1
|
Stafforini NA, Saldana-Ruiz N, DeRoo S, Schwarze U, Sweet MP, Zettervall SL. Multidisciplinary hybrid approach to management of a thoracoabdominal aneurysm in a patient with both Loeys-Dietz and vascular Ehlers-Danlos syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101519. [PMID: 38982994 PMCID: PMC11231742 DOI: 10.1016/j.jvscit.2024.101519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/22/2024] [Indexed: 07/11/2024] Open
Abstract
Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome are genetic aortopathies that result from abnormal collagen matrix formation associated with vascular complications and early death. Identification of simultaneous COL3A1 and SMAD3 mutations as well as subsequent open and endovascular repair have not been reported. We present a case of a staged complete aortic replacement in a patient with a 7-cm aneurysm of his aortic arch and confirmed genetic mutations for Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome. This case highlights that, despite increased operative risk, successful staged repair of the entire aorta can be achieved in a patient with multiple severe genetic aortopathies.
Collapse
Affiliation(s)
- Nicolas A Stafforini
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nallely Saldana-Ruiz
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Scott DeRoo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Ulrike Schwarze
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| |
Collapse
|
2
|
Bhandari A, Siu V, Duncan AA. Spontaneous celiac artery aneurysms in 13-year-old and 10-year-old brothers with PLOD1-related kyphoscoliotic Ehlers-Danlos syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101465. [PMID: 38694482 PMCID: PMC11061726 DOI: 10.1016/j.jvscit.2024.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/20/2024] [Indexed: 05/04/2024] Open
Abstract
PLOD1-related kyphoscoliotic Ehlers-Danlos syndrome is a rare, autosomal recessive connective tissue disorder characterized by congenital hypotonia, early-onset, progressive kyphoscoliosis, and generalized joint hypermobility. PLOD1-kyphoscoliotic Ehlers-Danlos syndrome is also associated with heightened vascular fragility, resulting in an elevated susceptibility to recurrent vascular complications such as arterial aneurysms, dissection, and spontaneous arterial rupture. We report the cases of two affected brothers: a 13-year-old boy presenting with spontaneous rupture of a celiac artery aneurysm and a 10-year-old boy presenting with a rapidly enlarging celiac artery aneurysm requiring urgent repair.
Collapse
Affiliation(s)
- Apoorva Bhandari
- Division of Vascular Surgery, University of Western Ontario, London, ON, Canada
| | - Victoria Siu
- Division of Medical Genetics, Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | - Audra A. Duncan
- Division of Vascular Surgery, University of Western Ontario, London, ON, Canada
| |
Collapse
|
3
|
Khoury MK, Eagleton MJ. Iliac artery aneurysm endoleak management in a patient with vascular Ehlers-Danlos syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101401. [PMID: 38379610 PMCID: PMC10877189 DOI: 10.1016/j.jvscit.2023.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/30/2023] [Indexed: 02/22/2024] Open
Abstract
Endovascular repair has traditionally been avoided in patients with connective tissue disorders. We describe successful treatment of multiple endoleaks of an expanding common iliac artery aneurysm previously treated with an endograft in a patient with vascular Ehlers-Danlos syndrome. The modalities used to treat the endoleaks were transgluteal embolization of the internal iliac artery and proximal and distal extension of the prior endograft. This case demonstrates endovascular management of endoleaks in patients with vascular Ehlers-Danlos syndrome can be safe and feasible.
Collapse
Affiliation(s)
- Mitri K. Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Fireman Vascular Center, Massachusetts General Hospital, Boston, MA
| | - Matthew J. Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Fireman Vascular Center, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Pennetta FF, Ferrer C, Tonidandel L, Coscarella C, Vagnarelli S, Giudice R. Disappearing multiple visceral aneurysms in Vascular Ehlers-Danlos syndrome. Vascular 2023:17085381231162126. [PMID: 36878244 DOI: 10.1177/17085381231162126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVE To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS). METHODS We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms. RESULTS Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.
Collapse
Affiliation(s)
| | - Ciro Ferrer
- Vascular and Endovascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Luca Tonidandel
- Vascular and Endovascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Carlo Coscarella
- Vascular and Endovascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Simone Vagnarelli
- Interventional Radiology Unit, 9262San Giovanni-Addolorata Hospital, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| |
Collapse
|
5
|
Iatrogenic Distal Aortic Rupture in a Patient with Vascular Ehlers–Danlos Syndrome. J Vasc Surg Cases Innov Tech 2023; 9:101156. [PMID: 37125345 PMCID: PMC10140053 DOI: 10.1016/j.jvscit.2023.101156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/18/2023] [Indexed: 03/13/2023] Open
Abstract
Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder that can result in significant morbidity and mortality. This report details an iatrogenic aortic rupture during an endovascular approach in the management of critical limb ischemia in a 27-year-old woman who presented with acute onset of severe sensory deficit of the left leg. Conversion to open repair with a midline laparotomy and an aortic-left popliteal bypass was performed. In the endovascular era, we highlight that even minimally invasive therapeutic interventions can have devastating adverse events in patients with vascular Ehlers-Danlos syndrome.
Collapse
|
6
|
Padmanaban V, Yee PP, Koduri S, Zaidat B, Daou BJ, Chaudhary N, Gemmete JJ, Thompson BG, Kazmierczak CD, Cockroft KM, Pandey AS, Wilkinson DA. Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review. World Neurosurg 2023; 170:e529-e541. [PMID: 36402305 DOI: 10.1016/j.wneu.2022.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS. METHODS We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases. RESULTS Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%. CONCLUSIONS Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.
