Arteria lusoria aneurysm with truncus bicaroticus: surgical resection without restoring blood supply to the right arm

Arteria lusoria, an aberrant or anomalous right subclavian artery, is the most common anomaly of the aortic arch. It may be associated with other congenital anomalies of the heart and great vessels-including, rarely, truncus bicaroticus (a common trunk of both common carotid arteries), and, even more rarely, aneurysmal formation.Herein, we report the case of a 72-year-old man who had both an atherosclerotic aneurysm of an aberrant right subclavian artery and truncus bicaroticus. We resected the aneurysm through a posterolateral thoracotomy and did not restore the distal pulsatile blood supply to the right arm. During long-term clinical follow-up, the patient experienced no arm ischemia or cerebrovascular insufficiency.Aneurysm of arteria lusoria should be suspected in the presence of a right superior mediastinal mass on chest radiographs and should be considered as a cause of new-onset dyspnea, chest pain, or dysphagia. Symptomatic right arteria lusoria aneurysm should be removed promptly after diagnosis. Despite disagreement among investigators regarding the need to restore pulsatile blood flow to the right arm, we recommend reconstructing that flow, when possible.

Origin of axial prestretch and residual stress in arteries

The structural protein elastin endows large arteries with unique biological functionality and mechanical integrity, hence its disorganization, fragmentation, or degradation can have important consequences on the progression and treatment of vascular diseases. There is, therefore, a need in arterial mechanics to move from materially uniform, phenomenological, constitutive relations for the wall to those that account for separate contributions of the primary structural constituents: elastin, fibrillar collagens, smooth muscle, and amorphous matrix. In this paper, we employ a recently proposed constrained mixture model of the arterial wall and show that prestretched elastin contributes significantly to both the retraction of arteries that is observed upon transection and the opening angle that follows the introduction of a radial cut in an unloaded segment. We also show that the transmural distributions of elastin and collagen, compressive stiffness of collagen, and smooth muscle tone play complementary roles. Axial prestresses and residual stresses in arteries contribute to the homeostatic state of stress in vivo as well as adaptations to perturbed loads, disease, or injury. Understanding better the development of and changes in wall stress due to individual extracellular matrix constituents thus promises to provide considerable clinically important insight into arterial health and disease.

Recent advances in the application of computational mechanics to the diagnosis and treatment of cardiovascular disease

During the last 30 years, research into the pathogenesis and progression of cardiovascular disease has had to employ a multidisciplinary approach involving a wide range of subject areas, from molecular and cell biology to computational mechanics and experimental solid and fluid mechanics. In general, research was driven by the need to provide answers to questions of critical importance for disease management. Ongoing improvements in the spatial resolution of medical imaging equipment coupled to an exponential growth in the capacity, flexibility and speed of computational techniques have provided a valuable opportunity for numerical simulations and complex experimental techniques to make a contribution to improving the diagnosis and clinical management of many forms of cardiovascular disease. This paper contains a review of recent progress in the numerical simulation of cardiovascular mechanics, focusing on three particular areas: patient-specific modeling and the optimization of surgery in pediatric cardiology, evaluating the risk of rupture in aortic aneurysms, and noninvasive characterization of intraventricular flow in the management of heart failure.

Popliteal artery aneurysms and popliteal phymas

For the differential diagnosis of popliteal phymas, popliteal artery aneurysms are evaluated. They are frequent among peripheral aneurysms. However, diagnosis is difficult in some patients because clinical symptoms vary. We report 2 patients who consulted our hospital for popliteal phymas. In these patients, surgery was performed via a posterior approach. In 1 patient, reconstruction was conducted using a great saphenous vein graft (SVG). Even when employing the posterior approach, SVG collection and reconstruction are possible without changing the posture for short-distance reconstruction. This procedure may prolong patency in comparison with artificial blood vessels.

[Surgical treatment of symptomatic aneurysm of popliteal artery]

The results of treatment of 17 patients, suffering symptomatic aneurysm of popliteal artery (APA) were analyzed. According to angiographic data, the APA thrombosis was revealed in 6 patients, and according to ultrasonographic Doppler scanning data the APA rupture with hematoma in adjacent tissues was diagnosed in 5 patients. The tactics of treatment was established in accordance with the distal blood flow character: the conservative therapy was conducted in the presence of APA up to 40 mm in diameter in condition of the artery passability preservation and poor distal blood flow--in 6 observation operative treatment was conducted in the presence of satisfactory distal blood flow--in 4, according to urgent indications due to critical ischemia--in 2, and for the aneurysm rupture--in 5. Operative treatment of symptomatic APA showed ineffective in presence of thrombotic complications in 23.1% patients. In conservative and surgical treatment of APA, complicated by an acute thrombosis, the poor results (the lower extremity amputation) were noted in 33.3% patients.

