Surgical and endovascular treatment of symptomatic aberrant right subclavian artery (arteria lusoria).

Right aberrant subclavian artery, also called arteria lusoria, is one of the most common intrathoracic arterial anomalies. Although mostly asymptomatic, the retroesophageal and retrotracheal course of the lusorian artery might result in unspecific thoracic pain, dysphagia, dyspnea, arterioesophageal or arteriotracheal fistulae with hematemesis or hemoptysis, and aneurysmal formation with relevant risk of rupture. The purpose was to present our experience with six patients with a symptomatic aberrant right subclavian artery, two patients with dysphagia or dyspnea caused by a nonaneurysmal lusorian artery, and four patients with arteria lusoria aneurysms. The operative procedures performed are described and discussed in view of the data reported in the literature. According to the classification of the lusorian artery pathology, a combined intervention with right subclavian artery transposition, distal or proximal lusorian artery ligation or proximal endovascular occlusion for nonaneurysmal disease, or endovascular thoracic aortic stent graft implantation for lusorian artery aneurysms seems to be an additional and minimally invasive approach with promising midterm results.

Strategies for prevention and operative treatment of aortic lesions related to spinal interventions.

STUDY DESIGN: A retrospective analysis of a case series was performed. OBJECTIVE: To give recommendations for the prevention and operative treatment of thoracic and thoracoabdominal aortic lesions in association with spinal interventions. SUMMARY OF BACKGROUND DATA: Aortic lesions after spinal interventions for traumatic vertebral fractures, segmental spondylodiscitis, or vertebral metastasis are fortunately rare, but associated with a high perioperative mortality rate and absolute numbers are unknown. Therefore, preventive strategies to avoid perioperative major vessel injuries and recommendations for the operative treatment of aortic lesions related to spinal surgery are required. METHODS: The clinical course of 10 patients with an acute aortic hemorrhage or an increased intraoperative risk for aortic injuries in association with primary or secondary spinal interventions is reported. All patients were evaluated before surgery by orthopedic trauma surgeons, vascular surgeons, and diagnostic radiologists. RESULTS: Five patients had preventive vascular interventions to avoid major aortic injuries during spinal reinterventions, and 5 patients were treated as an emergency for acute intraoperative hemorrhage related to spinal interventions. The operative treatment was performed by direct aortic sutures (n = 3), segmental alloplastic reconstructions (n = 2), or endovascular stent graft implantations (n = 3). Prophylactic banding of the thoracic aorta during thoracotomy or a femoral access for possible aortic balloon blockade was performed in patients with an estimated lower risk for an aortic laceration caused by malpositioned pedicle screws. No perioperative mortality was observed in patients treated by this interdisciplinary concept, but 1 patient treated under emergency condition for spondylodiscitis with an initially unrecognized aortic lesion died. CONCLUSION: In patients with complex spinal trauma, spondylodiscitis or difficult vertebral reinterventions, and an increased risk of major vessel injury, a preoperative interdisciplinary evaluation is recommended, even under emergency conditions. Endovascular stent graft technique is an additional option for prevention and treatment of suspected or acute aortic injuries of thoracic and infrarenal aortic lesions, whereas injuries to the visceral aortic segment still require advanced vascular reconstructions.

Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience.

BACKGROUND: Traumatic injuries of the thoracic aorta have a high morbidity and mortality. Treatment options include either open surgery or endovascular stent graft implantation. METHODS: We have reviewed retrospectively all our patients treated for acute and chronic traumatic injury of the thoracic aorta and compared the outcome of the endovascular versus open therapy. Age, gender, severity of injuries, interventional delay, perioperative morbidity, 30-day mortality, length of intensive care, and overall hospital stay were evaluated. RESULTS: In all, 46 patients were treated over the past 14 years. Overall 30-day mortality was 16% in patients treated for acute or contained aortic ruptures (n = 31) and not significantly different after endovascular versus open repair (13.3% versus 18.8%). There was no mortality in the patients receiving elective stent grafting or open surgery for chronic posttraumatic aortic aneurysms (n = 15). Conversion and/or operative revision following stent graft implantation occurred in three patients (12.5%). Neurologic complications were absent in the stent graft group (0 of 24), whereas paraplegia (n = 2) or minor neurologic (n = 3) deficits developed following open surgery (5 of 22; 22.7%; p = 0.013). Length of intensive care and overall hospital stay were significantly shorter for patients after elective stent graft treatment compared with open surgery (p = 0.045). CONCLUSIONS: According to our midterm results, minimally invasive endovascular repair for patients with acute traumatic ruptures and chronic posttraumatic aneurysms is an equally effective treatment option compared with open surgery, with advantages regarding perioperative neurologic complications and duration of hospital stay under elective circumstances.

Chlamydia pneumoniae in atherosclerotic lesions of patients undergoing vascular surgery.

The pathophysiological implications of Chlamydia pneumoniae in atherosclerotic lesions and its contribution to atherosclerotic complications remain unclear. Therefore, the purpose of the present study was to evaluate whether or not there is an association between the presence of Chlamydia pneumoniae in atherosclerotic lesions and the clinical manifestations as well as risk factors of atherosclerotic disease in patients undergoing vascular surgery. Specimens from atherosclerotic arteries were collected during endarterectomy of the carotid artery (n = 15), endarterectomy of the femoral artery (n = 19), or repair of an abdominal aortic aneurysm (n = 28). Detection of Chlamydia pneumoniae was performed by using immunohistochemical staining (IHC) with specific antibodies. Clinical manifestations of atherosclerotic disease were defined by the presence of cardiovascular risk factors, coronary heart disease, and previous vascular surgery. Inflammatory serum markers were determined in all patients prior to surgery. The specimens of all 62 patients revealed severe atherosclerosis in histological examination and a positive IHC was observed in 41 samples (66%). There were no differences regarding cardiovascular risk factors, coronary heart disease, events of previous vascular surgery, or inflammatory serum markers when comparing patients with positive and negative IHC. In conclusion, our findings showed no correlation between clinical or laboratory parameters of atherosclerosis and the presence of Chlamydia pneumoniae in atherosclerotic lesions. Therefore, Chlamydia pneumoniae appears to be a concomitant phenomenon rather than a causative principle in atherosclerosis.