Collapse
Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patricia P Yee
- Medical Scientist Training Program, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Bashar Zaidat
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Badih J Daou
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chris D Kazmierczak
- Department of Radiology, Oakland University-William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| |
Collapse
|
7
|
Zaazoue KA, Core JM, Altan A, Elboraey MA, Ritchie CA. Work-Up of Lower Extremity Swelling in a Patient With Ehlers-Danlos Syndrome. Cureus 2022; 14:e27973. [PMID: 36120264 PMCID: PMC9467485 DOI: 10.7759/cureus.27973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/05/2022] Open
Abstract
A 36-year-old woman with Ehlers-Danlos syndrome (EDS) presents with a painful and enlarging right lower extremity mass prompting imaging work up. Herein we present a case report of an uncommon complication and a unique treatment option of a large right anterior tibial artery pseudoaneurysm caused by repetitive microtrauma in a patient with EDS and a congenital club foot.
Collapse
|
8
|
Spontaneous compartment syndrome and endovascular repair of tibioperoneal trunk pseudoaneurysm in Ehlers-Danlos syndrome. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:701-705. [PMID: 34754994 PMCID: PMC8556759 DOI: 10.1016/j.jvscit.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/25/2021] [Indexed: 11/20/2022]
Abstract
Vascular Ehlers-Danlos syndrome is caused by mutations in the COL3A1 (collagen type III alpha-1) gene, resulting in loss of integrity of arteries and hollow organs. Patients are predisposed to dissection, aneurysm, and organ rupture. The median life expectancy is ∼51 years. We have described a unique presentation of spontaneous compartment syndrome, likely secondary to ischemia reperfusion injury, in a 32-year-old man with vascular Ehlers-Danlos syndrome. The compartment syndrome was treated with four-compartment fasciotomy, and subsequent evaluation demonstrated a pseudoaneurysm of the tibioperoneal trunk. Endovascular intervention and stent graft deployment guided by intravascular ultrasound successfully excluded the pseudoaneurysm with three vessel run off preserved.
Collapse
|
9
|
Eleshra A, Panuccio G, Spanos K, Rohlffs F, Kodolitsch Y, Detter NC, Tsilimparis N, Kölbel T. Endovascular Repair of Postdissection Thoracoabdominal Aortic Aneurysm in Patients With Vascular Ehlers-Danlos Syndrome. J Endovasc Ther 2021; 28:804-811. [PMID: 34152227 DOI: 10.1177/15266028211025038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report endovascular repair of postdissection thoracoabdominal aortic aneurysm (TAAA) in 2 patients with vascular Ehlers-Danlos syndrome (vEDS). CASE REPORTS Case 1. A 56-year-old vEDS male patient with a 50-mm type III TAAA [history of aortic root repair, hemiarch replacement, and thoracic endovascular aortic repair (TEVAR) for acute type A aortic dissection (TAAD) 7 years ago] was treated by a 2-stage procedure; first, cervical debranching of the left subclavian artery and second TEVAR and t-branch. The postoperative course was uneventful. Follow-up computed tomography angiography (CTA) 3.5 years postoperatively demonstrated aortic remodeling with patency of targeted visceral vessels and no endoleak. Case 2. A 47-year-old vEDS male patient presented with a TAAA (diameter of 67 mm). The patient had a history of aortic valve and arch replacement with elephant trunk for acute TAAD, and consequently a TEVAR and candy-plug procedure after a ruptured false lumen (FL) aneurysm of the descending thoracic aorta. He also had a surgical repair by an aorto-bi-iliac graft. Two years later, CTA demonstrated aneurysmal FL dilatation distally to the candy-plug and he was treated with fenestrated EVAR (F-EVAR). CONCLUSION Endovascular repair of postdissection TAAA was feasible and safe with good short-term outcome in 2 patients with vEDS.
Collapse
Affiliation(s)
- Ahmed Eleshra
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Yskertvon Kodolitsch
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - N Christian Detter
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
10
|
Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical Thrombectomy for Acute Ischemic Stroke: Considerations in Children. Stroke 2020; 51:3174-3181. [PMID: 32912096 DOI: 10.1161/strokeaha.120.029698] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.
Collapse
Affiliation(s)
- Lisa R Sun
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Dana Harrar
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gerald Drocton
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Carlos Castillo-Pinto
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Ryan Felling
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care and Pediatric Cardiology, Children's National Hospital, Washington, DC. (G.W.)
| | - Cameron G McDougall
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD. (C.G.M.)
| | - Philippe Gailloud
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Monica S Pearl
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.).,Department of Radiology, Children's National Hospital, Washington, DC. (M.S.P.)
| |
Collapse
|
11
|
Moramarco LP, Capodaglio CA, Quaretti P, Cionfoli N, Fiorina I, Disabella E, D'agostino AM, Urtis M, Arbustini E. Multivessel endovascular therapy for undiagnosed vascular type Ehlers-Danlos syndrome. Successful percutaneous transcatheter coil embolization of hepatic artery pseudoaneurysm with stenting of right renal and iliac arteries in emergency setting. BJR Case Rep 2020; 6:20200025. [PMID: 33299587 PMCID: PMC7709055 DOI: 10.1259/bjrcr.20200025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/17/2020] [Accepted: 06/21/2020] [Indexed: 11/05/2022] Open
Abstract
Among Ehlers-Danlos syndromes, the vascular type is the most severe because of its vascular complications. Transcatheter embolization of medium-sized arteries has become the first-line therapy for life-threatening hemorrhage. Ongoing multiple lesions causing hemorrhagic or ischemic complications in the acute phase can challenge patient management. Multivessel endovascular treatment has never been reported. In this study, we report successful single-session treatment by coiling of a ruptured pseudoaneurysm of the hepatic artery with stenting of dissected right renal and iliac arteries in a 46-year-old female. Percutaneous transfemoral approach was gained and sealed with a plug-based closure device. Genetic disease was subsequently confirmed by molecular analysis.
