Spontaneous aortic rupture in a patient with neurofibromatosis type 1

Endovascular treatment for a ruptured lumbar artery aneurysm in a patient with neurofibromatosis type 1

The present medical case report describes successful endovascular treatment via stent graft and coil packing for a ruptured lumbar artery aneurysm in a 55-year-old woman with neurofibromatosis type 1. Although less common, vasculopathy, such as an aneurysm, stenosis, rupture, and arteriovenous fistula, have been reported and can be a cause of death for patients with this disorder. However, only a few cases of a ruptured lumbar aneurysm have been reported.

Endovascular Repair for Abdominal Aortic Aneurysm Rupture With Neurofibromatosis Type 1

BACKGROUND

Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is a rare congenital disorder with an autosomal dominant inheritance. Severe perioperative complications owing to the congenital fragility of the vascular wall in NF1 patients have been reported. The optimal vascular surgical approach remains controversial. We describe endovascular aortic repair of an abdominal aortic aneurysm rupture in a patient with NF1.

CASE PRESENTATION

A 78-year-old woman with NF1 was transferred to our institution with a diagnosis of ruptured abdominal aortic aneurysm. The patient showed multiple café-au-lait spots, numerous neurofibromatosis, and severe scoliosis. Emergency endovascular aortic repair was performed, without technical difficulty. Despite an uneventful postoperative course, she developed an idiopathic left cervical hematoma caused by hemorrhage, and required tracheostomy due to severe airway obstruction. In addition, postoperative CT showed a newly developed saccular aneurysm at the proximal end of the stent graft. On postoperative day 40, she was transferred to a rehabilitation hospital, without recurrent bleeding and saccular aneurysm enlargement.

CONCLUSION

In patients with NF1 who require a vascular surgical procedure, surgeons should consider the vascular wall fragility in selecting the optimal treatment strategy and the possible complications.

Spontaneous rupture of the pancreatic arcade artery caused by neurofibromatosis type 1 successfully treated using emergency transcatheter arterial embolization, partial intra-aortic balloon occlusion, and stent graft placement: a case report and review of the literature

Background

Vascular abnormalities in neurofibromatosis type 1 (NF1) are rare, but are the second leading cause of death in persons with NF1. In NF1 vasculopathy (NF-V), fatal bleeding due to a spontaneous arterial rupture sometimes occurs. Ruptured extracranial arteries in patients with NF1 often involve thoracic vessels, such as the intercostal and subclavian arteries; very few reports exist regarding the abdominal region. Herein, we present the first case of intraperitoneal bleeding due to spontaneous pancreatic arcade artery (PAA) rupture associated with NF1, successfully treated by transcatheter arterial embolization (TAE) combined with stent-graft placement and partial intra-aortic balloon occlusion (IABO).

Case presentation

A 40-year-old woman complained of back and abdominal pain. Upon admission, her blood pressure was 85/41 mmHg and heart rate was 129 beats/min. Computed tomography (CT) showed large intraperitoneal bleeding due to PAA rupture. After CT scanning, her systolic blood pressure decreased to 50 mmHg. Therefore, we performed emergency TAE with partial IABO. She was treated by TAE of the anterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, and inferior pancreaticoduodenal artery. However, even after TAE, minor extravasation around the superior mesenteric artery continued, and her vital signs remained unstable. Stent-graft placement was selected to stop the haemorrhage, preserving normal blood flow of the superior mesenteric artery trunk. Excellent patency of the stent graft was confirmed on follow-up CT, and she was discharged on postoperative day 56.

Conclusion

PAA rupture associated with NF1 can be successfully treated by TAE combined with partial intra-aortic balloon occlusion, and stent-graft placement.

Spontaneous ascending aortic rupture in a pregnant woman with neurofibromatosis type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that affects 1 in 3000 individuals. Vascular involvement in NF-1 is a well-recognized, but rare, feature of this disease. In pregnant women, the risk of aortic dissection or rupture is elevated during pregnancy and the postpartum period. We report a pregnant woman who had a history of NF-1 with a spontaneous ascending aortic rupture. This rupture was successfully treated by emergent surgery. The mother and the 28-week-gestation newborn recovered uneventfully. During 7 years of follow-up, aorta of the patient shows no significant change. A review of the literature regarding the pathogenesis of this condition is also presented.

The endovascular management of neurofibromatosis-associated aneurysms: A systematic review

BACKGROUND

Neurofibroblastoma (NF) or Von Recklinghausen disease, is an autosomal dominant disorder affecting one in 3000 individuals. Cardinal features of NF include multiple café-au-lait macules, benign neurofibromas, and iris hamartomas. Albeit less common, vascular lesions of medium and large-sized arteries and veins are a well-recognized complication, which can lead to fatal consequences such as rupture.

METHOD

A systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and Meta-analysis (PRISMA) guidelines utilizing PubMed, EMBASE, and Cochrane databases.

RESULTS

There were 59 articles identified involving 66 patients (mean age 44.3 ± 30 years), of which 89% had neurofibromatosis type 1. There were 63.6% of patients who presented with aneurysm rupture, 33.3% presented with intact symptomatic aneurysms, and 3.1% presented with intact asymptomatic aneurysms. Anatomically, 4.5% of patients suffered from intracranial aneurysms; 12.1% suffered from visceral artery aneurysms (including hepatic, superior mesenteric, gastroduodenal and renal arteries), and other patients suffered from aneurysms within the chest, abdomen, pelvis, upper limbs and neck. Amongst the various endovascular procedures, coiling was performed in 83.3% of cases. There were 12 covered stents employed in 10 patients (18.2%), of which 7 were balloon-expandable grafts; 2 were self-expandable graft; 3 were not mentioned. The rates of major and minor complications were 15% and 6% respectively, with 4 cases (6%) of perioperative death. On a mean follow-up of 15 months (range 1.5-72 months), two patients developed a distant vascular lesion from the treated lesion.

CONCLUSION

Endovascular management is safe and effective even in hemodynamically unstable neurofibroblastoma patients at all ages. Vascular tree screening should be conducted in clinically suspicious patients to prevent fatal aneurysmal complications. A formal meta-analysis could not be performed due to the lack of randomized controlled trials.

Spontaneous Renal Artery Dissection in a Patient with Neurofibromatosis Type I

We present a case of spontaneous renal artery dissection (SRAD) in a 28-year-old female with history of neurofibromatosis type I (NF-1) treated successfully with endovascular stenting. The clinical presentation, diagnostic testing, and treatment options are discussed. An endovascular approach with stenting was successfully performed after failure of medical treatment with subcutaneous low molecular weight heparin. Patient's blood pressure and symptoms improved significantly. This may be the first reported case of SRAD in a patient with NF-1 successfully treated with endovascular stenting.