Management and therapeutic options for abdominal aortic aneurysm coexistent with horseshoe kidney.

BACKGROUND: Horseshoe kidney (HSK), referring to the abnormal fusion of the lower renal poles, represents one of the most common renal anomalies. One of its most significant features is the anomalous vasculature, with a number of accessory renal arteries originating from the aorta, the mesenteric arteries, and even the iliac arteries supplying both the renal kidneys and the renal isthmus. METHODS: A literature review was performed to identify and to present the most recent data regarding classification and imaging evaluation of HSK concomitant with abdominal aortic aneurysm (AAA). Furthermore, an in-depth analysis of both open surgical and endovascular repair is made for management of this rare medical condition. RESULTS: The anomalous renal vasculature of HSK has led to the introduction of a number of classification systems, with Eisendrath's being currently the most commonly used. The concomitant presence of HSK in patients suffering from AAA plays a major role in preoperative planning, with a number of factors taken into consideration in deciding on either an open repair or an endovascular approach. Open repair requires careful decision-making between a transperitoneal and a left retroperitoneal approach to reach the aneurysm sac. In addition, technical points include the decision to divide the renal isthmus or not and the necessity of salvage or reimplantation of anomalous renal vessels. On the other hand, an endovascular approach requires careful preoperative imaging and evaluation of both the renal function and vasculature to decide on catheterization and salvage of accessory renal arteries or their exclusion. CONCLUSIONS: The concomitant presence of AAA and HSK poses a challenge for the modern vascular surgeon, who must possess all required technical skills-both endovascular and open repair-to deal accordingly with this rarely encountered medical condition. Preoperative determination of the perfusion pattern is necessary for the treatment strategy.

Primary Stenting of Right-Sided Subclavian Artery Stenosis Presenting as Subclavian Steal Syndrome: Report of 3 Cases and Literature Review.

BACKGROUND: Right-sided subclavian artery stenosis (SAS) is a rare cerebrovascular disease involving the upper extremities. Considering an endovascular approach for its management requires increased endovascular and catheterization skills when compared with the left side, due to the close approximation of the right subclavian artery origin, vertebral, and common carotid arteries. METHODS: Three patients suffering from proximal right-sided SAS were treated in our center through primary stenting. Percutaneous transfemoral and transbrachial approaches were used for vascular access, whereas in 2 cases an additional carotid protection device was deployed intraoperatively. RESULTS: Technical success was met in all 3 cases, with no intraoperative or postoperative complications being observed. All patients resumed ambulation and were uneventfully discharged the next day with dual antiplatelet medication. No recurrent stenosis was reported in duplex ultrasound scan during 6-month follow-up, with all patients reporting resolution of their symptoms. DISCUSSION: Subclavian artery stenosis is an uncommon vascular disease, showing a 4-fold left, rather than right-sided predisposition. Although a low-grade stenosis is usually asymptomatic and may remain unobserved, a severe stenosis may cause retrograde blood flow in the ipsilateral vertebral artery, leading to a medical condition with various clinical symptoms, known as subclavian steal syndrome. A number of open surgical techniques exist for management of subclavian artery stenosis, although a paradigm shift in the 21st century has led to the introduction of minimally invasive techniques for its treatment, with available modalities including angioplasty, stenting, and the kissing stent technique.

Endovascular Treatment of Infrarenal Isolated Abdominal Aortic Dissection with Application of the Kissing Stents Technique: A Case Report and Review of the Literature.

Isolated abdominal aortic dissection (IAAD) is a rare form of aortic dissection involving usually the infrarenal part of the abdominal aorta. A 45-year-old male presented with lumbar pain and claudication. Computed tomography angiography (CTA) revealed an infrarenal IAAD extending to the left external iliac artery (EIA), causing ≥90% narrowing of the lumen. An endovascular approach was decided, with deployment of an aortic stent-graft and two balloon expandable stents in both common iliac arteries (IAs), applying the kissing stents technique. Post-surgical course was uneventful; 12 month follow-up showed excellent vessel patency. Endovascular therapy seems to be a feasible treatment option with promising long-term follow-up results.

Fenestrated and Branched Stent Grafting in Complex Aneurysmatic Aortic Disease: A Single-Center Early Experience.

