Endovascular repair of symptomatic carotid artery aneurysm with covered stent: A case report and literature review.

OBJECTIVES: Extracranial carotid artery true aneurysm is extremely uncommon, and definite treatment has traditionally involved open surgical repair. Although successful management of the internal carotid artery aneurysms using endovascular stenting and embolization has recently been reported, only a limited number of cases have been reported. METHODS: We present a case of symptomatic carotid true aneurysm repaired with covered stent and coil embolization of the external carotid artery. We also review the English literature and discuss the epidemiology, causes, diagnosis, and management options of internal carotid artery aneurysms. RESULTS: The patient did not have any complications, and was discharged home on the postoperative day 1 in stable condition. CONCLUSION: Our report suggests that endovascular procedure is feasible in the treatment of extracranial carotid artery aneurysms.

Hybrid repair of ruptured type B aortic dissection extending into an aberrant right subclavian artery in a patient with Turner's syndrome.

Turner's syndrome (TS) has been documented as the most common cause of aortic dissection in young women. However, little attention from vascular surgery has been paid to these patients. We report the first case of ruptured type B aortic dissection with aberrant right subclavian artery treated successfully with hybrid endovascular and open procedures in a patient with TS. Left carotid to subclavian artery bypass, thoracic endovascular aortic repair, and coil embolization of the aberrant right subclavian and left subclavian arteries were performed in an emergency setting. Literature on epidemiology, causes, and management options of acute aortic dissection in TS patients are reviewed and discussed.

Grading system modification and management of blunt aortic injury.

BACKGROUND: The traditional approach to blunt aortic injury (BAI) has been emergent intervention. This study aimed to utilize a modified imaging grading system that may allow us to categorize these injuries as needing emergent, urgent, or non-operative management. METHODS: From January 2003 to December 2011, 28 patients with BAI were managed at our institution. Imaging and medical records were reviewed retrospectively. BAI was classified into 4 grades based on imaging studies. Grade Ia: intimal tear, Grade Ib: intramural hematoma; Grade II: intimal injury with periaotic hematoma; Grade IIIa: aortic transection with pseudoaneurysm, Grade IIIb: multiple aortic injuries; and Grade IV: free rupture. Progression and clinical outcomes of ABI were analyzed. RESULTS: Of the 28 patients, 22 were males and 6 were females with mean age of 38 (range, 7 - 69) years. Twenty-five (89.3%) had descending thoracic aortic injury, two (7.1%) had abdominal aortic injury and one (3.6%) presented with multiple aortic injuries. Three patients (10.7%) with Grade I, 1 (3.6%) Grade II, 22 (78.6%) Grade III, and 2 (7.1%) Grade IV injuries. Twenty-five patients underwent thoracic endovascular aortic repair and 3 were managed medically. Median time between injury and surgical intervention was (2 ± 1) days. One (3.6%) patient developed paraplegia after thoracic endovascular aortic repair (TEVAR). One Type 2 endoleak spontaneously sealed within 1 month, and another patient died from ruptured Type 1 endoleak 3 years later. Median follow-up time was 16 (range, 1 - 96) months. Perioperative 30-day mortality rate was 3.6%. CONCLUSIONS: This study based on our modified BAI grading system indicated that Grade I BAI can be managed conservatively. Grade II injury requires close observation and repeated computerized tomography angiogram (CTA) within 48 - 72 hours. If injury appears worse on follow up imaging, surgery should be performed. Delayed repair of Grade III BAI is acceptable if associated life threatening traumatic injuries need to be addressed first.

Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients.