Collapse
Affiliation(s)
| | | | - Pietro Quaretti
- Unit of Interventional Radiology and Department of Radiology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Nicola Cionfoli
- Unit of Interventional Radiology and Department of Radiology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Ilaria Fiorina
- Unit of Interventional Radiology and Department of Radiology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Eliana Disabella
- Centre for Inherited Cardiovascular Diseases of Cardio-Thoracic-Vascular Surgery Department, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | | | - Mario Urtis
- Centre for Inherited Cardiovascular Diseases of Cardio-Thoracic-Vascular Surgery Department, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases of Cardio-Thoracic-Vascular Surgery Department, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
12
|
Olubajo F, Kaliaperumal C, Choudhari KA. Vascular Ehlers-Danlos Syndrome: Literature review and surgical management of intracranial vascular complications. Clin Neurol Neurosurg 2020; 193:105775. [PMID: 32197145 DOI: 10.1016/j.clineuro.2020.105775] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Vascular Ehlers-Danlos (vEDS) is a rare form of the Ehlers-Danlos Syndrome (EDS) where arterial fragility results from mutations in the gene that encodes type III collagen. The disease can lead to major neurological complications including carotico-cavernous fistulae (CCF), aneurysms of the Circle of Willis and endovascular procedures have an increased risk profile due to the delicate vasculature. Management of intracranial disease in vEDS requires an intricate understanding of the syndrome but is still associated with significant complications that lead to morbidity and mortality. As well as providing an approach to the management of neurovascular complications in vEDS, the relevant literature regarding nosology, aetiology and genetics of the condition is summarised here. Particular emphasis is placed on the two most common intracranial complications, namely carotico-cavernous fistulas and and cerebral aneurysms. Pros and cons of surgical and endovascular interventions are discussed and a technical discussion is concentrated on the surgical aspects of management.
Collapse
Affiliation(s)
- Farouk Olubajo
- Department of Neurosurgery, The Walton Centre, Lower Ln, Liverpool, L9 7LJ, United Kingdom.
| | | | - Kishor A Choudhari
- Department of Neurosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, United Kingdom
| |
Collapse
|
13
|
Howard R, Osborne N. Ruptured ulnar artery aneurysm in vascular Ehlers-Danlos syndrome. J Vasc Surg Cases Innov Tech 2020; 6:71-74. [PMID: 32072093 PMCID: PMC7016348 DOI: 10.1016/j.jvscit.2019.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 11/24/2022] Open
Abstract
Vascular Ehlers-Danlos syndrome (vEDS), also known as type IV Ehlers-Danlos syndrome, is a rare inherited connective tissue disease that affects 1 in 50,000 to 250,000 individuals. It is characterized by catastrophic vascular complications and hollow viscus rupture; 80% of patients with vEDS experience a vascular complication by the age of 40 years, and median life expectancy is 40 to 50 years. The central vasculature and visceral vasculature are most commonly affected; peripheral involvement is much less common. We describe the case of a 40-year-old woman with vEDS previously complicated by ruptured splenic and posterior tibial artery aneurysms who presented with a ruptured left ulnar artery aneurysm resulting in compartment syndrome.
Collapse
Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, Mich
| | | |
Collapse
|
14
|
Davis JR, Kiang SC, Dudley KM, Patel ST, Smith JC, Tomihama RT. Power-Injection Injury in a Patient with Ehlers-Danlos Syndrome. J Vasc Interv Radiol 2019; 30:1685-1687. [PMID: 31279686 DOI: 10.1016/j.jvir.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Jessica R Davis
- Department of Radiology and Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354
| | - Sharon C Kiang
- Division of Vascular Surgery and Department of Surgery, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354; Division of Vascular Surgery and Department of Surgery, Veterans Affairs Loma Linda Healthcare System, Loma Linda, California
| | - Kaci M Dudley
- Department of Radiology and Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354
| | - Sheela T Patel
- Division of Vascular Surgery and Department of Surgery, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354
| | - Jason C Smith
- Department of Radiology and Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354
| | - Roger T Tomihama
- Department of Radiology and Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, 11234 Anderson St., Suite MC-2605E, Loma Linda, CA 92354
| |
Collapse
|
15
|
Tinelli G, Ferraresi M, Watkins AC, Hertault A, Soler R, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Aortic treatment in connective tissue disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:518-525. [PMID: 29943958 DOI: 10.23736/s0021-9509.18.10443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.
Collapse
Affiliation(s)
- Giovanni Tinelli
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Marco Ferraresi
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| |
Collapse
|
16
|
Abstract
Background The most important structural proteins of the vascular wall are collagen and elastin. Genetically linked connective tissue diseases lead to degeneration, aneurysm formation and spontaneous dissection or rupture of arteries. The most well-known are Marfan syndrome, vascular Ehlers-Danlos syndrome (type IV), Loeys-Dietz syndrome and familial aortic aneurysms and dissections. Objective This review article addresses the current status of endovascular treatment options for important connective tissue diseases. Material and methods Evaluation of currently available randomized studies and registry data. Results The treatment of choice for patients that are mostly affected at a young age is primarily conservative or open repair. There is only limited evidence for endovascular aortic repair (EVAR) of abdominal aneurysms or thoracic endovascular aortic repair (TEVAR). Conclusion The progression of the disease with dilatation leads to secondary endoleaks and high reintervention rates with uncertain long-term results. For this reason, there is currently consensus that EVAR and TEVAR should be limited to justified exceptional cases and emergency situations in patients with genetically linked aortic diseases.
