento angular das artérias renais não se modifica, mesmo após a inserção dos fios guia rígidos, introdutores e da própria endoprótese. Assim, acreditamos ser possível, por meio de ...

Introduction: Endovascular aneurysm repair requires the precise deployment of the graft. In order to achieve accurate positioning, the anatomical and morphological characteristics of the aorta and its branches is mandatory. Software that perform three dimensional reformatting of multislice tomographic images, allow for the study of the whole aorto-iliac axis and the perpendicular visualization of the origin of the renal arteries. The correct length of the proximal neck can be evaluated and adequate graft fixation and sealing may be foreseen. A technique is presented, using an software, for the orthogonal correction of the position of the renal arteries in relation to the proximal neck, which may guide the radioscopic orientation intraoperatively. Methods: Within a multiplanar tomographic image reconstruction, virtual triangulation allows for the three dimensional orthogonal correction of the renal arteries' ostia position. The predetermined best angulations for visualization are annotated and used for the positioning of the surgical C-arm. Results/Discussion: Some authors discuss that the anatomic position of the renal vessels seen on the tomographic scan can change during the surgical procedure. It is known that the renal arterys' angular positioning does not alter, even after insertion of stiff guidewires, introducers, and the endograft itself. Therefore, it is possible, using concepts of spacial geometry and orthogonal correction, to predict the ideal bidimensional intraoperative positioning of the radioscopy device in order to reproduce the optimized renal artery ostial projection, ensuring the best accuracy during endograft deployment. Conclusion: As closer to the tomographic reproduction was the radioscopic correction, more careful is the visualization of the ostium of the renal artery, better is the exploitation of the lap for fixing and sealing and the endoprosthesis deployment is more accurate. .

Tissue Responses to Stent Grafts with Endo-Exo-Skeleton for Saccular Abdominal Aortic Aneurysms in a Canine Model

OBJECTIVE: We evaluated the effect of close contact between the stent and the graft on the induction of endothelial covering on the stent graft placed over an aneurysm. MATERIALS AND METHODS: Saccular abdominal aortic aneurysms were made with Dacron patch in eight dogs. The stent graft consisted of an inner stent, a expanded polytetrafluoroethylene graft, and an outer stent. After sacrificing the animals, the aortas with an embedded stent graft were excised. The aortas were inspected grossly and evaluated microscopically. RESULTS: The animals were sacrificed at two (n = 3), six (n = 3), and eight months (n = 2) after endovascular repair. In two dogs, the aortic lumen was occluded at two months after the placement. On gross inspection of specimens from the other six dogs with a patent aortic lumen, stent grafts placed over the normal aortic wall were covered by glossy white neointima, whereas, stent grafts placed over the aneurysmal aortic wall were covered by brownish neointima. On microscopic inspection, stent grafts placed over the normal aortic wall were covered by thin neointima (0.27 +/- 0.05 mm, mean +/- standard deviation) with an endothelial layer, and stent grafts placed over the aneurysmal aortic wall were covered by thick neointima (0.62 +/- 0.17 mm) without any endothelial lining. Transgraft cell migration at the normal aortic wall was more active than that at the aneurysmal aortic wall. CONCLUSION: Close contact between the stent and the graft, which was achieved with stent grafts with endo-exo-skeleton, could not enhance endothelial covering on the stent graft placed over the aneurysms.