BACKGROUND: The aim of this study is to present our early experience and highlight the technical difficulties associated with the use of fenestrated and branched stent grafts to treat patients with juxtarenal abdominal aortic aneurysm (AAA), pararenal AAA, and thoracoabdominal aortic aneurysms (TAAAs). METHODS: A prospectively held database maintained at our department was queried for patients who have undergone branched and fenestrated stent grafting for AAA or TAAA treatment. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality, morbidity, and reintervention rate were evaluated. RESULTS: A total of 8 patients underwent repair with a fenestrated or branched stent graft. All patients had aneurysmal degeneration of the juxtarenal aorta, pararenal aorta, and thoracoabdominal aorta not suitable to standard endovascular techniques. Two patients had a prior aortic repair, a failed migrated stent graft, and an old surgical tube graft after an open repair. One patient had a type III TAAA and 1 patient had a postdissection TAAA type I. For all patients, target vessel success rate was 96.4% (27/28) and mean hospital stay was 6.0 days (range 3-21). Thirty-day and 1-year mortality were 0%. Mean follow-up was 23 months (range 7-45). Two endoleaks occurred, 1 type III and 1 type II, which were treated endovascularly. No death or major complication occurred during follow-up. CONCLUSIONS: Fenestrated and branched endovascular stent grafts can be used to repair juxtarenal AAA, pararenal AAA, and TAAA in patients with significant comorbidities. However, several technical challenges have to be overcome due to the unique complex aortic pathology of each patient.

Endovascular Treatment of Type Ib Endoleak after Evar Using the IBD Device: A Case Report.

In the modern endovascular era, abdominal aortic aneurysm repair is still not free of complications with re-interventions following endovascular aneurysm repair (EVAR) being more common than with open surgical repair. A variety of endovascular, open surgical and combined techniques were described according to the anatomical considerations and general health of the patient to achieve the best possible result after these complications. In cases of type Ib endoleak following aorto-uni-lateral EVAR for an abdominal aortic aneurysm, the use of the internal branched device (IBD) constitutes a safe and effective technique.

Increased pulse wave velocity and arterial hypertension in young patients with thoracic aortic endografts.

BACKGROUND: Hypertension after thoracic endovascular aortic repair (TEVAR) is a medical complication not widely investigated. The aim of the study was to test the hypothesis that TEVAR in young patients suffering from thoracic aortic transection alters pulse wave velocity (PWV) and reflected wave velocity and induces arterial hypertension. METHODS: The data concerning 11 young patients (all men with a mean age of 26.9 years [range: 18-33]) treated with TEVAR for thoracic aortic transection were retrospectively collected and analyzed. PWV, systolic blood pressure (SBP), and pulse pressure (PP) were evaluated and compared with those recorded in 11 healthy young individuals matched for age and gender. RESULTS: Nine patients had postoperative arterial hypertension after TEVAR, and four had durable hypertension during the follow-up period (13-66 months after TEVAR). The SBP, the PP, and the PWV of the patients were greater compared with those of the control group (SBP: 134.1 ± 13.7 vs. 121.36 ± 7.1 mm Hg, P = 0.016; PP: 60.45 ± 19.42 vs. 44.1 ± 4.37, P = 0.020; and PWV: 10.41 ± 2.85 vs. 7.45 ± 0.66 m/sec, P = 0.006). CONCLUSIONS: Aortic endografts could produce a discontinuation of the pulsatile waves with a subsequent increase of aortic PWV. Increased PWV is an important risk factor for future cardiovascular events and should be evaluated in all patients after TEVAR.

Use of an amplatzer vascular plug in embolization of a pulmonary artery aneurysm in a case of hughes-stovin syndrome: a case report.

INTRODUCTION: Hughes-Stovin syndrome is a rare condition characterized by peripheral deep venous thrombosis accompanied by single or multiple pulmonary arterial aneurysms. The limited number of cases has precluded controlled studies of the management of pulmonary artery aneurysms, which usually cause massive hemoptysis leading to death. This is the first report of a new endovascular treatment of a single large pulmonary arterial aneurysm. CASE PRESENTATION: An 18-year-old Caucasian man was referred to our department with recurrent severe hemoptysis. His medical history included Hughes-Stovin syndrome diagnosed during a recent hospital admission. The patient was initially treated with corticosteroids. Because of his recurrent hemoptysis, we decided to embolize a 3.5 cm pulmonary arterial aneurysm using an Amplatzer Vascular Plug. The procedure was not complicated, and the patient's post-intervention course was uneventful. The patient has remained free from any complications of the embolization 36 months after the procedure. CONCLUSION: Percutaneous embolization of a single large pulmonary artery aneurysm with an Amplatzer Vascular Plug in a patient with Hughes-Stovin syndrome is a less invasive procedure that represents the best multidisciplinary approach in treating these patients.

Endovascular management of a late saccular aortic aneurysm after end-to-end repair of coarctation.

Post-coarctation surgical repair aneurysm formation is observed rarely with end-to-end anastomosis technique. The redo surgery is associated with high mortality and morbidity rate. Although the minimal invasive method with stented grafts has been reported in only small number of patients, this could represent a valid alternative treatment. We present a case of successful endovascular treatment of a patient with a late post-coarctation repair saccular aneurysm.