Endograft-assisted coil embolization of a celiac trunk aneurysm.

BACKGROUND: Celiac trunk aneurysms are rare but potential life-threatening lesions. Endovascular techniques are more often used for their treatment because of low rates of morbidity and mortality. CASE REPORT: We describe a modification of stent-assisted coil embolization technique more commonly used in the treatment of intracranial aneurysm, to exclude a 50-mm diameter celiac trunk aneurysm. The patient was a 67-year-old man who had a previous exclusion of a symptomatic aortic aneurysm, with occlusion of the inferior mesenteric and both hypogastric arteries. Anatomic features of the celiac trunk aneurysm and its branches do not allow treatment with a straight endograft or maintain direct flow to the hepatic artery. We then performed an endograft-assisted coil embolization of the aneurysm, with a straight flow line to the splenic artery. CONCLUSION: Endograft-assisted coil embolization is a feasible and safe technique to allow selective embolization of the sac and the presence of direct flow to the splenic artery and indirect flow to the hepatic artery.

Predictors of cervical bleeding after carotid endarterectomy.

BACKGROUND: The aim of this study is to determine the incidence of severe cervical bleeding requiring reintervention after carotid endarterectomy (CEA), to identify its predictive parameters, and to find out the influence of these on major complications. METHODS: This was a retrospective review of 502 CEAs carried out in 455 consecutive patients between 1995-2011 in our institution. The end points were: postoperative cervical bleeding that required reoperation and major postoperative complications (i.e., stroke, myocardial infarction, and death). Patients' demographics, antiplatelet and anticoagulant treatment, anaesthetic technique, surgical details, and perioperative management were registered. The end point predictors were univariate and multivariate analyzed. RESULTS: Neck bleeding after CEA occurred in 42 cases (8.4%), requiring reoperation in 28 cases (5.6%). In the univariate analysis, chronic anticoagulation and anticoagulation 24 hours before surgery were associated with reoperation for bleeding (16.6% vs. 4.8% [P = 0.02] and 17.8% vs. 4.7% [P = 0.014], respectively). The agent used for antiplatelet treatment before surgery was related to reoperation in the univariate analysis and was the only factor with statistical significance in the multivariate analysis: acetylsalicylic acid (ASA) 100 mg (2.4%), ASA 300 mg (1.5%), clopidogrel 75 mg (7.8%), ASA 100 mg associated with clopidogrel (3.3%), triflusal (5.5%), and ticlopidine (2.2%); there was a higher incidence of reoperation only in the group of patients who had taken clopidogrel 24 hours before CEA (4.7% vs. 1.05% [P = 0.06], respectively) but without statistical significance (odds ratio: 2; 95% confidence interval: 0.95-4.84). No reoperations were registered using vein patch compared to prosthetic patch (0% vs. 6.1% [P = 0.028]). Conversion to general anesthesia (22.2% vs. 4.9% [P = 0.014]) and noncontrollable postoperative hypertension (6.9% vs. 2.5% [P = 0.028]) were associated with a higher rate of reoperation. There were no statistically significant differences in the reoperation rates related to bleeding for anesthetic technique (local versus general), surgical procedure (classic endarterectomy versus eversion technique), type of prosthetic patch (Dacron/politetrafluoroethylene), use of shunt, intraoperative dose of heparin, protamine reversal, activated clotting time monitoring, or surgeon qualification level. The combined rate of stroke mortality was 2.6%. Reoperation for bleeding was not associated with an increased rate of thrombosis, stroke, death, or injury of cranial nerves. CONCLUSIONS: Postoperative severe bleeding after carotid surgery in our institution is not an uncommon complication. Its incidence is within the range reported in the literature, but it is not associated with major complications or mortality. Antiplatelet treatment with clopidogrel is the main risk factor associated with reintervention. Other factors, such as coagulation control, postoperative hypertension management, and the use of an autologous patch, could help reduce its incidence.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm.

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Popliteal artery aneurysm in patient with Klippel--Trénaunay--Weber syndrome.

BACKGROUND: The association of Klippel-Trénaunay-Weber syndrome (KTWS) with artery aneurysms is very rare. METHODS AND RESULTS: A 61-year-old man, diagnosed with left lower limb KTWS, presented with a venous ulcer and a popliteal aneurysm measuring 3.5 cm in diameter in the same limb. Endovascular treatment with covered stent was applied with good morphological and clinical results. CONCLUSION: We report a singular case of the association of a popliteal aneurysm with KTWS and its endovascular treatment. This treatment enabled exclusion of the popliteal artery aneurysm with safety and effectiveness and reduced the number of arteriovenous fistulas.