Collapse
|
17
|
Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature. J Pediatr Orthop 2017; 37:e4-e9. [PMID: 26422393 DOI: 10.1097/bpo.0000000000000656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature. METHODS The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients. RESULTS The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance. CONCLUSIONS Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype. LEVEL OF EVIDENCE Level V-expert opinion.
Collapse
|
18
|
|
19
|
Eagleton MJ. Arterial complications of vascular Ehlers-Danlos syndrome. J Vasc Surg 2016; 64:1869-1880. [PMID: 27687326 DOI: 10.1016/j.jvs.2016.06.120] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/30/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vascular Ehlers-Danlos syndrome (EDS) is a relatively rare genetic syndrome that occurs owing to disorders in the metabolism of fibrillary collagen. These defects affect the soft connective tissues resulting in abnormalities in the skin, joints, hollow organs, and blood vessels. Patients with these defects frequently present at a young age with spontaneous arterial complications involving the medium-sized arteries. Complications involving the hollow organs, such as spontaneous colonic perforation, are observed as well. Given the fragility of the soft tissue, open and endovascular intervention on patients with vascular EDS is fraught with high complication rates. METHODS A PubMed search was performed to identify manuscripts published related to vascular EDS. This search included more than 747 articles. These findings were cross-referenced using key terms, including endovascular, embolization, surgery, genetics, pathophysiology, connective tissue disorders, vascular complications, systematic review, type III collagen, and COL3A1. RESULTS The references in key articles and review articles were evaluated for additional resources not identified in the PubMed search. Care must be taken to balance the risk of intervention vs the risk of continued observation. Life-threatening hemorrhage, however, mandates intervention. CONCLUSIONS With careful, altered approaches to tissue handling, endovascular approaches may provide a safer option for managing the arterial complications observed in patients with vascular EDS. Additional hope may also be found in the use of pharmacologic agents that reduce the incidence and severity of the arterial complications.
Collapse
Affiliation(s)
- Matthew J Eagleton
- Department of Vascular Surgery, Cleveland Clinic Lerner College of Medicine-CWRU, Cleveland, Ohio.
| |
Collapse
|
20
|
Bashir Q, Thornton J, Alp S, Debrun G, Aletich V, Charbel F, Ausman J, Polet H. Carotid-Cavernous Fistula Associated with Ehlers-Danlos Syndrome Type IV. Interv Neuroradiol 2016; 5:313-20. [DOI: 10.1177/159101999900500408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/1999] [Accepted: 10/25/1999] [Indexed: 11/16/2022] Open
Abstract
A case of traumatic, direct, carotid cavernous fistula (CCF) associated with Ehlers — Danlos syndrome (EDS) Type IV is reported along with a review of the literature. Excluding the present case, three similar cases associated with EDS-TypeIV have already been reported by Gerard M. Debrun et Al1. Despite the risks associated with endovascular manipulation, the fistula was successfully closed by intravascular embolisation but the patient expired a few days later because of underlying disease-associated vascular and visceral complications.
Collapse
Affiliation(s)
| | - J. Thornton
- Department of Radiology, University of Illinois; Chicago
| | | | - G.M. Debrun
- Department of Radiology, University of Illinois; Chicago
| | - V.A. Aletich
- Department of Radiology, University of Illinois; Chicago
| | | | | | - H. Polet
- Department of Pathology, University of Illinois; Chicago
| |
Collapse
|
21
|
Gui X, Li F, Wu L, Zheng Y. Systemic Multiple Aneurysms Caused by Vascular Ehlers-Danlos Syndrome. Vasc Endovascular Surg 2016; 50:354-8. [PMID: 27206743 DOI: 10.1177/1538574416647501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic multiple aneurysms are rare and usually associated with collagen tissue disease, such as Ehlers-Danlos syndrome (EDS) or Marfan syndrome. In the present case, we describe a 39-year-old male patient with systemic multiple aneurysms and acute intraperitoneal hemorrhage who was clinically diagnosed with vascular EDS. Coil embolization of the distal segment of the common hepatic artery was performed, which resolved the patient’s symptoms. With this case presentation, we aim to increase the awareness of vascular EDS among clinicians and emphasize the extreme fragility of the arteries in patients with vascular EDS.
Collapse
Affiliation(s)
- Xinyu Gui
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Fangda Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Lingeer Wu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
22
|
Affiliation(s)
- Nathan J Aranson
- From Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - Michael T Watkins
- From Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston.
| |
Collapse
|
23
|
Abstract
Vasculopathies are the least publicized but most important manifestation of neurofibromatosis type 1 (NF1, or, von Recklinghausen disease) as the cause of morbidity and mortality in children and young adults afflicted with the disease. Occlusive or aneurysmal disease of arteries of all sizes may occur almost anywhere in the body. Coarctation or segmental hypoplasia of the abdominal aorta with or without renal artery ostial stenosis is a common cause of renovascular hypertension. Although rare, occlusive coronary artery disease in NF1 may result in myocardial infarction and sudden unexpected death. Visceral vasculopathy causes ischemic bowel disease; and catastrophic retroperitoneal or abdominal hemorrhage has been attributed to spontaneously ruptured arterial aneurysms. Peripheral vascular disease in NF1 with limb ischemia requiring an amputation is described for the first time here. Scanty information exists in the current pathology literature on NF1 vasculopathies, hence the presentation of this review.
