Resection of a Large Innominate Vein Aneurysm in a Patient with Neurofibromatosis Type 1.

BACKGROUND: Venous aneurysms are exceedingly rare manifestations of neurofibromatosis type 1 (NF1). There are only a handful of cases reported, and no prior cases describing treatment of mediastinal venous aneurysms in this patient population exist. CASE REPORT: A 58-year-old woman with NF1 presented with a right neck mass. The mass had recently doubled in size and was associated with cough, hoarseness of voice, and pain. Her pertinent medical history included untreated obstructive sleep apnea, severe pulmonary hypertension, and a recent hospital admission for pneumonia. On physical examination, numerous cutaneous neurofibromas were noted. The mass encompassed her right neck and supraclavicular area with marked respiratory variation. Computed tomography showed a complex 7-cm venous aneurysm including her right innominate, internal jugular, and subclavian veins. Surgical approach involved median sternotomy with right cervical extension and a right infraclavicular counter incision. Extracorporeal circulation was established through the left groin. Ligation of the right internal jugular vein was required. The aneurysm was completely excised, and venous reconstruction consisted of cryopreserved femoral vein anastomosed to right innominate and infraclavicular subclavian veins. Intraoperatively, her preexisting pulmonary hypertension resulted in acute right heart failure requiring placement of a right ventricular assist device (RVAD). She subsequently returned to the operating room for RVAD weaning and sternal closure. Her postoperative course was lengthy; however, many of her aneurysm-related symptoms resolved. CONCLUSIONS: This case represents management of the only innominate vein aneurysm in the setting of NF1 described in the literature. Vascular reconstruction is possible, however difficult. Careful preoperative planning and use of extracorporeal circulation was necessary in this case.

Periaortic pedicle screw removal with endovascular control of the aorta and intraoperative aortography: a case report and review of the literature.

Study Design Case report and review of the literature. Objective The objective of the article is to report the case of a 20-year-old patient with a threatened aortic injury from pedicle screw instrumentation successfully managed without aortic grafting. Methods The patient's clinical course is retrospectively reviewed. The offending hardware was removed after gaining endovascular control of the aorta. Results Intraoperative aortography was normal and no graft was placed. The patient remains asymptomatic at 2 years after surgery. Conclusions Hardware impinging on the aorta can safely be removed by gaining endovascular control of the aorta. In the setting of normal intraoperative aortography in a young patient, we recommend against further intervention to avoid the known morbidity of aortic grafting.

A design modification to minimize tilting of an inferior vena cava filter does not deliver a clinical benefit.

OBJECTIVE: In July 2007, our group began to use a modified conical inferior vena cava filter with additional stabilizing struts designed to reduce tilting of retrievable filters. We analyzed our experience with this modified filter (Cook Medical, Bloomington, Ind) from July 1, 2007 to December 31, 2008 and compared it to our experience with the standard filter (Günther Tulip, Cook Medical, Bloomington, Ind) from January 1, 2006 through December 31, 2008 to determine if adoption of the modified filter reduced tilting and delivered a discernible clinical benefit. METHODS: The primary outcome measure was tilt angle after deployment. Secondary outcomes were change in tilt angle between deployment and retrieval (self-centering) and retrieval failure due to inability to engage the filter hook. Measurements were retrospectively determined using the anteroposterior venogram at the time of placement and removal. Tilt angle was defined by the center line of the filter relative to the center line of the inferior vena cava (IVC). Statistical significance was assumed for P ≤ .05. RESULTS: During the study period, a total of 302 IVC filters were placed. Retrieval was attempted for 85 of 194 (44%) standard filters and 52 of 108 (48%) modified filters. The overall difference in tilt angle (degrees) between the standard (median [interquartile range] = 5 [3, 8]) and modified (5 [3, 8]) filters at the time of placement was not statistically significant (P = .44). Modified filters deployed through a femoral route (8 [4, 11]) had significantly greater tilt angles than modified filters deployed using jugular access (4 [2, 6]; P < .0001). At the time of retrieval, evidence of self-centering was observed more often with modified (32 of 52 [62%]) than standard (36 of 85 [42%]) filters (P = .03). Overall, there were only four failures to retrieve the filter due to excess tilting (standard, 3 of 85 [4%], modified, 1 of 52 [2%]; P = .59). CONCLUSION: Overall, tilt angle at insertion did not differ between the modified and standard filters, although more modified filters displayed self-centering. There was no difference between the groups in retrieval failure due to excess tilting. Despite its greater tendency to self-center, we did not recognize a measurable clinical advantage of the modified filter.

Delayed abdominal closure in the management of ruptured abdominal aortic aneurysm.

The objective of this study was to compare initial use of the open abdomen using the vacuum-pack technique followed by delayed abdominal closure with standard primary abdominal closure in the treatment of ruptured abdominal aortic aneurysm (rAAA) repair. A retrospective review identified 122 rAAA cases, which were divided into two management eras: era 1 (primarily closed) and era 2 (47% open abdomen).One hundred three patients were included in this review: 58 in era 1 and 45 in era 2. Evidence of one of three ischemia-reperfusion (IR) criteria, preoperative hypotension, estimated blood loss > or = 6 L, or intraoperative resuscitation with > or = 12 L, predicted mortality. These criteria were also used as surrogate clinical markers for abdominal compartment syndrome. The in-hospital mortality was higher in those with at least one IR criterion: 43% versus 10% (p = .0003). In those with at least one IR criterion, the initial 24-hour mortality was 21% for era 1 versus 0% for era 2 (p = .03), and the 30-day mortality was 40% for era 1 and 32% for era 2 (p = .77).Three IR criteria were identified and were associated with increased mortality. Patients with these risk factors who were treated with delayed abdominal closure had an improved acute survival rate and a trend for improved long-term survival.