Hyperemic maximal venous outflow unmasks symptomatic lower extremity venous obstruction

Venous obstruction is an underappreciated and often unrecognized component of the pathophysiology of symptomatic chronic venous disease (CVD). Moreover, standard methods used to detect venous obstruction, such as maximal venous outflow, are inadequate as they typically test patients at rest and in the supine position when the pathophysiology of CVD is defined in the upright patient performing exercise. This report describes a patient with incapacitating venous claudication in whom standard noninvasive venous function tests were normal and whose phlebography was interpreted as showing no evidence of venous obstruction. A postocclusive reactive hyperemic technique was used to unmask significant outflow obstruction, leading to operative correction and subsequent symptom resolution.

Effects of cyclosporine, tacrolimus and sirolimus on vascular changes related to immune response

BACKGROUND

Despite the use of newer immunosuppressors such as sirolimus (SRL) and tacrolimus (TRL) in heart transplantation, the rate of humoral rejection has remained unchanged. The aim of this study was to analyze the immunologic and histologic effects of cyclosporine (CsA), SRL, and TRL in a porcine model of arterial transplantation.

METHODS

Each transplant recipient animal (n = 49) received an autograft and an allograft and was then allocated to one of four treatment groups and a 7- or 30-day follow-up period, as follows: a WOT group (without immunosuppressor treatment), 7 days (n = 6) and 30 days (n = 5); a CsA group, 7 days (n = 5) and 30 days (n = 6); an SRL group, 7 days (n = 7) and 30 days (n = 8); and a TRL group, 7 days (n = 6) and 30 days (n = 6). The presence of donor-specific antibodies (DSA) was tested at the end of the follow-up period. Morphometric parameters and inflammatory infiltration were analyzed in the explanted grafts.

RESULTS

At 30-day follow-up, SRL was the only treatment capable of suppressing DSA formation (0 of 7 vs 4 of 5 in the WOT group; p < 0.05). SRL completely prevented aneurismal dilation and reduced the number of macrophages in the allografts. TRL treatment achieved a greater reduction of T lymphocytes. CsA did not prevent the reduction in total vascular area at 7 days that was achieved with the SRL and TRL groups. Animals treated with CsA had the largest number of T lymphocytes and macrophages in both follow-up periods.

CONCLUSIONS

SRL prevented DSA formation and reduced the number of macrophages as compared with TRL and CsA.

Postoperative hepatic artery aneurysms development and remodeling in Ehlers-Danlos syndrome type IV. Case report

Patients affected by Ehlers-Danlos syndrome (EDS) type IV are at risk for aneurysm formation and rupture. This case report shows the extreme vascular fragility of these patients. We studied a 31-year-old man that developed hepatic artery aneurysms 3 weeks after splenectomy. Computed tomography angiography showed the extreme vascular remodeling of the aneurysms. We conclude that remote site complications should be kept in mind by all surgeons in vascular EDS patients even after general surgery operations.

Hypothenar hammer syndrome: gray-scale and color Doppler sonographic appearances

We report a case of hypothenar hammer syndrome following a single severe blunt trauma in a 24-year-old man with a painful pulsatile mass, numbness in the fourth and fifth fingers, and intolerance to cold. The gray-scale and color Doppler sonographic findings are presented with correlation with MRI.

Saccular aneurysms of the extracranial internal carotid artery. Experience and review of the literature

The aim of this study was to describe the surgical technique employed and our results in the treatment of saccular aneurysms of the internal carotid artery at the extracranial level. We describe 3 cases of patients with saccular aneurysms of the extracranial internal carotid who underwent surgery at our unit within the last 3 years. We report on indications for treatment, surgical technique and results in terms of morbidity-mortality and also review the pertinent literature. Surgical treatment was indicated on the grounds of the patients being symptomatic: 2 had a history of cerebral ischemia, and 1 showed local compression symptoms. The surgical approach was presternocleidomastoid cervicotomy extended distally, and in 2 patients was accompanied by nasotracheal intubation to achieve adequate exposure. In 2 cases, we performed an aneurysmectomy with end-to-end anastomosis. In the third patient, the aneurysm neck was ligated from within the sac followed by aneurysmectomy. There was no mortality or neurological morbidity (local or general). The patients remain free from neurological symptoms with a patent carotid axis. Our clinical experience suggests that, despite the anatomically unfavorable location of this type of aneurysm and the greater complexity of the surgical technique, this patient group can be effectively treated. The frequent presence of an elongated carotid axis and an aneurysmal neck means the surgeon can easily restore arterial continuity by direct procedures.