Collapse
Affiliation(s)
- J T Lie
- Department of Pathology, University of California Davis School of Medicine, Davis, and the University of California Davis Medical Center, Sacramento, California USA
| |
Collapse
|
24
|
CT Angiographic Evaluation of Genetic Vascular Disease: Role in Detection, Staging, and Management of Complex Vascular Pathologic Conditions. AJR Am J Roentgenol 2014; 202:1120-9. [DOI: 10.2214/ajr.13.11485] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
25
|
Barajas BD, Sun A, Rimoin DL, Reinstein E. Recurrent compartment syndrome in a patient with clinical features of a connective tissue disorder. Am J Med Genet A 2013; 161A:1442-6. [PMID: 23633393 DOI: 10.1002/ajmg.a.35894] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 01/14/2013] [Indexed: 11/10/2022]
Abstract
Arterial complications are common in vascular type Ehlers-Danlos syndrome (EDS), accounting for 66% of first complications. Several cases in the literature have documented acute compartment syndrome (ACS) following vascular rupture in vascular type EDS. Other disorders of connective tissue have also demonstrated vascular fragility, leading to arterial aneurysm and rupture, but there have been no documented cases of ACS. Here, we report on a female patient with a history of recurrent compartment syndrome who exhibits some clinical findings seen in hypermobile and vascular EDS; however she does not meet clinical and molecular diagnostic criteria for either of them. We further review the literature on ACS in heritable connective tissue disorders and suggest that compartment syndrome may rarely complicate other heritable disorders of connective tissue.
Collapse
Affiliation(s)
- Brenda D Barajas
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | | | | | | |
Collapse
|
26
|
Respiratory complications of Ehlers–Danlos syndrome type IV. Leg Med (Tokyo) 2013; 15:23-7. [DOI: 10.1016/j.legalmed.2012.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 07/04/2012] [Accepted: 07/25/2012] [Indexed: 10/28/2022]
|
27
|
Sala Almonacil VA, Zaragozá García JM, Gómez Palonés FJ, Plaza Martínez Á, Ortíz Monzón E. Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome. Ann Vasc Surg 2012; 26:861.e11-5. [PMID: 22794344 DOI: 10.1016/j.avsg.2012.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/02/2012] [Accepted: 01/08/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. METHOD AND RESULTS A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. CONCLUSIONS We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS.
Collapse
|
28
|
Hori D, Yuri K, Nemoto K, Yamaguchi A, Adachi H. Early aortic endograft failure in the presence of periaortic lymphadenopathy with neurofibromatosis (von Recklinghausen’s disease). Gen Thorac Cardiovasc Surg 2012; 60:308-11. [DOI: 10.1007/s11748-011-0818-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 04/11/2011] [Indexed: 10/28/2022]
|
29
|
|
30
|
Lum YW, Brooke BS, Arnaoutakis GJ, Williams TK, Black JH. Endovascular Procedures in Patients With Ehlers–Danlos Syndrome: A Review of Clinical Outcomes and Iatrogenic Complications. Ann Vasc Surg 2012; 26:25-33. [DOI: 10.1016/j.avsg.2011.05.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/27/2011] [Accepted: 05/28/2011] [Indexed: 10/17/2022]
|
31
|
|
32
|
Yilmaz A, Dessing T, Botta L. Ascending aorta impending rupture: successful surgical management in a patient with type IV Ehlers–Danlos syndrome. J Cardiovasc Med (Hagerstown) 2010; 11:610-2. [DOI: 10.2459/jcm.0b013e3283314176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
33
|
Key NS, DE Paepe A, Malfait F, Shovlin CL. Vascular haemostasis. Haemophilia 2010; 16 Suppl 5:146-51. [PMID: 20590874 DOI: 10.1111/j.1365-2516.2010.02313.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
SUMMARY While the majority of this session will deal with selected inherited vascular abnormalities that may manifest as a haemorrhagic disorder, the initial discussion by Dr Key will focus on the interplay between the vessel wall and components of the coagulation system, with a focus on haemophilia A and B. Although it is generally accepted that physiological haemostasis is triggered by contact of blood with tissue factor (TF), there remains some controversy regarding the cellular origin of TF in vivo. In addition, the initiation and propagation of thrombin generation are highly dependent on the balance of pro- and anticoagulant functions of endothelium, a profile that varies significantly throughout the vasculature. Drs De Paepe and Malfait address heritable collagen disorders such as the Ehlers-Danlos syndromes (EDS), a heterogeneous group of diseases involving the skin, ligaments and joints, blood vessels and internal organs. Most EDS subtypes are caused by mutations in genes encoding fibrillar collagens, or in genes coding for enzymes involved in posttranslational modifications of collagens. Accurate biochemical and molecular testing is now available for most EDS subtypes and can direct genetic counselling and medical management for these disorders. Dr Shovlin reviews recent developments in hereditary haemorrhagic telengiectasia (HHT), a frequently undiagnosed disorder characterized by arteriovenous malformations in multiple organs. These abnormal blood vessels are the result of mutations in one of a number of genes whose protein products influence TGF-beta signalling in vascular endothelial cells. Several HHT management guidelines have been published and are discussed.