Tissue Responses to Endovascular Stent Grafts for Saccular Abdominal Aortic Aneurysms in a Canine Model

We investigated tissue responses to endoskeleton stent grafts for saccular abdominal aortic aneurysms (AAAs) in canines. Saccular AAAs were made with Dacron patch in 8 dogs, and were excluded by endoskeleton stent grafts composed of nitinol stent and expanded polytetrafluoroethylene graft. Animals were sacrificed at 2 months (Group 1; n = 3) or 6 months (Group 2; n = 5) after the placement, respectively. The aortas embedding stent grafts were excised en bloc for gross inspection and sliced at 5 to 8 mm intervals for histopathologic evaluation. Stent grafts were patent in all except a dog showing a thrombotic occlusion in Group 2. In the 7 dogs with patent lumen, the graft overhanging the saccular aneurysm was covered by thick or thin thrombi with no endothelial layer, and the graft over the aortic wall was completely covered by neointima with an endothelial layer. Transgraft cell migration was less active at an aneurysm than at adjacent normal aorta. In conclusion, endoskeleton stent grafts over saccular aneurysms show no endothelial coverage and poor transgraft cell migration in a canine model.

Procedimientos endovasculares en patología aneurismática de la aorta abdominal en el Hospital Durand / Endovascular procedures in pathology of abdominal aortic aneurysms

Para el tratamiento del aneurisma de la aorta abdominal, el procedimiento intraluminal ofrece mejores resultados hospitalarios y de postoperatorio inmediato que la cirugía convencional, pero lo mas importante para nuestra consideración es darle la oportunidad quirúrgica a pacientes con patologías agregadas y severas que antes del advenimiento de las endoprótesis quedaban sin tratamiento quirúrgico. Se implantaron 26 endoprótesis expansibles por balón, la permeabilidad de las endoprótesis fue en 21 casos (80,76%). Los procedimientos fueron Aortobiilíaca 12 (46,15%) Aorto aèrtica 1 (3,8%) Aortomonoilíaca 13 (50%)

For the elective treatment of abdominal aortic aneurysm, intraluminal procedure provides beter results and postoperative hospital than conventional surgery, but more importantly for us is give you the opportunity to surgical patients with severe diseases and added before stent remained without surgical treatment. Expandable stents were implanted 26 balloon, stent patency was 21 cases (80.76%). The procedures were aorto biilíaca 12 (46.15%) an aorto aortic (3.8%) aorto monoilíaca 13 (50%)

Aneurisma de aorta abdominal concomitante à neoplasia gástrica / Case Report - aneurysm abdominal aorta concomitant with gastric neoplasia

Objetivos: Relato de caso associado à revisão de artigos científicos publicados sobre a ocorrência simultânea de aneurisma de aorta abdominal e câncergástrico em um mesmo paciente.Metodologia: Relato de caso associado à revisão bibliográfica. Resultados: A prioridade terapêutica quando ocorrecâncer gástrico e aneurisma de aorta abdominal num mesmo paciente, deve ser avaliada conforme a severidade e a urgência de cada uma dessas doenças.Yasuda et al defendem a idéia de que se há coexistência entre aneurisma de aorta abdominal e doença malignano trato gastrointestinal ambas necessitando intervenção urgente, cirurgia simultânea deve ser realizada. Luebke et al indicam que a cirurgia para o câncer gástrico deve ser realizada ao mesmo tempo que a cirurgia para oaneurisma, visto que não aumenta a morbi-mortalidade pós-operatória.Conclusão: Há controvérsias entre a escolha do tratamento cirúrgico prioritário entre aneurisma de aortaabdominal e câncer gástrico, quando ocorrem simultaneamente no mesmo paciente. A maioria dos autorespesquisados enfatiza a necessidade de se estabelecer critérios de urgência entre as duas patologias coexistentes,para mensurar qual cirurgia deve ser priorizada.

Objective: Case report associated with revision of scientific articles published about the simultaneous occurrence of abdominal aortic aneurysm and gastriccancer at the same patient. Methods: Case report associated with bibliographical revision. Results: The main treatment when gastric cancer andabdominal aortic aneurysm happen at the same time on a patient, must be evaluated in agreement the severity andthe urgency of each one of these illnesses. Yasuda et al defends the idea if there is coexistence between abdominal aortic aneurysm and malignant illness in the gastrointestinal,both needing urgent intervention, simultaneous surgery must be carried through. Luebke et al indicates that thesurgery for the gastric cancer must be carried through at the same time that the surgery for the aneurysm, becauseit doesnÆt increase postoperative mortality. Conclusion: There are controversies envolving the choice of wicth is the priority surgical treatment between abdominal aortic aneurysm and gastric cancer, when they occur simultaneously in the same patient. The majority of the authors emphasizes the need of establishing criteria of urgency between these diseases, to tell which surgery must be prioritized.

