Spontaneous perforation of a non-aneurysmal atherosclerotic abdominal aorta or femoral artery

Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature

Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.

Spontaneous Deep Femoral Artery False Aneurysm Simulating a Neoplasm: A Rare Case and Literature Review

A 70-year-old woman presented to our attention with a painless pulsating mass at the level of the upper left thigh without any previous history of trauma, arterial surgery, or puncture of the femoral artery. Duplex ultrasound showed a nodular angiomatous-like formation with deep venous compression; computed tomographic angiography and magnetic resonance imaging reported the presence of capsulated lesion vascularized by muscular branch of deep femoral artery (DFA). The patient underwent surgical excision of a very rare thrombized DFA branch false aneurysm. Spontaneous DFA false aneurysm, although rare, will be considered in absence of trauma or vascular catheterization or previous aneurysmal rupture.

Giant Spontaneous Femoral Artery Pseudoaneurysm Treated with Covered Stents: Report of a rare presentation and review of literature

We report the case of a 62-year-old woman who presented with a one-month history of a pulsatile mass, with no antecedent trauma or intervention. Imaging showed a large pseudoaneurysm (PSA) of the distal portion of the left superficial femoral artery. The PSA was treated successfully with endovascular placement of covered stents.

Spontaneous femoral artery pseudoaneurysm in a young patient

Spontaneous femoral artery pseudoaneurysm is a rare disease and reported cases are very rare. Most of them are related to an underlying pathology of either atherosclerotic disease or connective tissue disease. We present a healthy, 29-year-old man with 2-month history of a painful pulsating mass at the level of the lower right thigh with no previous history of trauma, surgery, or puncture of the femoral artery. An angiogram revealed a right superficial femoral artery pseudoaneurysm. It was treated surgically by resection of the aneurysm and reconstruction with an interpositional saphenous vein graft. We report this case because of the rarity of this condition in a young patient with no underlying pathology.

Spontaneous femoral artery pseudoaneurysm in a young patient

Spontaneous femoral artery pseudoaneurysm is a rare disease and reported cases are very few. Most of them are related to underlying pathology either atherosclerotic disease or connective tissue disease. We present a 29-year-old healthy man with two months history of a painful pulsating mass at the level of the lower right thigh without any previous history of trauma, surgery or puncture of the femoral artery. An angiogram revealed a right superficial femoral artery pseudo-aneurysm. It was treated surgically by resection of the aneurysm, reconstruction with inter-positional saphenous vein graft. We reported this case because of its rare incidence in the young patient with no underlying pathology.

[Perforation of carotid artery causing cervical hematoma]

BACKGROUND

Perforation of the carotid artery is a rare, life-threatening emergency. This entity is usually caused by failed puncture of jugular veins, external trauma, or infection of the vascular wall. The existence of spontaneous rupture as a cause of vessel rupture is discussed in the literature.

CASE REPORT

The case of a 57-year-old woman who suffered painful cervical swelling on the left side for 2 days is described. Six weeks prior to this, she had received transjugular intrahepatic shunt implantation (TIPS) via the jugular vein because of liver cirrhosis. Further signs were vocal cord dysfunction and Horners' syndrome on the left side. Computed tomography (CT) with contrast agent revealed a huge mass surrounding the common carotid artery. Differentiation between a solid tumor and carotid dissection was primarily not possible. Radiological considerations also comprised an abscess or even a paraganglioma. Only color duplex sonography revealed a pendular blood flow slightly caudal of the carotid bifurcation. In agreement with the CT findings, a calcified plaque appeared directly downstream of the presumed vessel injury. Operative revision was performed in collaboration with the vascular surgeon. Transluminal endarteriectomy and vessel reconstruction with patch plasty was performed.

CONCLUSION

Cervical hematoma caused by carotid injury of unknown origin is a rare differential diagnosis of sudden cervical swelling. In this case, failed venous puncture in conjunction with pre-existing arterial plaque and therewith inflammation of the vessel wall could have caused the injury and delayed carotid rupture.

Abdominal aortic disease caused by penetrating atherosclerotic ulcers

OBJECTIVE

Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induced aortic dissection, aortic rupture, and secular aortic aneurysm and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta.

METHOD

Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture, and isolated abdominal aortic dissection over the past 15 years, giving a total of 65 cases.

RESULTS

The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, and the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic, including pain (40%, n = 26), shock (4.6%, n = 3), and lower limb embolism (9.2%, n = 6). The remaining 40% of cases were asymptomatic (n = 26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths.

CONCLUSION

We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection, or rupture. (English translation of Jpn J Vasc Surg 2010; 19: 723-730.).

