Can upwelling signals be detected in intertidal fishes of different trophic levels?

For intertidal fishes belonging to three species, the herbivore Scartichthys viridis (Blenniidae), the omnivore Girella laevifrons (Kyphosidae) and the carnivore Graus nigra (Kyphosidae), mass and body size relationships were higher in individuals from an upwelling zone compared with those from a non-upwelling zone. RNA:DNA were higher in the herbivores and omnivores from the upwelling zone. Higher biomass and RNA:DNA in the upwelling intertidal fishes may be a consequence of an increased exposure to higher nutrient availability, suggesting that increased physiological conditioning in vertebrates from upwelling areas can be detected and measured using intertidal fishes of different trophic levels.

DISSECT: a new mnemonic-based approach to the categorization of aortic dissection.

OBJECTIVE/BACKGROUND: Classification systems for aortic dissection provide important guides to clinical decision-making, but the relevance of traditional categorization schemes is being questioned in an era when endovascular techniques are assuming a growing role in the management of this frequently complex and catastrophic entity. In recognition of the expanding range of interventional therapies now used as alternatives to conventional treatment approaches, the Working Group on Aortic Diseases of the DEFINE Project developed a categorization system that features the specific anatomic and clinical manifestations of the disease process that are most relevant to contemporary decision-making. METHODS AND RESULTS: The DISSECT classification system is a mnemonic-based approach to the evaluation of aortic dissection. It guides clinicians through an assessment of six critical characteristics that facilitate optimal communication of the most salient details that currently influence the selection of a therapeutic option, including those findings that are key when considering an endovascular procedure, but are not taken into account by the DeBakey or Stanford categorization schemes. The six features of aortic dissection include: duration of disease; intimal tear location; size of the dissected aorta; segmental extent of aortic involvement; clinical complications of the dissection, and thrombus within the aortic false lumen. CONCLUSION: In current clinical practice, endovascular therapy is increasingly considered as an alternative to medical management or open surgical repair in select cases of type B aortic dissection. Currently, endovascular aortic repair is not used for patients with type A aortic dissection, but catheter-based techniques directed at peripheral branch vessel ischemia that may complicate type A dissection are considered valuable adjunctive interventions, when indicated. The use of a new system for categorization of aortic dissection, DISSECT, addresses the shortcomings of well-known established schemes devised more than 40 years ago, before the introduction of endovascular techniques. It will serve as a guide to support a critical analysis of contemporary therapeutic options and inform management decisions based on specific features of the disease process.

Customised stent graft for complex thoraco-abdominal aneurysm associated with congenital pelvic kidney.

INTRODUCTION: The association of aortic aneurysm with congenital pelvic kidney is an uncommon condition and has been described in association with abdominal aortic aneurysm (AAA) open repairs. REPORT: We present a case of a patient with a type IV thoraco-abdominal aortic aneurysm (TAAA) extending into the left common and internal iliac arteries associated with a congenital pelvic kidney who was treated with a customised endovascular prosthesis involving proximal fenestrations, bifurcation fenestration and a left internal deep iliac branch device. DISCUSSION: Although branch technology continues to evolve, cases such as this are encouraging for future widespread use. This approach allowed us to offer TAAA repair without compromising renal function in a patient with multiple co-morbidities who probably would not have withstood conventional open treatment.

Selective arterial embolisation: a first line measure for obstetric haemorrhage?

Selective arterial embolisation is increasingly used to arrest intractable postpartum haemorrhage. We report a case of postpartum haemorrhage following a placenta praevia, which had a successful outcome with selective arterial embolisation as the first treatment option. This technique should be more widely available, and in many instances should be considered before and in lieu of any surgical intervention.

Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?