Collapse
Affiliation(s)
- N S Key
- Harold R Roberts Comprehensive Hemophilia Diagnostic and Treatment Center, University of North Carolina, Chapel Hill, NC, USA.
| | | | | | | |
Collapse
|
34
|
Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Iida Y, Obitsu Y, Komai H, Shigematsu H. Successful coil embolization for rupture of the subclavian artery associated with Ehlers-Danlos syndrome type IV. J Vasc Surg 2009; 50:1191-5. [DOI: 10.1016/j.jvs.2009.05.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Revised: 05/29/2009] [Accepted: 06/30/2009] [Indexed: 11/30/2022]
|
36
|
Contemporary management of vascular complications associated with Ehlers-Danlos syndrome. J Vasc Surg 2009; 51:131-8; discussion 138-9. [PMID: 19879095 DOI: 10.1016/j.jvs.2009.08.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/04/2009] [Accepted: 08/04/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVES There has been debate regarding the safety of performing elective procedures in patients with vascular manifestations associated with Ehlers-Danlos syndrome (EDS). The purpose of this study was to review the surgical management and clinical outcomes of EDS patients undergoing vascular procedures at a tertiary medical center with multimodality expertise in connective tissue disorders. METHODS All patients with EDS undergoing endovascular and open vascular procedures at a single-institution academic medical center from 1994 to 2009 were retrospectively reviewed. Clinical data were evaluated including patient demographics, length of stay (LOS), and mortality outcomes during hospital course and long-term follow-up. RESULTS A total of 40 patients with EDS were identified, including individuals diagnosed with classic (n = 15), hypermobility (n = 16), and vascular (n = 9) types of EDS. These patients collectively underwent 45 endovascular and 18 open procedures for vascular disease during the time period, including embolization (n = 37), angioplasty (n = 8), arterial bypass (n = 5), and aortic aneurysm repair (n = 13). All cases were performed electively, except for one (2%) urgent endovascular and one (5%) emergent open procedure. Endovascular procedures were associated with a median LOS (interquartile range [IQR]) of 2 (1 to 3) days with no procedure-related mortality or in-hospital deaths among all EDS types, whereas open vascular procedures had median LOS (IQR) of 6 (5 to 8) days with one (6%) in-hospital death occurring in a vascular EDS patient. Survival free of any complication at 5 years was 85% and 54% following endovascular and open procedures, respectively. CONCLUSIONS The elective surgical management of vascular disorders in EDS patients using open and endovascular procedures has been associated with good outcomes. Our results suggest that vascular interventions in these EDS patients can be safely performed and should not be withheld until rupture or acute symptoms arise.
Collapse
|
37
|
Malfait F, Paepe AD. Bleeding in the heritable connective tissue disorders: Mechanisms, diagnosis and treatment. Blood Rev 2009. [DOI: 10.1016/j.blre.2009.06.001 doi:dx.doi.org] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
38
|
Malfait F, Paepe AD. Bleeding in the heritable connective tissue disorders: Mechanisms, diagnosis and treatment. Blood Rev 2009; 23:191-7. [DOI: 10.1016/j.blre.2009.06.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Lipinski MJ, Lipinski SE, Kripalani S, Friesen LD, Uthlaut BS, Braddock SR. An unusual presentation of Ehlers-Danlos syndrome vascular type with deep vein thrombosis: A case for multidisciplinary management. Am J Med Genet A 2009; 149A:698-701. [DOI: 10.1002/ajmg.a.32687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
40
|
|
41
|
Callewaert B, Malfait F, Loeys B, De Paepe A. Ehlers-Danlos syndromes and Marfan syndrome. Best Pract Res Clin Rheumatol 2008; 22:165-89. [PMID: 18328988 DOI: 10.1016/j.berh.2007.12.005] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ehlers-Danlos syndromes (EDS) and Marfan syndrome (MFS) are multisystemic disorders that primarily affect the soft connective tissues. Both disorders have benefited from recent advances in clinical and molecular characterization, allowing improvements in clinical diagnosis and management. EDS are a heterogeneous group of conditions characterized by skin hyperextensibility, atrophic scarring, joint hypermobility and generalized tissue fragility. The current classification proposes six subtypes based on clinical, biochemical and molecular characteristics. However, examples of unclassified variants and 'overlap phenotypes' are becoming more common. Mutations in genes encoding fibrillar collagens or collagen-modifying enzymes have been identified in most forms of EDS, including the classic and vascular subtypes (collagen type V and III, respectively), and the rare arthrochalasis, kyphoscoliosis and dermatosparaxis variants (type I collagen defects). To date, the genetic background of the hypermobility type of EDS remains unclear, although some new insights have been gained recently. MFS is an autosomal-dominant disorder that affects the cardiovascular, ocular and skeletal system with aortic root dilation/dissection, ectopia lentis and bone overgrowth, respectively. Advances in therapeutic, mainly surgical, techniques have improved median survival significantly, yet severe morbidity and a substantial risk for premature mortality remain associated. The disorder is caused by mutations in the FBN1 gene, encoding the microfibrillar protein fibrillin-1. Recently, new insights in the pathogenesis changed the prevailing concept of this type 1 fibrillinopathy as a structural disorder of the connective tissue into a developmental abnormality manifesting perturbed cytokine signalling. These findings have opened new and unexpected targets for aetiologically directed drug treatments.
