Endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome is a connective tissue disorder caused by abnormal collagen synthesis. Vascular complications, including aneurysm formation and spontaneous arterial perforations, are difficult to manage surgically and result in significant operative mortality due to blood vessel fragility. We describe the first reported successful endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome. We discuss the advantages endovascular surgery offers over open surgery in these patients. We believe that endovascular repair of abdominal aortic aneurysms preferentially over open repair merits consideration in patients with Ehlers-Danlos syndrome.

Endovascular management of blunt abdominal aortic injury.

The endovascular management of blunt aortic injuries is being used more frequently in the trauma patient. Traumatic aortic injuries usually occur in the descending thoracic aorta near the origin of the left subclavian artery. Many reports in the literature demonstrate the efficacy of endovascular repair of blunt thoracic aortic injury. We report here an unusual case of abdominal aortic dissection secondary to blunt abdominal trauma following a fall. The patient also had associated intra-abdominal injuries requiring bowel resection and repair of small bowel mesenteric lacerations. He was treated with a bifurcated abdominal endograft with an excellent result after the initial operation was performed to treat the bowel injuries.

Secondary conversion of the Gore Excluder to operative abdominal aortic aneurysm repair.

OBJECTIVE: Reports continue to document the occurrence of major adverse events after endovascular aortic aneurysm repair. Although many of these problems can be successfully managed through endovascular salvage, operative conversion with explantation of the endoprosthesis remains necessary in some patients. We report herein a review of all patients initially enrolled in multicenter US clinical trials of the Excluder endograft who underwent secondary conversion to open surgical repair. METHODS: Clinical data and relevant medical records of patients enrolled in phase I and II multicenter US clinical trials of the Excluder endograft were retrospectively reviewed for adverse events and further narrowed to those patients who underwent secondary operative conversion. Hospital records, operative and anesthesia reports, and all imaging studies were analyzed at initial implantation and at the time of subsequent open surgical repair. RESULTS: Late open conversion was performed in 16 (2.7%) of the 594 patients enrolled in the Excluder clinical trials. Presumed endotension accounted for 8 of 16 of secondary conversions. In two of these patients, however, an endoleak was identified at the time of open surgical repair. Of the remaining eight patients, two underwent conversion for device infection, five for persistent endoleak, and one for aneurysm rupture. The overall 30-day mortality was 6.25% (1/16), with one death occurring in a patient with a ruptured aneurysm. Of patients who underwent conversion because of endotension, the maximal abdominal aortic aneurysm diameter (mean +/- SD) at the time of initial implantation and subsequent graft removal was 61 +/- 11 mm and 70 +/- 10 mm, respectively. The mean time to open conversion for treatment of endotension was 37 +/- 12 months (range, 20-50 months; median, 42 months). Freedom from conversion was 98.6% and 96.7% at 24 and 48 months, respectively. CONCLUSIONS: Endotension in the absence of a demonstrable endoleak has been a major indication for late surgical conversion in patients treated with the Excluder endograft. Given the potential presence of an undetected endoleak and the possible effects of progressive sac enlargement on long-term device stability, continued close surveillance of patients with assumed endotension is required. Should changes in device design eliminate endotension, a further reduction in the already low incidence of late open conversion of the Excluder endograft can be anticipated.

Repair of mycotic aortic pseudoaneurysm with a stent graft using transesophageal echocardiography.

A 54-year-old man who underwent uneventful orthotopic heart transplantation 1 year previously had low-grade fever and dyspnea. Imaging studies revealed an ascending aortic pseudoaneurysm (AAP), which was repaired with a 5-mm polyester patch, with circulatory arrest and cardiopulmonary bypass. Intraoperative cultures of the AAP grew methicillin-resistant Staphylococcus aureus, and the pseudoaneurysm recurred after 6 weeks despite intravenously administered antibiotic therapy. A 28.5-mm x 3.3-cm Gore Excluder aortic cuff was deployed in the ascending aorta through a left axillary artery cutdown with use of combined transesophageal echocardiography and fluoroscopy. In addition, controlled hypotension and asystole were established with administration of adenosine to facilitate precise device deployment. Postoperative imaging with transesophageal echocardiography and magnetic resonance angiography revealed complete resolution of the AAP, and the patient had done well at 7-month follow-up. Treatment of a mycotic aortic pseudoaneurysm with an endoprosthesis in a patient without other treatment alternatives can be performed safely, with acceptable short-term results.

The Reliability of Computer-Processed EEG in the Determination of ECT Seizure Duration.

The reliability of single-channel analog EEG and two-channel, computer-processed EEG (cEEG) in determining seizure duration during electroconvulsive therapy (ECT) was studied in 144 consecutive individual treatment sessions of 14 hospitalized patients. Seizure durations determined by post hoc, blind readings of data generated by each method were compared. These estimates of seizure duration were also compared to those determined by the "cuff" method. We found that under our study conditions, the cEEG method was more reliable than the EEG method in two tests of reliability: the cEEG method had fewer readings with a discrepancy of 10 s or more between readers, and had a higher degree of correlation between readers. There was no difference, however, between the cEEG and EEG methods when comparing mean differences and the mean absolute difference between readers within the methods. We also found that the EEG and cEEG methods detected seizure durations that were substantially longer than those detected by the "cuff" method. We conclude that under our study conditions, cEEG was more reliable than analog EEG in certain measures of reliability.