BACKGROUND: Retroperitoneal haematoma is a rare clinical entity with variable aetiology, which is increasing in incidence mainly due to complications related to interventional procedures. There is no general consensus as to the best management plan for patients with retroperitoneal haematoma. METHODS: A literature review was undertaken using MEDLINE, all relevant papers on retroperitoneal haemorrhage or haematoma were used. RESULTS: The diagnosis is often delayed as symptoms are nonspecific. Retroperitoneal haematoma should be suspected in patients with significant groin, flank, abdominal, back pain or haemodynamic instability following an interventional procedure. Spontaneous haemorrhage usually occurs in patients who are anticoagulated. Multi-slice CT and arteriography are important for diagnosis. Most haemodynamically stable patients can be managed with fluid resuscitation, correction of coagulopathy and blood transfusion. Endovascular treatment involving selective intra-arterial embolisation or the deployment of stent-grafts over the punctured vessel is attaining an increasingly important role. Open repair of retroperitoneal bleeding vessels should be reserved for cases when there is failure of conservative or endovascular measures to control the bleeding. Open repair is also required if endovascular facilities or expertise is unavailable and in cases where the patient is unstable. If treated inappropriately, the mortality of patients with retroperitoneal haematoma remains high. CONCLUSION: There is a lack of level I evidence for the best management plans for retroperitoneal haematoma, and evidence is based on small cohort series or isolated case reports. Conservative management should only be reserved for patients who are stable. Interventional radiology with intra-arterial embolisation or stent-grafting is the treatment of choice. Open surgery is now rarely required.

Endoluminal repair of distal aortic arch aneurysms causing aorto-vocal syndrome.

PURPOSE: We have evaluated the efficacy of endovascular repair of distal aortic arch aneurysms (DAAA) causing recurrent laryngeal nerve palsy. MATERIAL AND METHODS: Eight patients (five male and three female) with median age of 72 years (range: 59-80) presented with left recurrent laryngeal nerve palsy associated with DAAA. All patients were considered unfit for open surgery. The median aneurysm size was 5.9 cm (range: 5-7.3). Thirteen stents were deployed: eight Gore, four Endofit and one Talent. Epidural anaesthesia was used in all patients. The left subclavian artery was covered in all and the left common carotid in three who had a preliminary right to left carotid-carotid bypass. Routine follow-up (FU) was with computed tomography (CT) at 3-6 months and yearly thereafter. RESULTS: Exclusion of the aneurysm sac was achieved in all patients. Thirty-day mortality was 0%, with no paraplegia or stroke. Early complications included: rupture of the external iliac artery (one) and common femoral artery thrombectomy (one). One patient died of unknown cause at 17 months. The mean FU in the remaining seven patients was 21 months (range: 6-51). Aneurysm size decreased in five, was unchanged in one and increased in one. Three patients had improvement in voice quality postoperatively. One patient had a recurrent type 1 endoleak which was restented twice. No late deaths have occurred. CONCLUSION: Though technically the procedures involved were more complicated, endovascular repair of DAAA causing aorto-vocal syndrome is safe and offers a realistic alternative to open surgery. Hoarseness of the voice can improve postoperatively and is associated with reduction in aortic sac diameter.

Ruptured thoracoabdominal aortic aneurysm in a renal transplant patient with Alport's syndrome.

Alport's syndrome is a rare genetic disorder of type IV basement membrane collagen synthesis that typically presents with nephropathy, deafness, and ocular abnormalities. To the best of our knowledge, this is the first report in the world's literature of ruptured thoracoabdominal aortic aneurysm in a young patient with Alport's syndrome and a renal transplant. Hypotheses on an association between collagen disease in Alport's syndrome and aortic aneurysms are discussed.

The aortic arch and ascending aorta: are they within the endovascular realm?

Aneurysms involving the ascending aorta and arch have been historically treated with open surgical techniques requiring cardiopulmonary bypass and, in cases involving the aortic arch, utilizing deep hypothermic circulatory arrest. The reported rates of mortality range from 0% to 16.5% for surgery addressing ascending aorta and arch pathology, and stroke rates of 2% to 18%. These statistics highlight the invasiveness of these procedures. Continued development and evolution of endovascular stent-grafts has allowed for the application of endovascular interventions in the proximal descending thoracic aorta and visceral aortic segments. Based on early experiences, attention has been focused on the ascending aorta and aortic arch, where unique challenges exist and have been addressed by both extra-anatomic bypass and novel methods incorporating branched and fenestrated devices. Device evolution, coupled with increased experience by the aortic interventionalist, has resulted in successful cases of endovascular management of every section of the aorta, including aortic valve replacement. However, these experiences have also been accompanied by significant complications. In this light, new endovascular endeavors must be considered in the context of conventional treatment options, hybrid procedures, and novel branched devices. Patient factors, such as specific anatomic issues, comorbid diseases, and functional levels must play an important role in the determination of therapeutic options. Ultimately, a clinician who understands the disease and is familiar with all treatment options (interventional, medical, and open surgical) will be best suited to provide care for the aortic patient. Finally, as with any assessment of interventional strategies, rigorous follow-up and serial imaging are essential.

