The endovascular management of visceral artery aneurysms and pseudoaneurysms.

OBJECTIVE: Visceral artery aneurysms may be treated by aneurysm exclusion, excision, revascularization, and endovascular techniques. The purpose of this study was to review the outcomes of the management of visceral artery aneurysms with catheter-based techniques. METHODS: Between 1997 and 2005, 90 patients were identified with a diagnosis of visceral artery aneurysm. This was inclusive of aneurysmal disease of the celiac axis, superior mesenteric artery (SMA), inferior mesenteric artery, and their branches. Surveillance without intervention occurred in 23 patients, and 19 patients underwent open aneurysm repair (4 ruptures). The endovascular treatment of 48 consecutive patients (mean age 58, 60% men) with 20 visceral artery aneurysms (VAA) and 28 visceral artery pseudoaneurysms (VAPA) was the basis for this study. Electronic and hardcopy medical records were reviewed for demographic data and clinical variables. Original computed tomography (CT) scans and fluoroscopic imaging were evaluated. RESULTS: The endovascular treatment of visceral artery aneurysms was technically successful in 98% of 48 procedures, consisting of 3 celiac axis repairs, 2 left gastric arteries, 1 SMA, 12 hepatic arteries, 20 splenic arteries, 7 gastroduodenal arteries, 1 middle colic artery, and 2 pancreaticoduodenal arteries. Of these, 29 (60%) were performed for symptomatic disease (5 ruptured aneurysms). Procedures were performed in the endovascular suite under local anesthesia with conscious sedation (94%). The femoral artery was used as the preferential access site (90%). Coil embolization was used for aneurysm exclusion in 96%. N-butyl-2-cyanoacrylate (glue) was used selectively (19%) using a triaxial system with a 3F microcatheter for persistent flow or multiple branches. The 30-day mortality was 8.3% (n = 4). One patient died from recurrent gastrointestinal bleeding after gastroduodenal embolization, and the remaining died of unrelated causes. All perioperative deaths occurred in patients requiring urgent or emergent intervention in the setting of hemodynamic instability. No patients undergoing elective intervention died in the periprocedural period. Postprocedural imaging was performed after 77% of interventions at a mean of 16 months. Complete exclusion of flow within the aneurysm sac occurred in 97% interventions with follow-up imaging, but coil and glue artifact complicated CT evaluation. Postembolization syndrome developed in three patients (6%) after splenic artery embolization. There was no evidence of hepatic insufficiency or bowel ischemia after either hepatic or mesenteric artery aneurysm treatment. Three patients required secondary interventions for persistent flow (n = 1) and recurrent bleeding from previously embolized aneurysms (n = 2). CONCLUSION: Visceral artery aneurysms and pseudoaneurysms can be successfully treated with endovascular means with low periprocedural morbidity; however, the urgent repair of these lesions is still associated with elevated mortality rates. Aneurysm exclusion can be accomplished with coil embolization and the selective use of N-butyl-2-cyanoacrylate. Current catheter-based techniques extend our ability to exclude visceral artery aneurysms, but imaging artifact hampers postoperative CT surveillance.

Endovascular management of acute critical ischemia secondary to blunt tibial artery injury.

We report a case of acute limb-threatening ischemia from blunt traumatic tibial arterial disruption managed with endoluminal techniques. An otherwise healthy 37-year-old man involved in a motorcycle crash sustained a compound fracture of his right tibia and fibula. Arterial insufficiency developed after surgical reduction of the orthopedic injuries that warranted selective angiography of the involved extremity. This demonstrated complete occlusion of the infrageniculate circulation at the level of the ankle. Recanalization of the posterior tibial artery was achieved by using coronary balloon-expandable stents, thereby reestablishing in-line flow to the foot. Clinical and noninvasive surveillance at 2 years confirmed patency of the recanalized artery with the absence of any ischemic symptoms. Arterial reconstruction of the infrapopliteal arterial tree poses a formidable challenge in the setting of blunt trauma. Recent improvements in endovascular skills, endoluminal technology, and imaging capabilities have allowed percutaneous reconstruction of challenging arterial pathology. Endovascular treatment of blunt tibial injuries is an alternative to complex open reconstructions. These patients require close long-term postoperative surveillance because the durability of such a repair remains unknown.

Emerging drugs in peripheral arterial disease.

Peripheral arterial disease (PAD) is the manifestation of atherosclerotic occlusion within a peripheral vascular bed. This can occur in any noncoronary arterial bed, but PAD most commonly refers to atherosclerosis in the aorto-iliac system and infrainguinal vessels that lead to symptoms in the lower extremities. The disease most often becomes clinically apparent in elderly individuals, commonly presenting as intermittent claudication. More advanced, or multisegmental disease, may present with ischaemic rest pain or tissue loss. Although the limb manifestations of PAD can be disabling, PAD is also a marker of coronary or cerebrovascular atherosclerosis. In fact, approximately 80% of mortality in PAD patients is secondary to a cardiovascular event. In accordance with this, initial medical management of this disease focuses on preventative and risk reduction strategies to minimise the risk of cardiovascular morbidity and mortality. At present, the majority of recommendations with respect to risk reduction therapy in PAD patients are extrapolated from the coronary and cerebrovascular literature. Limb-directed therapy in PAD intends to minimise symptoms and serve as an adjunct to surgical intervention. However, existing data on the efficacy of these agents suggests that they are only partially effective. In addition, the effect of existing nonoperative intervention on the progression of disease has not been completely elucidated. As such, new therapies are under development, which target various goals, including minimising local progression of disease, minimising disability, reducing systemic cardiovascular morbidity/mortality and augmenting the durability of surgical intervention.