Sonographic diagnosis of inferior mesenteric artery aneurysm and marginal artery of Drummond

We report the case of a patient in whom sonographic examination revealed an aneurysm of the inferior mesenteric artery with severe proximal stenosis and poststenotic dilatation--the enlargement of the proximal portion of the artery of Drummond. This collateral pathway should be kept in mind when studying bowel ischemia, especially when stenosis is present or when there is occlusion of the superior mesenteric artery.

Matrix Metalloproteinase-9 May Play a Role in Recanalization and Recurrence after Therapeutic Embolization of Aneurysms or Arteries

PURPOSE

Matrix metalloproteinase (MMP)-9 plays various roles in vascular healing and angiogenesis. This study was conducted to determine if MMP-9 is involved in healing or recanalization after therapeutic occlusion of arteries or aneurysms.

MATERIALS AND METHODS

Angiographic and pathologic changes were investigated in canine bilateral venous pouch carotid aneurysms embolized with gelatin sponges with or without previous endothelial denudation, a procedure that can prevent recanalization. To assess a potential role of MMP-9, messenger RNA (mRNA) and protein were compared in denuded and nondenuded aneurysms 4, 7, and 14 days after embolization. To assess if MMP-9 is essential to arterial recanalization, transmyocardial angiography and pathologic findings were compared 14 days after carotid occlusion with platinum coils in MMP-9-knockout and wild-type mice.

RESULTS

Denudation of the endothelial lining led to improved angiographic results at 3 weeks (P < .001). Neointimal closure of the aneurysm neck was more complete in denuded versus nondenuded aneurysms. Denudation was followed by a decrease in MMP-9 mRNA (86%, P < .05) and protein (30%, P < .05) 7 days after embolization and a decrease in von Willebrand factor compared with nondenuded aneurysms. MMP-9 immunostaining of axial sections from embolized aneurysms confirmed MMP-9-positive endothelialized clefts, which were absent in denuded aneurysms. Transmyocardial angiography and pathologic examination showed recanalization of one of nine coiled carotid arteries of MMP-9-knockout mice, compared with five of seven controls (P = .035).

CONCLUSIONS

MMP-9 may play a role in recanalization of arteries after coil occlusion and in recurrences after sponge embolization of aneurysms.

Significance of the Early Postoperative Duplex Result in Infrainguinal Vein Bypass Surveillance

BACKGROUND

Duplex surveillance of infrainguinal vein grafts may not be efficient.

METHODS

Consecutive patients who had received infrainguinal vein grafts were enrolled in a duplex surveillance program. A first scan at 6 weeks after surgery categorized grafts into four groups: (a) low risk grafts, (b) mild flow disturbance, (c) intermediate stenosis and (d) critical stenosis. Disease progression was assessed over time.

RESULTS

Of 364 grafts followed-up for a median of 23 months, 236 (65%) had no flow abnormality at 6-weeks, and had a 40-month cumulative patency rate of 82%. The remaining 128 (35%) grafts had a flow disturbance. Of 29 critical stenoses, 15 were repaired, 11 occluded and three did not change. Of 57 intermediate lesions, 32 progressed to critical, nine occluded, two were repaired and 14 did not change or improved. Of 42 mild lesions, 16 progressed to a higher grade, four occluded and 22 did not change or improved. There was no significant difference in graft patency between grafts with repaired stenoses and those without stenoses, but grafts with untreated critical stenoses were associated with lower patency (p<0.001).

CONCLUSIONS

A duplex scan 6 weeks after operation can predict those patients who require continuing duplex surveillance.

Splenic artery aneurysms in pregnancy--a systematic review

Visceral artery aneurysm is an uncommon pathology, with a potential for rupture. Splenic artery aneurysms (SAA) are most commonly (60%) associated with a high mortality rate of 25% in case of aneurysm rupture. This increases disproportionately to 75% among pregnant women with fetal mortality of 95%. Although this is a rare event, because of the associated catastrophic consequences, prompt management of splenic artery aneurysms (SAA) is of prime importance. This systematic review provides up-to-date information about the management of splenic artery aneurysms in pregnancy.