Neurological complications following endoluminal repair of thoracic aortic disease.

Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.

Hybrid repair of type B dissecting aneurysm with associated Kommerell's diverticulum.

Endovascular therapy has revolutionised vascular surgery. Complex open surgical procedures may be replaced with a combination of extra-anatomical reconstruction and endovascular treatment. This minimally invasive approach is associated with a lower peri-operative morbidity and mortality than open repair. We describe a novel 2-stage treatment in a patient with Type B thoracic aortic dissection with subsequent aneurysmal dilatation and the added difficulty of a concomitant aneurysmal aberrant right subclavian artery (Kommerell's diverticulum).

Large infra-renal abdominal aortic aneurysms: endovascular vs. open repair--single centre experience.

Endovascular aneurysm repair (EVAR) has become an established alternative to open repair (OR). We present a consecutive series of 486 elective patients with large infra-renal aortic abdominal aneurysm, comparing OR with EVAR. Prospective data collected during an 8-year period from January 1997 to October 2005 was reviewed. Statistical analysis performed using SPSS data editor with chi(2) tests and Mann-Whitney U-tests. There were 486 patients with 329 OR (293 males, 36 females) with median age of 72 years with median diameter 6.3 cm and 157 EVAR (148 males, 9 females) with median age 75 years with median diameter 6.1 cm. Mortality was 13 (4%) for OR and 5 (3.2%) for EVAR (three of whom were in the UK EVAR 2 trial). Blood loss was significantly less for EVAR 500 ml vs. 1500 ml for OR. Sixty-five (19.8%) patients with OR had significantly more peri-operative complications compared with 14 (8.9%) with EVAR. The length of stay in hospital was significantly less for EVAR. This non-randomised study shows that although EVAR does not have a statistically significantly lower mortality, it does have statistically significantly lower complication rates compared with OR. EVAR can be achieved with good primary success, but long-term follow-up is essential to assess durability.

Successful treatment of a chronic post-traumatic 5-year-old osteoporotic vertebral compression fracture by percutaneous vertebroplasty.

Osteoporotic vertebral compression fracture (VCF) is a frequently encountered clinical problem associated with chronic pain and disability. Conservative treatment in the form of bed rest, pain control and bracing may create a vicious circle, in which reduced activity leads to further reduction in bone density and fracture risk. Percutaneous vertebroplasty (PVP) is an accepted treatment modality for osteoporotic vertebral body collapse present for less than 1 year, vertebral myeloma, haemangioma, metastasis and recent traumatic fractures (between 3 and 12 months). We describe an osteoporotic patient in whom successful PVP was performed, under general anaesthesia using CT and fluoroscopic guidance, in a post-traumatic 5-year-old VCF with complete alleviation of debilitating pain. In the light of our experience, we suggest that PVP should be carried out in a series of similar patients to asses its value as a treatment option in patients with chronic osteoporotic vertebral fractures for pain relief and improvement in mobility, independent of fracture age.

Case report: Endovascular repair of a ruptured abdominal aortic aneurysm under local anaesthesia.

Abdominal aortic aneurysm (AAA) is a common degenerative condition affecting the elderly population. Rupture carries a high overall mortality. Elective endovascular stent graft repair is well described. We describe a patient with ruptured AAA and co-morbid conditions making him unfit for surgery and general or epidural anaesthesia, who was successfully treated by endovascular stent graft under local anaesthesia.

The management of mycotic aortic aneurysms: is there a role for endoluminal treatment?

BACKGROUND: Mycotic aneurysms are rare. Conventional surgical options include ligation or excision with in-situ or extra-anatomical reconstruction. The use of endoluminal stenting for mycotic aneurysms in the presence of sepsis is controversial, but may be a temporising measure, or sometimes the only option in the management of critically ill patients who are not fit for surgery. METHODS: A literature review was undertaken using Medline, all relevant papers on endoluminal management of mycotic aneurysm were taken into account. RESULTS: Open surgical repair of mycotic aortic aneurysm is associated with considerable peri- and post-operative morbidity and mortality. Endoluminal treatment with stent-grafts has been introduced as an alternative, and early results are promising. CONCLUSION: No level I evidence for the endoluminal treatment of mycotic aneurysms exists. Ideally a randomised controlled trial of open surgery versus endoluminal treatment should be performed but this may be difficult to perform because of the low incidence of infected aneurysms.