Limited Feasibility in Endovascular Aneurysm Repair Using Currently Available Graft in Korea

Despite the wide acceptance of endovascular aneurysmal repair in patients with abdominal aortic aneurysm (EVAR), stringent morphologic criteria recommended by manufacturers may preclude this treatment in patients with AAA. The purpose of this study was to investigate how many patients are feasible by Zenith and Excluder stent graft system, which are available in Korea. Eighty-two AAA patients (71 men, mean age 70 yr) who had been treated surgically or medically from January 2005 to December 2006 were included. Criteria for morphologic suitability (MS) were examined to focus on characteristics of aneurysm; proximal and distal landing zone; angulation and involvement of both iliac artery aneurysms. Twenty-eight patients (34.1%) were feasible in Zenith stent graft and 31 patients (37.8%) were feasible in Excluder. The patients who were excluded EVAR had an average of 1.61 exclusion criteria. The main reasons for exclusion were an unfavorable proximal neck (n=34, 41.5%) and problem of distal landing zone (n=25, 30.5%). There was no statistical significance among gender, age or aneurysm size in terms of MS. Only 32 patients (39%) who had AAA were estimated to be suitable for two currently approved grafts by strict criteria. However, even unfavorable AAA patients who have severe co-mobidities will be included in EVAR in the near future. Therefore, more efforts including fine skill and anatomical understanding will be needed to meet these challenging cases.

Disección aórtica toracoabdominal asintomática como hallazgo incidental: a propósito de un caso / Thoracoabdominal aortic dissection as an asymptomatic incidental finding: a purpose of a case

El Aneurisma se define como la dilatación del diámetro aórtico mayor a 5 cm. 40 por ciento de los mismos se localiza en aorta ascendente. El diagnóstico clínico sólo es posible en casos sintomáticos, con dolor torácico sordo, generado por expanción y compresión de estructuras vecinas, en una radiografía simple de tórax se ve la imagen de crecimiento aórtico o ensanchamiento del mediastino. Confirmación diagnóstica debe incluir estudio tomográfico o angiografía para definir el aneurisma con las ramas aórticas. 58 por ciento de los pacientes es asintomático, sin antecedentes de importancia. Se presenta una paciente femenina de 24 años de edad asintomática cardiovascular hasta el 24-01-2006, cuando inicia cuadro de dolor torácico súbito y disnea, radiografía de tórax, se evidencia gran imagen paracardíaca izquierda de densidad agua impresiona estar en relación con aorta descendente. La tomografía computarizada y ecosonograma transesofágico, concluye: aneurisma toracoabdominal con disección tipo B. Se procede a una toracotonomía posterolateral izquierda con freno laparotomía con abordaje de saco aneurismático y colocación de prótesis aórtica, desde la emergencia de la subclavia izquierda hasta por encima de las arterias renales. Evoluciona bien. Se concluye en la importancia de la clínica y los estudios radiológicos.

Relação morfológica entre o diâmetro, o colo proximal e distal dos aneurismas da aorta abdominal / Anatomic features related to diameter, proximal and distal neck of abdominal aortic aneurysms

Objetivo: Analisar relevantes aspectos anatômico-morfológicos dos aneurismas da aorta abdominal encontrados em necropsia. Método: Foram estudados 43 espécies compreendendo a aorta abdominal aneurismática. Para restabelecer o diâmetro arterial e a morfologia do aneurisma, um dispositivo que permite a distensão da parede arterial com pressão controlada foi introduzido na luz arterial. As medidas feitas nos espécimes consistiram de diâmetro transverso (látero-lateral e ântero-posterior), comprimento do aneurisma, diâmetro transverso e comprimento do colo proximal e distal...