OBJECTIVE: Groin wound infection is an important cause of postoperative morbidity in vascular surgery patients, especially when prosthetic grafts are involved. The objective of this study was to investigate if Prevena (Kinetic Concepts, Inc, San Antonio, Tex), a negative pressure incision management system, could reduce the risk of groin wound infection in patients after vascular surgery. METHODS: Ninety patients (115 groin incisions) underwent longitudinal or transverse femoral cutdown for vascular procedures. A retrospective chart review was performed on 63 consecutive incisions in patients in the non-Prevena group from December 2009 to November 2010 and on 52 consecutive incisions in patients in the Prevena group from January 2011 to December 2011. Prevena was applied intraoperatively and removed 5 to 7 days postoperatively. The non-Prevena group received either a skin adhesive or absorbent dressing. Groin incisions were assessed, and infection was graded based on Szilagyi classifications. Student t-test and two-sample proportion z test were used for statistical analyses. A P value < .05 was considered statistically significant. RESULTS: Comorbidities and known risk factors for infection were compared; there were no statistically significant differences between the two groups. Prosthetic material was used in 34 (65%) incisions in the Prevena group and 29 (46%) incisions in the non-Prevena group. Fifty (96%) incisions within the Prevena group and 60 (96%) in the non-Prevena group were classified as clean surgical wounds. Wounds were evaluated at 7 days and 30 days postoperatively. Of 63 groin incisions in 49 patients in the non-Prevena group, 19 (30%) incisions had groin wound infections. Wound infections were classified into Szilagyi grade I (10; 16%), Szilagyi grade II (7; 11%), and Szilagyi grade III (2; 3%). Of 52 groin incisions in 41 patients in the Prevena group, three (6%) incisions had Szilagyi grade I wound infections. No grade II or III infections occurred in this group. Overall incidence of infection between the two groups was statistically significant (P = .0011). CONCLUSIONS: In this clinical study, Prevena negative pressure dressing significantly decreased the incidence of groin wound infection in patients after vascular surgery.

Acute aortic occlusion in a child secondary to lap-belt injury treated with thromboendarterectomy and primary repair.

Abdominal aortic injury as a result of blunt trauma is a rare event and has been described in few children. A 6-year-old girl presented with acute bilateral lower extremity ischemia, and a triad of acute aortic occlusion, intra-abdominal visceral injury, and a lumbar chance fracture after sustaining a seat belt injury from a motor vehicle collision. An emergency aortic thromboendarterectomy and primary repair were performed. This represents one of the few reports of acute traumatic aortic thrombosis in a child and highlights the surgical treatment of acute abdominal aortic injury in a pediatric patient.

A contemporary experience of open aortic reconstruction in patients with chronic atherosclerotic occlusion of the abdominal aorta.

OBJECTIVE: To examine and report surgical results from a contemporary experience of open abdominal aortic reconstruction in patients with chronic atherosclerotic abdominal aortic occlusion (CAAAO). METHODS: Between January 1999 through May 2010, 54 patients with CAAAO were identified and retrospectively reviewed. CAAAOs were categorized into infrarenal aortic occlusions (IRAOs) and juxtarenal aortic occlusions (JRAOs) based on superior extension of thrombus and requirement for supra-renal aortic clamping to repair. Morbidity, mortality, hospital stay, and operative variables were assessed. The χ2 or Fisher test and the Wilcoxon rank sum test were used to compare demographic and operative variables between two aortic occlusion groups (IRAO and JRAO). Univariate and multivariate analyses were performed to assess factors associated with surgical outcomes and hospital stay. The Kaplan-Meier method was used to calculate survival and patency rates. RESULTS: Fifty patients underwent aortic reconstructions with aorto-bifemoral or iliac bypass, and three underwent a remote axillo-femoral bypass procedure. There were 35 (64.8%) males, and 19 (35.2%) females. Median age was 51.9 years (range, 32-72 years). Of the two CAAAO groups, there were 20 IRAOs and 33 JRAOs. Aorto-renal thromboendartectomy was performed in 26 (49.1%) patients; 26 (75.8%) among JRAOs versus 1 (5%) of IRAOs (P<.01). Proximal aortic clamps were required in 28 (85%) of JRAOs and 3 (15%) of IRAOs (P<.01). Thirty-day and in-hospital mortality was zero. Median length of hospital stay was 7 days (range, 4 to 66 days), and median intensive care unit length of stay was 3 days (range, 1-22 days). Complications included cardiopulmonary dysfunction in four (8%), postoperative renal insufficiency in 10 (18.9%), and other postoperative complications in 15 (28.3%). All 10 with renal insufficiency recovered renal function to baseline creatinine or a creatinine value<1.1 mg/dL. Mean increases in right and left ankle-brachial indicess were 0.54±0.25 and 0.59±0.22, respectively. On univariate analysis, coronary artery disease and African American race were predictors of postoperative complications (P=.048). Age was significantly associated with total complications. Patients with postoperative complications and/or renal insufficiency were older than those without such complications (P=.02) Independent predictors of prolonged hospital stay were intraoperative blood replacement (P=.003), postoperative complications (P<.01), and postoperative renal insufficiency (P<.01). Prolonged intensive care unit stay was predicted by JRAO (P=.04), postoperative complications (P=.02), and postoperative renal insufficiency (P=.013). Survival at 3, 5, and 7 years were 86.6%, 76.5% and 50.9%, respectively. The reduced survival rates were predicted by previous myocardial infarction and existing coronary artery disease (P<.01). CONCLUSION: Abdominal aortic reconstruction is a safe method for treating CAAAO with low associated morbidity and mortality. Aorto-renal thromboendartectomy with supra-renal aortic clamping and aortic replacement remains an effective treatment for those with significant pararenal aortic disease, and can be performed without significant renal impairment.