Collapse
Affiliation(s)
- Bert Callewaert
- Ghent University Hospital, Centre for Medical Genetics, De Pintelaan 185, B-9000 Ghent, Belgium
| | | | | | | |
Collapse
|
42
|
Naidu SG, Chong BW, Huettl EA, Stone WM. Percutaneous embolization of a lumbar pseudoaneurysm in a patient with type IV Ehlers-Danlos syndrome. J Vasc Surg 2007; 46:1036-8. [PMID: 17980288 DOI: 10.1016/j.jvs.2007.05.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 05/24/2007] [Indexed: 11/18/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary connective tissue disorder. Patients with type IV EDS are prone to develop visceral pseudoaneurysms and aortic aneurysms. Surgical and endovascular interventions are fraught with complications and high morbidity. We present a case of a patient with type IV EDS who presented with a new psoas pseudoaneurysm arising from a hypertrophied lumbar artery which was treated with percutaneous embolization by using n-butyl cyanoacrylate glue and coils.
Collapse
Affiliation(s)
- Sailen G Naidu
- Department of Radiology, Division of Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
| | | | | | | |
Collapse
|
43
|
Stone WM, Fowl RJ, Money SR. Ruptured hepatic artery aneurysm: a novel approach to distal control. J Vasc Surg 2007; 46:574-5. [PMID: 17826249 DOI: 10.1016/j.jvs.2007.04.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 04/30/2007] [Indexed: 10/22/2022]
Abstract
We describe a unique method for obtaining distal control in a ruptured hepatic artery aneurysm. A 34-year-old man with Ehlers-Danlos syndrome type IV presented with a ruptured left hepatic artery aneurysm. The distal aneurysm was within the parenchyma of the liver. Proximal control was obtained with pledgeted sutures. The distal hepatic artery was difficult to control. Injection of 5 mL of thrombin into the distal left hepatic artery resulted in hemorrhage control. This technique should be considered in select patients in whom distal arterial control is challenging.
Collapse
Affiliation(s)
- William M Stone
- Division of Vascular Surgery, Mayo Clinic, Phoenix, AZ 85052, USA.
| | | | | |
Collapse
|
44
|
Lim SP, Duddy MJ. Endovascular Treatment of a Carotid Dissecting Pseudoaneurysm in a Patient with Ehlers-Danlos Syndrome Type IV with Fatal Outcome. Cardiovasc Intervent Radiol 2007; 31:201-4. [PMID: 17687602 DOI: 10.1007/s00270-007-9135-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 06/23/2007] [Accepted: 06/27/2007] [Indexed: 10/23/2022]
Abstract
We present a patient with Ehlers-Danlos syndrome type IV (EDS IV) with a carotid dissecting pseudoaneurysm causing severe carotid stenosis. This lesion was treated endovascularly. Unfortunately, the patient died of remote vascular catastrophes (intracranial hemorrhage and abdominal aortic rupture). This unique case illustrates the perils of endovascular treatment of EDS IV patients and the need for preoperative screening for concomitant lesions. It also shows that a dissecting pseudoaneurysm can feasibly be treated with a covered stent and that closure is effective using Angioseal in patients with EDS IV.
Collapse
Affiliation(s)
- Siok Ping Lim
- Department of Radiology, Selly Oak Hospital, University Hospital, Birmingham NHS Foundation Trust, Raddlebarn Road, Birmingham, West Midlands B29 6JD, UK.
| | | |
Collapse
|
45
|
Bade MA, Queral LA, Mukherjee D, Kong LS. Endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome. J Vasc Surg 2007; 46:360-2. [PMID: 17664111 DOI: 10.1016/j.jvs.2007.03.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 03/20/2007] [Indexed: 11/25/2022]
Abstract
Ehlers-Danlos syndrome is a connective tissue disorder caused by abnormal collagen synthesis. Vascular complications, including aneurysm formation and spontaneous arterial perforations, are difficult to manage surgically and result in significant operative mortality due to blood vessel fragility. We describe the first reported successful endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome. We discuss the advantages endovascular surgery offers over open surgery in these patients. We believe that endovascular repair of abdominal aortic aneurysms preferentially over open repair merits consideration in patients with Ehlers-Danlos syndrome.
Collapse
Affiliation(s)
- Maseer A Bade
- Cardiac, Vascular, and Thoracic Surgery Associates, Falls Church, VA 22033, USA.
| | | | | | | |
Collapse
|
46
|
Abstract
Ehlers-Danlos syndrome type IV, the vascular type of Ehlers-Danlos syndromes (EDS), is an inherited connective tissue disorder defined by characteristic facial features (acrogeria) in most patients, translucent skin with highly visible subcutaneous vessels on the trunk and lower back, easy bruising, and severe arterial, digestive and uterine complications, which are rarely, if at all, observed in the other forms of EDS. The estimated prevalence for all EDS varies between 1/10,000 and 1/25,000, EDS type IV representing approximately 5 to 10% of cases. The vascular complications may affect all anatomical areas, with a tendency toward arteries of large and medium diameter. Dissections of the vertebral arteries and the carotids in their extra- and intra-cranial segments (carotid-cavernous fistulae) are typical. There is a high risk of recurrent colonic perforations. Pregnancy increases the likelihood of a uterine or vascular rupture. EDS type IV is inherited as an autosomal dominant trait that is caused by mutations in the COL3A1 gene coding for type III procollagen. Diagnosis is based on clinical signs, non-invasive imaging, and the identification of a mutation of the COL3A1 gene. In childhood, coagulation disorders and Silverman's syndrome are the main differential diagnoses; in adulthood, the differential diagnosis includes other Ehlers-Danlos syndromes, Marfan syndrome and Loeys-Dietz syndrome. Prenatal diagnosis can be considered in families where the mutation is known. Choriocentesis or amniocentesis, however, may entail risk for the pregnant woman. In the absence of specific treatment for EDS type IV, medical intervention should be focused on symptomatic treatment and prophylactic measures. Arterial, digestive or uterine complications require immediate hospitalisation, observation in an intensive care unit. Invasive imaging techniques are contraindicated. Conservative approach is usually recommended when caring for a vascular complication in a patient suffering from EDS type IV. Surgery may, however, be required urgently to treat potentially fatal complications.