Computer Simulation of Hemodynamic Changes After Right Lobectomy in a Liver with Intrahepatic Portal Vein Aneurysm

BACKGROUND/PURPOSE

Intrahepatic portal vein aneurysm is rare and its natural history is unknown. A 22-year-old healthy man, who wished to donate part of his liver to his diseased father, was incidentally diagnosed to have an intrahepatic portal vein aneurysm. The surgical decision of performing live donor hepatectomy for such a patient is normally difficult. We combined modern imaging reconstruction technologies with scientific computing as a new modality to foresee the risks of surgical complications.

METHODS

Cross-sectional computed tomography images were used to reconstruct the three-dimensional image of portal vein distribution using the 3D-Doctor v3.5 software. The reconstructed images were further employed to generate surface and interior meshes with CFX software. Simulated hemodynamic changes in velocity, pressure, and wall stress were determined for the right lobectomy case pre- and postoperatively.

RESULTS

The simulation results indicated that aneurismal pressure would be elevated significantly to 12.03 mmHg after operation. The left segmental portal venous blood flow would increase from 2.95- to 4.25-fold. The area near the branch point of one left segmental portal vein, which supplies blood to liver segment 4, and the portal vein aneurysm would endure high shear stress gradient. The resulting elevated aneurismal pressure may cause the thin wall to enlarge and rupture, while the high shear stress gradient would lead to vascular endothelial cell injury. Living donor surgery was not recommended hemodynamically based on the simulated results.

CONCLUSION

Scientific computing and modern imaging technologies can be applied together to aid surgeons to make the best decision in difficult clinical situations.

Surgical technique and long-term results after popliteal artery aneurysm repair: Results from 717 legs

BACKGROUND

This study investigated the importance of surgical technique on long-term outcome after treatment of popliteal artery aneurysms (PAAs).

METHODS

Records from 571 patients (717 legs) primarily operated on for PAAs were identified in the Swedish Vascular Registry. Surgical approach, type of graft, and anastomotic and ligation techniques were studied. After mean 7.2 years (range, 2 to 18 years) information on amputation was obtained for all patients, and 190 patients were re-examined with ultrasound imaging.

RESULTS

The approaches used were medial (medial approach group, MAG) in 87%, posterior (PAG) in 8.4%, endovascular in 3.6%, and other in 1.4%. Primary patency at 1 year with venous and prosthetic grafts was 85% vs 81% in the PAG (P = .719) and 90% vs 72% in the MAG (P < .001). Sixty-three legs (8.8%) were amputated <or=1 year, and 80 (11%) had been amputated at re-examination or by the end of follow-up. The median time from operation to amputation of 17 legs amputated after 1 year was 3.1 years (range, 1.1 to 9.8 years). The frequency of late amputation was 3.7% (2/54) in the PAG and 2.6% (15/571) in the MAG. In a Cox regression model, age (odds ratio [OR] 1.06/year, P < .001), emergency procedure (OR 2.67, P < .001), and prosthetic graft (OR 2.02, P = .008) were independently associated with long-term amputation rate. The risk of expansion of the excluded PAA at re-examination was 33% in the MAG and 8.3% in the PAG (P = .014). It was not affected by the ligation technique used.

CONCLUSIONS

The risk of late amputation was higher with prosthetic grafts. Operation with a posterior approach decreased the risk of expansion.

The medial versus the posterior approach in the repair of popliteal artery aneurysms: A multicenter case-matched study

OBJECTIVES

This study was conducted to compare the early and mid-term results of the medial and posterior approaches in the surgical treatment of popliteal artery aneurysms (PAAs).

METHODS

From 1992 to 2006 in three hospitals, 110 popliteal aneurysms needed surgical repair by a posterior or a medial approach. Of 36 aneurysms repaired by the posterior approach, 33 could be case-matched to a medially excluded PAA according to the criteria of (1) patient age, (2) cardiovascular comorbidity, (3) indication for PAA repair, (4) diameter of PAA at time of surgical repair, (5) number of distal outflow vessels at time of surgical repair, and (6) type of bypass or interposition graft (venous or polytetrafluoroethylene).