Recurrent aortic angiosarcoma--a case report and review of the literature.

Primary aortic tumors are rare; only 86 cases of primary aortic angiosarcoma have been reported since its first description in 1873. The diagnosis of aortic angiosarcoma is usually confirmed by postoperative pathologic examination or postmortem study. The authors present a case of primary aortic angiosarcoma with postresection recurrence.

Endovascular management of traumatic axillary artery dissection--a case report and review of the literature.

A 43-year-old man was admitted to this hospital with a cool, slightly numb, left upper extremity after trauma. Physical examination revealed a cool left forearm and hand, with no distal pulses. An intraoperative angiogram demonstrated short-segment dissection and occlusion of the left axillary artery. A 10 mm x 40 mm self-expanding stent was placed across the intimal flap to reinstitute peripheral flow. Early postoperative duplex scanning showed normal flow through the axillary artery.

Gene expression after crush injury of human saphenous vein: using microarrays to define the transcriptional profile.

BACKGROUND: Vein graft stenosis is believed to be the pathophysiologic response of vascular tissue to injury and is the major cause of vein graft failure. Therapeutic interventions might improve with knowledge of the physiologic pathways involved in the hyperplastic response to vascular injury. In this study, our purpose was to identify induced, early pathways that might be important in the human response to vascular injury. STUDY DESIGN: Human saphenous vein from 7 patients was organ cultured or crush injured and cultured for 48 or 72 hours after harvest. Gene expression was determined for syngeneic veins at harvest and at the experimental time points and compared to determine which genes were induced or repressed. Expressed genes (the transcriptional profile) were then assigned to functional physiologic classes. RESULTS: At 72 hours, in both organ-cultured and crush-injured vein, the gene for the Wnt ligand protein (WNT5A) was induced. At 48 hours in the organ-cultured vein only, the gene for the Frizzled protein (FZD2), a subunit of the Wnt receptor complex, was repressed. At 72 hours in injured vein only, the gene for the product of Wnt signaling (WISP1) was induced; the gene for the Wnt-binding, soluble Frizzled-related protein (FRZB) was repressed; and the gene for Dickkopf (DKK1) protein, which binds to the low density lipoprotein receptor-related protein subunit of the Wnt receptor complex, was induced. CONCLUSIONS: Early induction of WNT5A, coupled with the coordinated induction and repression of genes that modulate the Wnt signaling pathway, led to the early, selective induction of WISP1 and no other Wnt-inducible genes. This early, selective expression of a limited gene set might characterize the human vascular response to injury, and could enable development of therapies to treat the clinical sequelae of this response.

Inferior vena cava filter ensnarement by central line guide wires--a report of 4 cases and brief review.

Ensnarement of inferior vena cava filters with central line guide wires is an infrequent complication that has been sporadically reported. The authors present 4 patients who experienced this complication. They review the literature, make recommendations to avoid this preventable complication, and recommend what to do once the complication occurs.

Recurrent asystolic cardiac arrest and laparoscopic cholecystectomy: a case report and review of the literature.

Laparoscopic surgery has become a durable alternative for both gynecologic and general surgical procedures, but reported complications are increasing. We describe the case of a 70-year-old male undergoing routine laparoscopic cholecystectomy for gallstone pancreatitis who developed asystolic cardiac arrest intraoperatively. A review of the literature revealed 2 cases of asystolic cardiac arrest during laparoscopy: one was during laparoscopic cholecystectomy and one was during diagnostic laparoscopy for gynecologic evaluation.

Necrotizing fasciitis of the head and neck: a report of two patients and review.

BACKGROUND: Necrotizing fasciitis is a disfiguring condition that can be fatal. The head and neck region is rarely affected. However, when involved, the functional and cosmetic sequelae can be considerable. MATERIALS AND METHODS: We present two case histories, discuss salient diagnostic points, treatment, and review published data on this topic. RESULTS: With a timely diagnosis we were able to diagnose and appropriately treat these patients. CONCLUSIONS: Necrotizing fasciitis is a disfiguring condition that can be fatal if not diagnosed in a timely fashion. Diagnosis and treatment require a high index of suspicion, immediate operative intervention, broad-spectrum antibiotics, and appropriate supportive care.

Ultrasound-guided thrombin injection of iatrogenic pseudoaneurysm at a community hospital.

The purpose of this study was to report the success rate of treating pseudoaneurysm using ultrasound-guided thrombin injection at a community hospital. Over 16-month period, 42 patients with femoral artery pseudoaneurysms were treated using ultrasound-guided thrombin injection. Our results showed that ultrasound-guided thrombin injection has a high success rate, and can be safely performed at a community hospital.