A case of spontaneous rupture of nonaneurysmal left iliac artery due to penetrating atherosclerotic ulcer

We report on a patient with spontaneous rupture of a nonaneurysmal left common iliac artery in whom hemorrhagic shock developed. A 64-year-old woman presented with hemodynamic collapse accompanied by sudden abdominal pain. She was transported to the emergency department. Angiography showed a penetrating atherosclerotic ulcer in the left common iliac artery. Emergency surgery was performed with graft replacement (14 x 7 mm woven Dacron graft). Severe calcification was observed in the left common iliac artery, and an ulcer of the iliac artery was confirmed as the source of hemorrhage. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. We conclude that rupture may occur in patients with severe atherosclerotic change, even in the absence of aneurysm.

Spontaneous rupture of the superficial femoral artery treated with endovascular stent-grafting

Spontaneous rupture of the superficial femoral artery (SFA) is rare. It may occur in the presence of an SFA aneurysm or in a nonaneurysmal, but usually atherosclerotic, artery. Previously these ruptures have been treated by surgical exclusion, often with bypass grafting. We report a case of spontaneous rupture of a nonaneurysmal SFA treated successfully with endovascular stent-grafting.

Spontaneous perforation of a nonaneurysmal infrarenal aorta

Spontaneous perforation of a nonaneurysmal abdominal aorta due to a penetrating atherosclerotic ulcer (PAU) is exceedingly rare. We describe the case of a 57-year-old man with a perforating PAU of the infrarenal aortic wall and discuss the clinical presentation, diagnostic pathways, and therapeutic options based on a comprehensive review of the literature. Since a PAU of the aorta can give rise to chronic mild to moderate abdominal or back pain, a computed tomographic scan of the abdomen should be performed in patients with evidence of vascular disease and persistent abdominal or back discomfort. Surgical resection or stent-graft placement is indicated in symptomatic patients or in asymptomatic patients with radiographic signs of progressive PAU.

Bilateral spontaneous rupture of the muscular branch of the superficial femoral artery with pseudoaneurysm formation

Superficial femoral artery muscular branch avulsion may occasionally be associated with blunt trauma in the absence of fractures or even minor injuries. Spontaneous rupture of the superficial femoral artery or its muscular branches is extremely rare, with only five previously reported cases. We report the first case of bilateral spontaneous rupture of the muscular branch of the superficial femoral artery with pseudoaneurysm formation in a young, healthy patient. The patient denied any history of trauma to both his lower limbs. On both occasions, the patient had early surgical intervention with open evacuation of the hematoma and ligation of the avulsed artery. The patient recovered completely without any postoperative complications.

Penetrating Atherosclerotic Ulcers of the Infrarenal Aorta: Life-threatening Lesions

OBJECTIVES

To analyze the incidence, clinical features, natural history, and treatment of penetrating atherosclerotic ulcers (PAU) of the abdominal aorta.

MATERIAL AND METHODS

From January 2000 to June 2003, an abdominal PAU was diagnosed at our institution in eight patients (seven men, one woman; mean age 70 year). These eight cases were analyzed together with 38 additional cases found in a review of the literature (total 46 cases).

RESULTS

Occurring at an incidence of approximately 1%, abdominal PAU are less common than thoracic PAU. Seventy percent of cases are symptomatic: pain 52.5% (n =21), acute lower limb ischemia due to distal embolism 12.5% (n =5), shock 5% (n =2). Diagnosis is usually made by CT (66%) (n =26) that demonstrates a PAU in 35% (n =16) of cases, a subadventitial pseudoaneurysm in 28% (n =13), and rupture in 37% (n =17). An intramural hematoma (IMH) is observed in 9% (n =4) of cases. There were no cases of aortic dissection in this series. Calcifications of the abdominal aorta were frequent (56%) (n =26); while intra-aortic mural thrombus was found in 24% of cases (n =11), and 46% of patients (n =21) had an associated aneurysm. Twelve patients were treated medically while 34 underwent surgery (one postoperative death).

CONCLUSION

Review of the literature and this series suggests that PAU of the abdominal aorta is a life-threatening lesion, the main risk being rupture. Surgical management is recommended owing to its low morbidity and mortality.

Rare complication of saccular aneurysm and histological dissection: an autopsy study of 5865 elderly cases

The purpose of this study was to examine complicated lesions of saccular aneurysm and dissection. We investigated the ascending aortae in 5865 consecutive elderly autopsy cases, and 5 cases (0.085%) of aortic saccular aneurysms associated with dissection at the edges were selected. Their edges characteristically protruded like a shelf, which histologically consisted of an inner part of the dissected media. All patients were female and their mean age was 76.8 (67-89) years. The aneurysmal walls at the center showed severe fragmentation and disappearance of the elastic lamellae of the remaining outer media. Thus, partial sections of these lesions were not sufficient but cross-sections of the whole diseased regions including the edges were essential for diagnosis. One patient had 3 saccular aneurysms and an adjacent shallow depression, which we called "healed microscopic dissection". Histologically, it showed disappearance of the inner media and was replaced by fibrosis in continuation from the intima. This lesion showed no findings of intramural hemorrhage or thrombus, and thus it will differ from organized thrombi in the dissected false lumen. Another patient presented had an aneurysmal rupture which resulted in cardiac tamponade. This case implies the need for surgical treatment of this entity.