RESULTS

During the 30-day postoperative period, seven complications (21%) occurred in each group, no patients died, and no amputations were necessary. Two patients in the posterior group vs none in the medial group (P < .05) needed thrombectomy because of occlusion of the reconstruction. The mean follow-up was 47 months (range, 2 to 176). In this period, 13 deaths occurred, but none were related to the previous interventions. The primary patency rates at 6 months and at 1, 3, and 4 years were 84%, 79%, 66%, and 66% in the posterior group and 96% (P < .05), 93% (P < .05), 76% (P = NS), and 69 % (P = NS) for the medial group, respectively. The secondary patency rates at 6 months, and at 1, 3, and 4 years were 100%, 100%, 100%, and 90% in the posterior group and 96%, 96%, 96%, and 90% in the medial group, respectively (P = NS). Limb salvage rates were 97% for the posterior group and 100% for the medial group (P = NS). No neurologic complications or venous damage was seen in either group. Irrespective of approach, venous reconstructions resulted in significantly higher patency rates compared with prosthetic reconstructions at the 3-year follow-up (84% vs 67%, P < .01). During follow-up, which included duplex scanning, two patients in the medial group needed renewed surgical intervention and posterior exclusion because of persistent flow and growth of the native aneurysm.

CONCLUSION

Early (<1 year) primary patency rates of the medial approach were significantly better than the posterior approach, possibly because of the limited posterior exposure. However, in the absence of a significant difference in long-term primary and secondary patency rates between the posterior and medial approach, and considering the substantial risk of aneurysm growth after medial approach (up to 22%), the posterior approach might be the surgical method of preference for PAA repair in the long run.

Cardiac involvement in systemic inflammatory diseases

Systemic inflammatory diseases represent a large group of rare diseases that may involve all organs and also the heart. The three layers of the heart can be affected and some manifestations such as pericarditis in systemic lupus erythematosus are rather well known, yet others are not known even for cardiologists. Modern sophisticated imaging techniques reveal cardiac abnormalities in most of these diseases and the reported frequency of cardiac involvement ranges widely depending upon the applied diagnostic methods and selection of patients. The clinical significance of these findings is not always established. However, better knowledge and awareness of cardiac involvement is necessary because it conveys a major risk for mortality in several of these rare diseases.

Surgical and endovascular treatment of atherosclerotic popliteal artery aneurysms

Popliteal artery aneurysms are the most common peripheral aneurysms. Patients with unrecognized aneurysms may present with acute limb ischemia and considerable threat for limb loss due to thromboembolic complications. This article reviews short-term and long-term results of surgical and endovascular treatment for mainly elective repair of popliteal artery aneurysms. A systemic review was conducted of data in the English literature from 1990. The review included 1 prospective randomized trial, 6 prospective studies, and 42 retrospective studies on the management of popliteal artery aneurysms. These studies contained 2 197 patients with 2 882 popliteal artery aneurysms. Short-term results are acceptable, with average 1-year patency rates of 90% for surgical treatment and 75% for endovascular treatment, and respective limb salvages rates of 95% and 100%. Endovascular treatment lacks long-term follow-up, whereas venous surgical repair has an average 5-year patency rate of up to 85% (prosthetic grafts, 40-80%). There is a need for randomized trials comparing long-term results of surgical versus endovascular treatment of popliteal artery aneurysms. So far, long-term results of elective surgical repair for popliteal artery aneurysms are acceptable if venous grafts are used. In any case, acute repair of popliteal artery aneurysms must be avoided.

Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair

AIM

The aim of this prospective comparative study was to compare the results of 8-years experience of endovascular treatment (ET) of popliteal aneurysms (PAs) using the Hemobahn/Viabahn endograft with those achieved with open repair (OR). Endpoints were primary and secondary patency rate.

METHODS

The study was a prospective randomized clinical trial from January 1999 to December 2003 and a prospective comparative study from January 2004 to December 2006. Patients with an asymptomatic aneurismal lesion in the popliteal artery 2 cm at angio-computed tomography were included in the study. Indication for ET was PA (proximal and distal neck length >1 cm); contraindications were: 1) age <50 years; 2) poor distal run-off; 3) contraindication to antiplatelet, anticoagulant or thrombolytic therapy.

RESULTS

Between January 1999 and December 2006, of a total of 42 patients with 48 PA, 27 were treated with OR (group A) and 21 with ET (group B). The primary patency rate was 100% in group A and 80.9% in group B at 12 months and 71.4% and 88.1%, respectively, at 72 months; the secondary patency rate at 72 months was 88.15% and 85.9% in groups A and B, respectively. No statistical differences were observed at the log-rank test. During the entire study period, 3 (14.3%) patients in group B required conversion to open surgery because of endograft occlusion.

CONCLUSION

Within the power limitations of this study, ET for asymptomatic PA in patients with suitable anatomy can be considered safe, with long-term results comparable with those of OR.

Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?

AIM

Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort.

METHODS

Between June 1998 and February 2007, 73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel.

RESULTS

Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016).

CONCLUSION

Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.