Giant pararenal abdominal aortic aneurysm.

Inflammatory aortic aneurysms are unusual vascular lesions and most commonly involve the infrarenal segment of the abdominal aorta. These complex aneurysms represent a challenge to the vascular surgeon and become even more difficult as the extent of the aneurysm and size of the inflammatory mass increase. Although well described, few cases of giant inflammatory aneurysms are reported. In this case, we review the clinical presentation and surgical management of a patient with a giant pararenal abdominal aortic aneurysm and highlight an uncommon morphologic pattern of aortic disease and provide a review of relevant literature.

Multiple hereditary exostoses as a rare nonatherosclerotic etiology of chronic lower extremity ischemia.

Nonatherosclerotic etiologies of arterial insufficiency are uncommon but important causes of chronic lower extremity ischemia. We report a patient with multiple hereditary exostoses (MHE) presenting with lifestyle-limiting lower extremity claudication and popliteal artery occlusion secondary to a large osteochondroma. The presence of MHE with associated osteochondroma resulting in arterial occlusion is a rare condition. Management strategies for treating large osteochondromas adjacent to or with vessel involvement in asymptomatic patients remain undefined.

Pathology case of the month. 39-year-old woman with abdominal pain and weight loss. Takayasu's arteritis (TA).

A 39-year-old white woman presented with a history of aortoiliac occlusive disease diagnosed in 1992 attributed to oral contraceptive use. Shortly thereafter, aortoiliac replacement was performed. Mild hyperlipidemia was diagnosed in 2001. At the current clinic visit, she presented to her primary care physician with a 3-month history of postprandial midepigastric abdominal pain relieved by vomiting and a 30-pound weight loss. Her evaluation included an esophagogastroduodenoscopy, a colonoscopy, and an abdominal ultrasound, all of which were within normal limits. Because of her medical history, the patient underwent an arteriogram, which revealed brachiocephalic stenosis (Figure 1), occlusion of the left subclavian artery (Figures 2a and 2b), and narrowing of the superior and inferior mesenteric arteries (not shown). Since she had discontinued her oral contraceptives in 1992 and her hyperlipidemia was mild, the rheumatology service was consulted to evaluate this patient. On physical examination, she had decreased left brachial and radial pulses and a right carotid bruit. Laboratory evaluation revealed a normal complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C - reactive protein. Subsequent testing included a prothrombin time, activated partial thromboplastin time, protein S, protein C, reptilase time, antithrombin III, anticardiolipin antibody, antiphospholipid antibody, lupus anticoagulant, homocysteine, RPR, and a lipid profile. All test results were within normal limits. Due to the severity of her abdominal pain, the patient underwent superior mesenteric artery (SMA) bypass surgery. Sections from the aorta resected in 1992 are shown in Figures 3 and 4.