Collapse
Affiliation(s)
- Dominique P Germain
- Centre de référence pour la maladie de Fabry et les maladies héréditaires du tissu conjonctif (syndromes d'Ehlers-Danlos, pseudoxanthome élastique, mucopolysaccharidoses), Assistance Publique-Hôpitaux de Paris, Paris, France.
| |
Collapse
|
47
|
Tonnessen BH, Sternbergh WC, Mannava K, Money SR. Endovascular repair of an iliac artery aneurysm in a patient with Ehlers-Danlos syndrome type IV. J Vasc Surg 2007; 45:177-9. [PMID: 17210404 DOI: 10.1016/j.jvs.2006.08.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 08/26/2006] [Indexed: 10/23/2022]
Abstract
Ehlers-Danlos type IV (EDS-IV) is an inherited condition most notable for its associated vascular complications. Patients are prone to aneurysm formation, arterial dissection, and spontaneous vessel rupture. Intervention for the vascular pathology of EDS-IV carries high morbidity and mortality. We describe a case of a 57-year-old man with EDS-IV and an expanding iliac aneurysm who underwent successful endovascular repair with a stent-graft. Endovascular aneurysm repair is feasible and should be considered for patients with EDS-IV.
Collapse
Affiliation(s)
- Britt H Tonnessen
- Section of Vascular Surgery, Ochsner Clinic Foundation, New Orleans, LA 70123, USA
| | | | | | | |
Collapse
|
48
|
Wennberg PW, Kalsi H. Aneurysms of the Peripheral Arteries. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
49
|
Perdu J, Boutouyrie P, Lahlou-Laforêt K, Khau Van Kien P, Denarié N, Mousseaux E, Sapoval M, Julia P, Zinzindohoué F, Touraine P, Dumez Y, Trystram D, Vignal-Clermont C, Gimenez-Roqueplo AP, Jeunemaitre X, Fiessinger JN. Syndrome d’Ehlers-Danlos vasculaire. Presse Med 2006; 35:1864-75. [PMID: 17159712 DOI: 10.1016/s0755-4982(06)74919-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The vascular type of Ehlers-Danlos syndrome (EDS) is a rare genetic disease transmitted as an autosomal dominant trait. It is distinguished from other forms of EDS by its unstable acrogeric morphotype and by vascular, gastrointestinal, and obstetrical complications. Diagnosis is based on various clinical signs, noninvasive imaging, and on the identification of a mutation of the COL3A1 gene, which provides diagnostic certainty but has a sensitivity of only 61%. When two major diagnostic criteria are present, a genetic test should be proposed, performed and its result presented in a multidisciplinary group. The precautionary principle requires that preventive measures be implemented when the diagnosis is suspected. All artery puncture, surgery, and gastrointestinal and uterine endoscopy are contraindicated, permissible only in life-threatening emergencies. Straining against a closed glottis and all other situations or drugs likely to raise blood pressure must be avoided. Contraception must be discussed to avoid pregnancy during the diagnostic period. Arterial lesions suggestive of the disease include dissecting aneurysms of the internal carotid and iliac arteries and of the anterior visceral branches of the abdominal aorta, fusiform aneurysms of the splenic artery, and early onset nontraumatic direct carotid-cavernous fistulae. Early-onset varicose veins, spontaneous peritonitis or unusually important perineal lesions after giving birth should also attract the physician's attention. Psychological treatment and support of patients and their families is essential, to help them both to live with their disease and to deal with the information and screening issues. The prognosis of Ehlers-Danlos syndrome, vascular type, is grim but there is wide interindividual variability and life expectancy is best among patients receiving regular follow-up. Management by an experienced multidisciplinary team, implementation of drastic prevention measures and, depending on the results of the BBEST study, the possible prescription of beta-blockers should help to reduce the risk of complications and justify hope for a real improvement in prognosis in the near future.
Collapse
Affiliation(s)
- Jérôme Perdu
- Groupe Multidisciplinaire de Prise en Charge du Syndrome d'Ehlers-Danlos Vasculaire, Hôpital européen Georges Pompidou, Paris.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
D'Souza ES, Williams DM, Deeb GM, Cwikiel W. Resolution of Large Azygos Vein Aneurysm Following Stent-Graft Shunt Placement in a Patient with Ehlers-Danlos Syndrome Type IV. Cardiovasc Intervent Radiol 2006; 29:915-9. [PMID: 16252082 DOI: 10.1007/s00270-004-4189-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ehlers-Danlos syndrome (EDS) type IV is a rare connective tissue disorder associated with thin-walled, friable arteries and veins predisposing patients to aneurysm formation, dissection, fistula formation, and vessel rupture. Azygos vein aneurysm is an extremely rare condition which has not been reported in association with EDS in the literature. We present a patient with EDS type IV and interrupted inferior vena cava (IVC) with azygos continuation who developed an azygos vein aneurysm. In order to decrease flow through the azygos vein and reduce the risk of aneurysm rupture, a stent-graft shunt was created from the right hepatic vein to the azygos vein via a transhepatic, retroperitoneal route. At 6 month follow-up the shunt was open and the azygos vein aneurysm had resolved.
Collapse
Affiliation(s)
- Estelle S D'Souza
- Department of Radiology, University of Michigan Hospitals, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0030, USA
| | | | | | | |
Collapse
|