Ongoing angiogenesis in blood vessels of the abdominal aortic aneurysm

Pathogenesis of the abdominal aortic aneurysm has been attributed to neovascularization of the aortic wall. However, it is not clear whether angiogenesis persists in the aneurysm. In sections of aneurysms, we determined the immunohistochemical distributions of the alpha v beta 3 integrin, tenascin and endothelial nitric oxide synthase (eNOS), which are markers respectively, of angiogenesis, matrix remodeling and vasoregulatory function. In addition, we used reverse transcription followed by in situ PCR, to determine the distribution of alpha v mRNA. All aneurysm specimens exhibited extensive increases of wall vascularization as compared with the control aortic wall, and showed the presence of perivascular inflammatory exudates containing macrophages and lymphocytes. The neovascularization consisted of thick-walled vessels in the media and adventitia, and capillaries in the subintima. The majority of vessels stained positively for the alpha v beta 3 antigen and eNOS. Tenascin was deposited as bands that circumscribed thick-walled vessels. The distribution of av mRNA was extensive and was positive even in those vessels that failed to stain for the alpha v beta 3 protein. No staining was evident in control aortas for the alpha v beta 3 antigen, tenascin or alpha v mRNA. The upregulation of av mRNA and the alpha v beta 3 integrin in blood vessels surrounded by a matrix expressing tenascin, indicates that angiogenesis is an ongoing process in the mature aortic aneurysm.

O uso do agente embolizante Onyx na oclusão de vazamentos pós-tratamento endovascular de aneurisma da aorta abdominal / The use of Onyx to seal endoleaks after endovascular treatment of abdominal aortic aneurysm

Doze cães foram utilizados neste estudo a fim de se criar aneurismas de aorta abdominal (AAA) que apresentassem vazamentos após tratamento endovascular. Uma etapa seguinte foi a oclusão destes vazamentos com o material embolizante Onyx. A presença e posterior oclusão dos vazamentos foram confirmados através de tomografias computadorizadas e angiografias. Obteve-se sucesso na criação do modelo experimental com vazamento em 9/12 cães. Onyx foi capaz de ocluir os vazamentos em todos os cães testados. A oclusão manteve-se estável até o final do estudo e a análise histológica demonstrou reação inflamatória mínima ao Onyx / Twelve mongrel dogs were used in this study to create abdominal aortic aneurysm (AAA) with endoleak after endovascular treatment. The next step was seal this endoleak with an embolic material called Onyx. The presence or occlusion of the endoleaks was proved by computer tomography and angiography. Succeed in the creation of the experimental model was observed in 9/12 dogs. Onyx was capable to seal endoleaks in all nine dogs that survived from AAA creation. The occlusion was stable until the end of the study and the histological analysis showed minimal inflammatory response to Onyx...

Aneurisma de la aorta abdominal: diagnóstico diferencial con la fibrosis retroperitoneal idiopática (Enfermedad de Ormond): a propósito de un caso / Abdominal aorta aneurism: differential diagnostic with idiopathic retroperitoneal fibrosis (Ormond Disease): to purpose of a case

Informar de una patología inusual del retroperitoneo la cual fue diagnósticada erróneamente como un aneurisma de aorta posiblemente fisurado. Descripción del caso clínico y revisión de la literatura. Servicio de Cirugía Cardiovascular. Hospital "Miguel Pérez Carreño". El hallazgo intraoperatorio reveló un intenso proceso inflamatorio retroperitoneal y aórtico compatible histológicamente con enfermedad de Ormond. La fibrosis retroperitoneal es una entidad infrecuente, por lo general es idiopática, relacionada con la administración de medicamentos u otras entidades. En la bibliografía no está descrito el diagnóstico diferencial con aneurisma de aorta